Holiday Guide for Families

 

 

 

 

 

 

This post is written for the friends and relatives of people in recovery from substance use disorders.

What to do:

1. Do invite your loved one in recovery to family functions, and treat her with the same respect you treat the rest of the family. If you have resentments from her past behavior, you can address this privately, not at the holiday dinner table. Perhaps given how holidays can magnify feelings, it’s best to keep things superficial and cheery. Chose another time if you have a grievance to air.
2. Allow your relative some privacy. If the person in recovery wishes to discuss her recovery with the entire family, she will. Let her be the one to bring it up, though. Asking things like, “Are you still on the wagon or have you gone back to shooting drugs?” probably will embarrass her and serve no useful function.
3. Accept her limitations graciously and without comment. Holidays can be trigger for drug use in some people, and your relative may want to go to a 12-step meeting during her visit. Other people in recovery may need some time by themselves, to pray, meditate, or call a recovering friend. Allow them to do this without making it a big deal.
4. Remember there are no black sheep. We are all gray sheep, since we all have our faults. In some families, one person, often the person with substance use disorder, gets unfairly designated as the black sheep. She gets blamed for every misfortune the family has experienced. Don’t slip into this pattern at holiday functions.

What not to do:

1. Don’t ask the recovering person if she’s relapsed. If you can’t tell, assume all is well with her recovery. If she looks intoxicated, you can express your concern privately, without involving everyone.
2. Don’t use drugs, including alcohol, around a recovering person unless you check with them first. Ask if drug or alcohol use may be a trigger, and if it is, abstain from use yourself. If you must use alcohol or other drugs, go to a separate part of the house or to another location.  Being around drugs including alcohol can be a bigger trigger during the first few years of recovery, but any recovering person can have times when they feel vulnerable, so check with them privately before you break open a bottle of wine.
3. If your family’s usual way of celebrating holidays is to get “ all liquored up,” then understand why a recovering relative may not wish to come to be with family at this time, and don’t take it personally. For some of us, remaining in recovery is a life and death issue, so please accept we will do what we must to remain in recovery, even if that means making a holiday phone call rather than making a holiday visit.
4. If your recovering loved one is in medication-assisted treatment with methadone or buprenorphine, don’t feel like you have the right to make dosage recommendations. Don’t ask “When are you going to off of that medication? (meaning methadone or buprenorphine) Your loved one may taper off medication completely at some point, or he may not. Either way, that’s a medical decision best made by the patient and his doctor. Asking when a taper is planned is not your business.
5. Refrain from giving hilarious descriptions of your loved one’s past addictive behavior, saying, “But I’m only joking!” This can hurt her feelings, and keep her feeling stuck with an identity as a drug user. She can begin to believe that with her family, being an addict is a life sentence.
6. Remember your loved one is more than the disease from which they are recovering. Some people have diabetes and some people have substance use disorders. These diseases are only a small part of who they are.

I hope this helps.

May all my readers have a Merry Christmas and Happy Holidays!

My Favorite Patients Have Opioid Use Disorder

 

 

I’m lazy and bloated from too much tryptophan from turkey, so I’m going to post an article today that’s a re-run. I wrote it for a physicians’ magazine, and I’m pleased to say it was published (around six or so years ago). The original title was “My Favorite Patients are Drug Addicts,” but in keeping with newer language, I updated the title:

When I was a fresh faced, newly unleashed graduate from my Internal Medicine residency twenty-three years ago, I never dreamed my favorite patients would be drug addicts.

In medical school, I learned little about drug and alcohol addiction and its treatment, and in residency, even less. I was well trained in the management of acute alcohol withdrawal, acute GI bleeding from alcoholic gastritis, and antibiotic coverage of endocarditis in an injection heroin user, but I couldn’t tell any of these patients how to find recovery from the actual underlying cause of their problems. I could only treat the sequellae, and I didn’t always do that with much grace.

The addicted person caused their own miseries, I thought, and since these were the Reagan years, they should “just say no” when offered drugs. My attitudes mirrored those of the attending physicians in my residency program. When an addict was admitted twice for endocarditis, needing an artificial valve the first admission, and its replacement on the second admission for re-infection, I was just as irritated as the attending and the rest of the house staff. I remember we discussed whether we could ethically refuse him treatment if he came in a third time! We were so self-righteous, though we had offered him little in the way of treatment for his disease of addiction. We might have had a social worker ask him if he wanted to go away for inpatient treatment, he said no, and that’s where our efforts ended.

