Feeling exceptionally lazy again today, I decided 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 in the magazine article category, 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.
Here it is:
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.