I knew nothing about medication-assisted therapies for opioid addiction. Now I know better.

I was working part time in primary care when a colleague, the medical director at a local drug addiction treatment center, asked me if I could work for him at this center for a few days while he was out of town. He was a good friend so I agreed. I thought it would be easy money, and fun, doing admission histories and physicals on addicts entering the inpatient residential program, and I was right…but I also saw patients entering the clinic’s methadone program.

This appalled me. It seemed seedy, shady, and maybe a “fringe” area of medicine. It just seemed like a bad idea to give opioid addicts methadone. However, I had made a commitment to my friend, so I told myself I would work those few days, tell my friend politely when he returned that I didn’t “believe” in methadone (as if it were a unicorn or some other mythical beast) and could not work there again.

But when I talked to these patients they surprised and intrigued me. Some patients were intravenous heroin addicts, but most were addicted to pain pills, like OxyContin, various forms of hydrocodone, and morphine. Most of them had jobs and families, and expressed an overwhelming desire to be free from their addiction. I was most intrigued by how the patients talked about methadone treatment. They said such things as “It gave me my life back” and “Now I don’t think about using drugs all the time” and “Methadone saved my marriage and my life”.

Huh? With methadone, weren’t they still using drugs?

My curiosity piqued, I started reading everything I could find about methadone – and to my surprise discovered that the treatment of opioid addiction with methadone is one of the most evidence-based treatments used in medicine today, with forty years worth of solid data proving its efficacy. So why had I never heard of it? I could have referred many intravenous heroin addicts that I saw during my residency, which happened to be during the height of the spread of HIV, for effective treatment of their addiction. Because of methadone’s unique pharmacology, it blocks physical opioid withdrawal symptoms for greater than 24 hours in most patients, and also blocks the euphoria of illicit opioids. At the proper dose, patients should not be sedated or in withdrawal, and are able to function normally, working and driving without difficulty. Therefore, methadone maintenance is not “like giving whiskey to the alcoholic” as some ill informed people – like me – have accused.

For the next eight years I happily worked part time with my friend at this drug treatment center, and saw most methadone patients improve dramatically. Certainly methadone did not work for everyone, but it was a good treatment for many addicts. I did see some tough characters, but I was struck by how normal most of the patients seemed; most were not scary thugs as I had imagined, but housewives and construction workers.

Then I began hearing about a second medication to treat opioid addiction, called buprenorphine, better known by its brand name, Suboxone. The principle of this drug is the same as for methadone: it is a long-acting opioid, can be dosed once per day, and at the proper dose removes the physical withdrawal symptoms, and does not impair patients or give them a high. As an added bonus, it can be prescribed through a doctor’s office. In 2000, the Drug Addiction Treatment Act allowed doctors, for the first time in about 80 years, to prescribe specifically approved schedule III, IV, or V controlled opioid for the purpose of treating people with opioid addiction. Shortly after this, the FDA approved buprenorphine for the treatment of opioid addiction, and the drug became available in 2003. In order to prescribe buprenorphine, a doctor must take an eight hour training course, petition the DEA for a special “X” number, and give notice to CSAT, the Center for Substance Abuse Treatment, of her intent to prescribe. Doctors prescribing buprenorphine also must have the ability to refer patients for the counseling that is so necessary for recovery from addiction.

Buprenorphine, a partial opioid agonist, is a milder opioid and there’s a ceiling on its opioid effects, making it a safer and better choice for many patients than methadone. It is particularly good for addicts with relatively short periods of addiction, and fairly stable lives. Since it is a milder opioid, it is relatively easier to taper, if appropriate.

I started prescribing buprenorphine from a private office and loved it from the first. Initially, Suboxone was expensive, but now generic forms have been approved, and prices have come down a little. Opioid treatment programs, formerly known as “methadone clinics” have started offering buprenorphine in addition to methadone.

The opioid addicts I met both in the opioid treatment program and in my private office have not been what I expected. The vast majority are ordinary, likeable people with jobs and families. They are your hairdresser, your grocery clerk, the guy that works on your furnace. They sit beside you at the movies and behind you at church. Because they have built a tolerance to the sedating effects of opioids, they do not look impaired or high; they are able to function normally in society…as long as they have a supply of opioids.

If they are in withdrawal, without a source for opioids, they will be sick. Some people compare opioid withdrawal to having the flu, but it is not. It is like having the flu…and then being hit by a truck. Most addicts in opioid withdrawal are unable to work because of the severe muscle aches, nausea, vomiting, and diarrhea. Many of these patients are blue collar workers with physically demanding jobs who initially used pain pills to mask their physical pain so that they can work harder, better, faster…never guessing that what seemed to be helping was actually causing them more harm than they could imagine.

Some patients seen in the office setting were professionals. Most professionals can afford the more expensive inpatient thirty- to ninety- day rehabs, a luxury for many of the working middle class. But I saw some lawyers, nurses, even policemen with opioid addiction who refused to consider inpatient treatment even if they could afford it. These professionals were concerned about their livelihood if it became public that they had a problem with addiction, or because they were unwilling to take time off work. They were willing to come to a doctor’s office where no one would know why they were being seen, and they did very well on buprenorphine.

I am thrilled when seeing a patient respond positively to treatment with buprenorphine. Many return on the second visit looking like younger and happier versions of themselves. On the second visit, a common phrase is “It’s a miracle!” Many patients say they just feel normal, even though they had forgotten what normal felt like. When an addict begins to recover, the changes are usually dramatic; they begin to smile, to restore relationships, to rejoin their families and their communities. When an addict recovers, the ripple effect extends throughout the community.

We know now that addiction is indeed a chronic disease much like asthma and diabetes. Just like these diseases, there are behavior components that can make the disease worse, and there are genetic and personal factors that put some people at higher risk. Sadly, many addicts are still treated with distain and disgust by their doctors, an attitude we would not tolerate towards any other disease. This causes patients to hide addiction from their doctors, and the disease worsens.

Many people, even doctors, still object to the use of medication assisted therapies for addicts, saying “it’s trading one drug for another,”  when in reality it is trading active addiction for medication, when prescribed responsibly and appropriately. Drug-free recovery is ideal, but with opioid addiction, it does patients a disservice to dismiss the mountains of evidence proving the effectiveness of medication-assisted therapies with buprenorphine and methadone.

Detoxification alone (usually five to seven days) does not work, and shows relapse rates of up to 96%. If detoxification alone worked, the policy of imprisonment for addicts promulgated in the 1950’s would have solved the opioid addiction problem. It didn’t.

For most patients, their big question is: “How soon can I get off of this drug?” Most express a desire to be completely drug free at some point, but I think it’s important to get each patient involved in a recovery program before tapering their medication. This can be an intensive outpatient program at a treatment center, an individual therapist, or through 12-step recovery.

Some patients, particularly those with both opioid addiction and chronic pain, prefer to remain on buprenorphine or methadone indefinitely as the safest treatment for both problems, and these patients also seem to do very well.

As for me, I plan to continue treating addicts of all types. These patients have been among the most grateful that I have encountered in primary care, and show the most improvement. When I treat addicts and see peace return to a face that had been filled with shame, I get a unique feeling of accomplishment. These are events I am honored to witness.

 

September is National Recovery Month!

September is National Recovery Month, so it’s a good time to come back from my blogging break. Following are some things that 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.

….understanding it’s more important what I think of me than what other people think of me.

….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.

 

Things You Can Do to Reduce the Impact of Addiction in Your Community

Sometimes it’s frustrating to hear repeatedly on the news that opioid addiction is such a problem. It’s easy to feel helpless about the situation, and doubtful about how you can help. In this blog entry, I’m going to describe some very specific things you can do to reduce the impact of addiction on our society.

 If you are an addict, get help immediately. Many people have so much shame about becoming addicted that they’re mortified to seek help, fearing the stigma attached to addiction and to an admitted addict, so it takes tremendous courage to admit you have this problem. If you are getting medications from your doctor, tell her the truth. Tell her you are misusing the medicine and need help. She should be able to guide you to an appropriate addiction treatment center, to get an evaluation. At a good treatment center, you should be informed of all of your treatment options. This should include information on both medication-free treatment and medication-assisted treatment.

 If you are doctor shopping for prescriptions, stop it now. As more and more doctors use their states’ prescription monitoring database, sooner or later you will be discovered by one of your doctors. In my state of North Carolina, doctor shopping is a felony, because it’s considered using false pretenses to get a controlled substance. Instead, get treatment. If you’re selling these medications, stop it before you go to jail or kill someone.

 Get rid of all old medication in your cabinets, especially if they are controlled substances like opioid pain pills, sedatives, sleeping pills, or stimulants. According to a recent survey, most young people got their first opioid drug from friends or family. Many times, they took what they found in their parents’ medicine cabinets, or in their friends’ parents’ medicine cabinets. Some communities have regular “drug take back” days, where people bring unused medication for disposal. If you don’t have these in your community, you can wet the pills and mix them with coffee grounds or cat litter, and then throw them in the garbage. The coffee grounds and cat litter will deter addicts looking for medication. Don’t flush pills in the toilet, because there are fears the medication can enter our water supply.

 Don’t share your medication, with anyone, even family. In this country, sharing medication is so common people don’t realize it’s a crime. Some people feel that if it’s their medicine, and they bought it, they have the right to do with it what they want. This isn’t true. Giving controlled substances to another person is a crime, and dangerous as well. Selling a controlled substance is even worse. Speak up to friends and family, letting them know you don’t think it’s OK for Aunt Bea to give Jimmy one of her Xanax pill because his nerves are bad today. Jimmy needs to see his own doctor.

 Give your children clear and consistent anti-drug messages. Don’t glamorize your own past drug use, including alcohol, by telling war stories. It should go without saying, though I’m going to say it: don’t use drugs with your kids, including alcohol and marijuana. Also, don’t err in the opposite direction, and exaggerate the harms of drug use, because you’ll lose credibility with your kids. Some may remember how the film “Reefer Madness” was mocked. Talk to your kids in an age-appropriate way about drugs and alcohol, even if they don’t appear to be listening.

 If you have a family member addicted to prescription medication, call their doctor to describe what you see. The doctor probably can’t discuss your relative’s treatment, unless given permission, but your doctor can accept information. Write a letter, and be specific with what you’ve witnessed. If your loved one runs out of medication early and then buys off the street, let the doctor know.

 If you feel your addicted loved one is seeing an unscrupulous doctor, report what you know to your state’s medical board. These professional organizations are the best equipped to review a doctor’s pattern of care, to decide if the doctor is prescribing inappropriately. Charts are often reviewed by other doctors who decide if the standard of care is being met.

 Underage drinking is serious. For each year you can postpone your child’s first experimental drug use, including alcohol, you reduce his risk of addiction by around five percent. (1) Don’t involve your kids in your own alcohol consumption; for example, don’t send you kids to the refrigerator to get you a beer. Don’t allow adolescents to drink in your house, fooling yourself with the idea of, “At least I know where they are.” Not only is it illegal, but it’s harmful.

 Don’t use drugs or alcohol to treat minor emotional discomfort, unless you have discussed it with your doctor. For example, don’t use pain pills to help you sleep. Don’t use the Xanax your doctor prescribed for your fear of flying to treat the sadness you feel from breaking up with a boyfriend. Try to get out of the mindset that there’s a pill for every bad feeling, and try to help your friends and family see this, too.

 See a doctor for the treatment of serious mental illness. Some mental disorders are so severe that they require medication. There are many non-addicting medications that treat depression, anxiety, and other mental disorders. Getting the appropriate treatment has been shown to decrease your risk of developing an addiction to alcohol and other drugs.

 Monitor your adolescent’s friends. Youngsters with friends who use drugs are more likely to begin using drugs. Of course, most youngsters who experiment with drugs and alcohol won’t develop addiction, but the younger experimentation begins, the more likely it is that addiction will develop. Older siblings can be a good or harmful influence.

1. Richard K. Ries, David A. Fiellin, Shannon C. Miller, and Richard Saitz, Principles of Addiction Medicine, 4th ed. (Philadelphia, Lippincott, Williams, and Wilkins, 2009) ch.99, pp1383-1389.

Story of a Recovering Addict

Following is an interview that I did with a recovering addict. He now has over 13 years in recovery, and has a master’s degree in addiction counseling.  His history demonstrates how NA can help an addict, and illustrates some of the main tenants of 12-step recovery.

JB: What kinds of drugs did you use?

ML: Everything. I shot cocaine, Dilaudids, heroin, quarter-grain morphine tablets, and always alcohol. Alcohol and marijuana were just a given. They were daily.

JB: Can opioid addicts get clean just using NA?

ML: Yeah. My sponsor did, and other people [have].

JB: What percentage of people in NA used opioids?

ML: Back in1982, when I entered recovery, it seemed like seventy-five percent of people in NA used opiates. Then in the 1980s, more people addicted to crack came into NA, so now I’d estimate about fifty percent or less. But there’s no numbers [statistics kept by NA].

JB: How else has NA changed?

ML: Back in the early days of NA, most addicts hit a low bottom, before coming to NA, but now, with the growth of treatment centers, drug courts, information on the internet…when my father told me I had to leave the house unless I got help, I looked in the phone book and there were only two numbers to call for help. I called the Council on Alcoholism and got directed to AA. There’s been such a growth in [addiction treatment resources]. Every family has had experience with some kind of addiction. There’s more acceptance and knowledge now. People get to NA before they hit the kind of bottom that I did. That’s a good thing.

JB: How effective is NA? Some people say that only two percent of people who go to a twelve step meeting stay clean. What do you say to that?

ML: (laughs) I’d like to know where they got their numbers.

A lot of people get their start in NA and find other means to recover…other fellowships, churchs,…it’s an individual thing. It depends on what kind of living situation the individual is in, how willing the individual is [to get clean], and what kind of recovery the people at those [NA] meetings have. It depends on how deeply they get involved in that fellowship [NA].

In my case, I went to meetings for more than a year, but I didn’t work any steps. But I stayed clean, by going to meetings and getting support from the people at the meetings. Then I moved away and didn’t have that support. It didn’t take long for me to relapse. I was around old friends I used with, old sights and sounds…It takes more than just going to meetings to be successful. There are always exceptions, though. Some people have stayed clean for years that way.

In my case, the seed was planted. I wasn’t at a point where I could honestly look at my situation. So after I skinned my ass up [experienced consequences from using drugs], I went to inpatient treatment and then a halfway house. Plus meetings [Narcotics Anonymous and Alcoholics Anonymous]. I had a little more honesty, a little more willingness. But that second time, I didn’t work all the steps. I had three and a half years clean, got to the fourth step, and I relapsed. That relapse happened when my priorities shifted from going to meetings five or six times per week to relationships, working twelve hour days, hunting and fishing. Looking back, being surrounded by people in recovery was carrying me along.

It wasn’t long. I hadn’t experienced the change that comes from working all of the steps. It was only a matter of time before the self-deception set in. How in the hell could I talk myself into thinking I could sell dope, without using it? I was dissatisfied with my job, went traveling, and met “X.” He knew I’d hauled dope out of Florida in the past, for my brother in law. He asked about my connections and asked if I could help him move some kilos. I told him I still knew a few people, but I can’t be handling the stuff. I talked myself into believing I could sell that stuff and not use it. Insane.

That led to two and a half years in state prison. This put me in a controlled environment. I knew enough about recovery and the twelve steps and the change that can happen. I’d heard enough about it that I reached out and asked people I knew in NA to get me some [recovery reading] material. That was in 1988. They didn’t have as many 12-step meetings or substance abuse programs [in jail] then like they have now. I had to reach out and ask for help. I paid “Y” [an inmate] a candy bar so he would allow me to have an NA meeting in his cell, because it was the biggest. I paid a candy bar to him each meeting. He’d never been to a meeting in his life. This was in the county jail.

When we both got to state prison, they had NA meetings there. He got real involved. He got clean and is still clean today! He has twenty-one years in recovery, works in construction, and travels the world. I went to an AA meeting a few years ago, when I was visiting a town in Alabama, and it turned out he was speaking that night. He pointed to me and said, “That man is one of the reasons I’m here.” (At this point, ML tears up and takes a pause).

I had regular correspondence with friends, who sent me recovery literature. There was a “black market” step working guide. I used it and that’s the first time I did a “fearless and searching moral inventory” of myself. I didn’t have anyone to do my fifth step with [this is the step where the addict admits to God, himself, and another human being the exact nature of his wrongs].

At this point, I was in the county jail, about to go to state prison. This guy from Minnesota was in jail for thirty days for old warrants. It turns out he had a few years of recovery. He heard my fifth step and guided me through step seven. He mentioned his dad got [was sentenced to] forty years for murder. In the late 1970’s, when I was bringing cocaine out of Miami, the guy who set me up with the Columbians was named “Z”. I would meet him in a field [to exchange drugs] and he had a young boy with him. The guy who heard my fifth step was his son!

I’d been going in the front door of this state prison for six years, as an NA member, bringing meetings to the prisoners. Now I was in that prison. I progressed on through the steps, and experienced a change in my being…a real deep change that I can’t put into words. I recognized it was the beginning of a change that would continue to occur over a lifetime.

I relapsed once more, after nearly ten years clean. I got away from people in recovery, quit doing all the things I’d done on a regular basis, like prayer and meditation, meetings, contact with people in recovery. That relapse lasted a year. I was rescued by the Macon County Sheriff’s Office. I knew I was going to die. I was waiting for the overdose, the gunshot, whatever. I had no hope.

An addict always has the potential for relapse. I don’t care who they are, where they are, how long they’ve been clean or whatever. But once I experienced change on a deep level, mentally, emotionally, spiritually, and then used drugs again…you’re not the same addict. You don’t have the hustle. You can’t be as thoughtless, selfish, and solely self-focused as you were, before you experienced that change. I knew I couldn’t use drugs successfully, and I knew it was going to kill me. But when I lost that support, when I pushed away that foundation, that God of my understanding…That allows self-deception. It might be only momentarily, but you forget. You forget who you are, and if you’re where substances are available, you’re deceived.

JB: How’s your recovery now?

ML: Awesome. If you’d asked me in 1999 how I’d be doing now, I wouldn’t have gotten close. My life today is better than it’s ever been. I’m extremely blessed and grateful to be where I’m at today. I’m blessed to have the work, the people, a wonderful fiancée … I’m blessed to be able to share my life with the people I have in my life.

JB: What kind of work do you do?

ML: I work as a counselor. I work in a jail’s substance abuse treatment program. Looking at what they have available in jails now…fully staffed treatment programs, right in the county jail! From having to pay a candy bar to hold a meeting to where they have whole dorms in the county jail to treat addiction…the change has been awesome to see.

            This addict, ML,  described how his recovery progressed over time, and how he had setbacks and relapses. Obviously, given the morbidity and mortality of active addiction, treatment professionals and addicts prefer relapse-free recovery, but for many, relapse is part of the recovery process. Many fortunate addicts are able to get back into recovery, before catastrophe occurs.

ML is also a good example of how 12-step recovery meetings can help. Addiction treatment professionals should always inform addicts seeking recovery about these meetings, and encourage addicts to go to at least a half-dozen meetings, before deciding if 12-step recovery is right for them or not.

There are many recovering opioid addicts who used 12-step resources or other counseling to become completely opioid free and were able to get through both the acute physical opioid withdrawal and the more prolonged post-acute opioid withdrawal. Therefore, it does appear that drug-free recovery may be a reasonable goal for some opioid addicts who are motivated to do the work of recovery. For addicts who find the spiritual theme of 12-step recovery unacceptable, secular recovery groups are available.

            12-step recovery is free, widely available, and proven to work. It’s still the best deal in town.

“My Favorite Patients Are Addicts”

Feeling exceptionally lazy today, Idecided to post a blog containing an article I wrote for the physician magazine Medical Economics. It was published in April of 2010, and I got some great feedback from other doctors. And since I’m a wannabe writer, I also submitted it to the annual Writers Digest writing competition under magazine article, and I won 8th place. I was over the moon about this, because this is a huge competition. I got a certificate which I framed and put on the top of my bookcase at home. I’m prouder of this article than anything else I’ve written, because I was able to be heard by people in my profession. If you prefer, you can go right to the magazine’s site: http://medicaleconomics.modernmedicine.com/memag/issue/issueDetail.jsp?id=18947

Here it is:

When I was a fresh faced, newly unleashed graduate from my Internal Medicine residency nineteen years ago, I never dreamed my favorite patients would be drug addicts.

In medical school, I learned little about drug and alcohol addiction and its treatment, and in residency, even less. I was well trained in the management of acute alcohol withdrawal, acute GI bleeding from alcoholic gastritis, and antibiotic coverage of endocarditis in an injection heroin user, but I couldn’t tell any of these patients how to find recovery from the actual underlying cause of their problems. I could only treat the sequellae, and I didn’t always do that with much grace.

The addicted person caused their own miseries, I thought, and since these were the Reagan years, they should “just say no” when offered drugs. My attitudes mirrored those of the attending physicians in my residency program. When an addict was admitted twice for endocarditis, needing an artificial valve the first admission, and its replacement on the second admission for re-infection, I was just as irritated as the attending and the rest of the house staff. I remember we discussed whether we could ethically refuse him treatment if he came in a third time! We were so self-righteous, though we had offered him little in the way of treatment for his disease of addiction. We might have had a social worker ask him if he wanted to go away for inpatient treatment, he said no, and that’s where our efforts ended.

I knew nothing about medication-assisted therapies for opioid addiction. Now I know better.

I was working part time in primary care when a colleague, the medical director at a local drug addiction treatment center, asked me if I could work for him at this center for a few days while he was out of town. He was a good friend so I agreed. I thought it would be easy money, and fun, doing admission histories and physicals on addicts entering the inpatient residential program, and I was right…but I also saw patients entering the clinic’s methadone program.

This appalled me. It seemed seedy, shady, and maybe  a “fringe” area of medicine. It just seemed like a bad idea to give opioid addicts methadone.  However, I had made a commitment to my friend, so I told myself I would work those few days, tell my friend politely when he returned that I didn’t “believe” in methadone (as if it were a unicorn or some other mythical beast) and could not work there again.

But when I talked to these patients they surprised and intrigued me. Some patients were intravenous heroin addicts, but most were addicted to pain pills, like OxyContin, various forms of hydrocodone, and morphine. Most of them had jobs and families, and expressed an overwhelming desire to be free from their addiction. I was most intrigued by how the patients talked about methadone treatment. They said such things as “It gave me my life back” and “Now I don’t think about using drugs all the time” and “Methadone saved my marriage and my life”.

Huh? With methadone, weren’t they still using drugs?

My curiosity piqued, I started reading everything I could find about methadone – and to my surprise discovered that the treatment of opioid addiction with methadone is one of the most evidence-based treatments used in medicine today, with forty years worth of solid data proving its efficacy. So why had I never heard of it? I could have referred many intravenous heroin addicts that I saw during my residency, which happened to be during the height of the spread of HIV, for effective treatment of their addiction.  Because of methadone’s unique pharmacology, it blocks physical opioid withdrawal symptoms for greater than 24 hours in most patients, and also blocks the euphoria of illicit opioids. At the proper dose, patients should not be sedated or in withdrawal, and are able to function normally, working and driving without difficulty. Therefore, methadone maintenance is not “like giving whiskey to the alcoholic” as some ill informed people – like me – have accused.

For the next eight years I happily worked part time with my friend at this drug treatment center, and saw most methadone patients improve dramatically. Certainly methadone did not work for everyone, but it was a good treatment for many addicts. I did see some tough characters, but I was struck by how normal most of the patients seemed; most were not scary thugs as I had imagined, but housewives and construction workers.

Then I began hearing about a second medication to treat opioid addiction, called buprenorphine, better known by its brand name, Suboxone. The principle of this drug is the same as for methadone: it is a long-acting opioid, can be dosed once per day, and at the proper dose removes the physical withdrawal symptoms, and does not impair patients or give them a high. As an added bonus, it can be prescribed through a doctor’s office.

In 2000, the Drug Addiction Treatment Act allowed doctors, for the first time in about 80 years, to prescribe specifically approved schedule III, IV, or V controlled opioid for the purpose of treating people with opioid addiction. Shortly after this, the FDA approved buprenorphine for the treatment of opioid addiction, and the drug became available in 2003. In order to prescribe buprenorphine, a doctor must take an eight hour training course, petition the DEA for a special “X” number, and give notice to CSAT, the Center for Substance Abuse Treatment, of her intent to prescribe. Doctors prescribing buprenorphine also must have the ability to refer patients for the counseling that is so necessary for recovery from addiction.

Buprenorphine, a partial opioid agonist, is a milder opioid and there is a ceiling on its opioid effects, making it a safer and better choice for many patients than methadone. It is particularly good for addicts with relatively short periods of addiction, and fairly stable lives. Since it is a milder opioid, it is relatively easier to taper, if appropriate.

I started prescribing buprenorphine from a private office and loved it from the first. I did notice that the demographics of office patients were different from the methadone clinic; unfortunately Suboxone is expensive, at a minimum of $6 per 8mg pill, and some patients needed up to four pills per day. It became evident that only people of financial means or medical insurance were able to afford the office visit, the medication, drug screens and other lab tests, and individual counseling. At methadone clinics, most patients are self pay and could pay a day at a time, usually a fee of $10 – $15 per day. All services were bundled into that one daily charge.

The opioid addicts I met both in the methadone clinic and in a private office have not been what I expected. The vast majority are ordinary, likeable people with jobs and families. They are your hairdresser, your grocery clerk, the guy that works on your furnace. They sit beside you at the movies and behind you at church. Because they have built a tolerance to the sedating effects of opioids, they do not look impaired or high; they are able to function normally in society…as long as they have a supply of opioids.

If they are in withdrawal, without a source for opioids, they will be sick. Some people compare opioid withdrawal to having the flu, but it is not. It is like having the flu…and then being hit by a truck. Most addicts in opioid withdrawal are unable to work because of the severe muscle aches, nausea, vomiting, and diarrhea. Many of these patients are blue collar workers with physically demanding jobs who initially used pain pills to mask their physical pain so that they can work harder, better, faster…never guessing that what seemed to be helping was actually causing them more harm than they could imagine.

Some patients in the office were professionals, though not many. Most professionals can afford the more expensive inpatient thirty- to ninety- day rehabs, a luxury for many of the working middle class. But I saw some lawyers, nurses, even policemen with opioid addiction who refused to consider inpatient treatment even if they could afford it. These professionals were concerned about their livelihood if it became public that they had a problem with addiction, or because they were unwilling to take time off work. They were willing to come to a doctor’s office where no one would know why they were being seen, and they did very well on Suboxone.

I am thrilled when seeing a patient respond positively to treatment with buprenorphine.  Many return on the second visit looking like younger and happier versions of themselves. On the second visit, a common phrase is “It’s a miracle!” Many patients say they just feel normal, even though they had forgotten what normal felt like. When an addict begins to recover, the changes are usually dramatic; they begin to smile, to restore relationships, to rejoin their families and their communities. When an addict recovers, the ripple effect extends throughout the community.

We know now that addiction is indeed a chronic disease much like asthma and diabetes. Just like these diseases, there are behavior components that can make the disease worse, and there are genetic and personal factors that put some people at higher risk. Sadly, many addicts are still treated with distain and disgust by their doctors, an attitude we would not tolerate towards any other disease. This causes patients to hide addiction from their doctors, and the disease worsens.

Many people, even doctors, still object to the use of medication assisted therapies for addicts, saying “it’s trading one drug for another”, when in reality it is trading active addiction for medication, when prescribed responsibly and appropriately. Drug free recovery is the ideal, but with opioid addiction, it does patients a disservice to dismiss the mountains of evidence that medication assisted therapies of buprenorphine and methadone work for many opioid addicts who cannot or will not go to inpatient treatment programs of 30 to 90 days. Detoxification alone (usually five to seven days) does not work, and shows relapse rates of up to 96%. If detoxification alone worked, the policy of imprisonment for addicts promulgated in the 1950’s would have solved the opioid addiction problem. It didn’t.

For most patients, their big question is: “How soon can I get off of this drug?” Most express a desire to be completely drug free at some point, but I try to get them directed into a recovery program of some sort for counseling first. This can be through an intensive outpatient program at a treatment center, an individual therapist, or through 12-step recovery. Many patients who chose 12-step recovery seem to be able to taper off buprenorphine (or methadone) and remain abstinent from all drugs; they also seem to be the most satisfied with their lives in recovery.

Some patients, particularly those with both opioid addiction and chronic pain, prefer to remain on buprenorphine indefinitely as the safest treatment for both problems, and these patients also seem to do very well.

As for me, I plan to continue treating addicts of all types. These patients have been among the most grateful that I have encountered in primary care, and show the most improvement. When I treat addicts and see peace return to a face that had been filled with shame, I get a unique feeling of accomplishment. These are events I am honored to witness.