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.

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Walmart in North Wilkesboro, NC, Refuses to Fill Buprenorphine Prescriptions

 

 

When one of my patients told me he could no longer fill his prescription for Suboxone films at Wal-Mart, I was puzzled. Surely this couldn’t be true, especially not in an area of the country where people die from opioid use disorder too frequently.

My patient said, and I have no way of verifying this information, that the DEA visited  the Walmart in North Wilkesboro, NC, and told them if they continue filling prescriptions from the doctor at the pain clinic, they would be accused of some sort of collusion. In response, the Wal-Mart – allegedly – decided not to stock any form of buprenorphine.

Yes, my fingers itched to call Walmart to determine if this was true.

Completely in keeping with Walmart’s reputation for efficiency, I was cut off the first two times I asked to speak to a pharmacist. On my third try, I left my cell number and asked the pharmacist to call me. Surprisingly, he did call, after only fifteen minutes or so.

I asked him if it was true that Walmart no longer fills buprenorphine prescriptions, and he said yes, that’s true. I asked was that for all forms of buprenorphine, including the films, Zubsolv, generics, etc., and he said yes, all of them. He was obviously reticent to give any further information. I asked him if that was for one doctor, and if my patients could still fill prescriptions there. Again, he answered that Walmart had decided not to stock any buprenorphine  products for any patient or doctor. Starting to feel a little riled, I asked him if he thought that decision would interfere with appropriate treatment of a potentially fatal illness, he just repeated Walmart had decided not to stock buprenorphine at all.

So that’s that, right?

I don’t think so.

At a time when Congress passed CARA, the Comprehensive Addiction Recovery Act, which contained specific provisions to increase access to buprenorphine, Walmart’s pharmacy refuses to sell buprenorphine?

At a time when Health and Human Services passes a new law enabling physicians to have up to two-hundred and seventy-five patients instead of only one hundred patients, Walmart’s pharmacy refuses to sell buprenorphine?

During the same week that NIDA, the National Institute on Drug Abuse, announces increased access to buprenorphine will help the opioid overdose epidemic, Walmart’s pharmacy refuses to sell buprenorphine?

Can buprenorphine be misprescribed and misused? Yes, of course it can. Not as often as all other opioid pain medications, but it can be misused. But I don’t know of any pharmacy that refuses to stock all opioids just because some patients misuse them. That’s not appropriate. Walmart hasn’t stopped selling prescriptions for Opana, oxycodone, hydrocodone, Xanax, Valium, or clonazepam.

So can’t we – and by we, I mean the brain trust that is Walmart –  think of a better option than refusing to sell buprenorphine to any patient, rather than pinpointing the real problem?

I wanted to hear the reasoning behind this decision, so I called Walmart’s corporate office, the division of Media Relations. I told the nice lady answering the phone that I was a doctor who treated addiction, and that I also had a blog. I told her about the local Walmart pharmacy’s unusual decision, and I wanted to hear Walmart’s side. I wanted to know the reason Walmart decided not to stock buprenorphine in the middle of an opioid use disorder crisis.

I waited on hold for a long while, and then the lady, Delores, said she didn’t have any information on this but that she would look into this and call me back. I gave her my cell phone and I’m still waiting.  Since this was all done on a Friday afternoon, I’m not surprised I didn’t get a return call yet.

I’m going to make some noise about this one. I’ll keep you posted.

In the meantime, I’m not going to spend any money at Walmart. I know Walmart won’t miss the couple of hundred dollars my family spends each month on household items and some groceries. But if you see me at Food Lion, Lowe’s Foods, or even better, the IGA, you’ll see a smile on my face as I check out. My decision won’t break them, but it will make me feel better.

Who Should NOT Be in Medication-Assisted Therapy with either Methadone or Buprenorphine?

I spend much time and effort explaining how medication-assisted treatment for opioid addiction works for many addicts. It occurred to me that I should explain who isn’t a good candidate for such treatment.

I enthusiastically support medication-assisted treatment (MAT) of opioid addiction, but no treatment works for everyone. MAT doesn’t work for every opioid addict. Here are some reasons a patient may not be suitable for MAT:

1. The patient isn’t addicted to opioids. That seems obvious, but occasionally I encounter an addict who wants to be started on methadone even though he’s not addicted to opioids. Rarely, an addict using cocaine, benzodiazepines or other drugs will come to the OTP after they have heard how well it worked for other (opioid) addicts. After I explain that buprenorphine (Suboxone) and methadone only work on opioid addiction, some of these patients have become angry.

One patient accused me of discriminating against her because of the type of drug she used. I said yes, but only because methadone doesn’t treat cocaine addiction. (I tried to refer her for more appropriate treatment.)

2. The patient takes opioids for pain, but has never developed the disease of addiction.
Such a patient may be physically dependent, but lacks the hallmark indicators of addiction, such as misuse of medication, obsession and compulsion regarding opioids.

Opioid treatment programs, (OTPs) have stringent regulations put on them by both federal and state government, because OTPs are designed to treat patients with addiction. These patients have lost the ability to control their intake of opioids, so the OTP regulates a maintenance dose of either methadone or buprenorphine to keep the patient out of withdrawal and able to function normally.

If a patient has only pain and no addiction, there’s no reason to enroll in an opioid treatment program, because patients without addiction are still able to take opioid medication as prescribed. Pain medication can be prescribed by any doctor with a DEA license.

Opioid treatment programs aren’t intended to treat chronic pain, but if a patient with both addiction and chronic pain finds methadone also helps with pain, it’s a nice benefit. Many of these patients do find they have less pain once they’re out of the miserable cycle of intoxication and withdrawal. So less pain is a happy side effect of addiction treatment.

3. The opioid addict presenting for treatment has been physically dependent for less than one year.
Methadone is difficult to get off of, and federal and state regulations say it cannot be prescribed for opioid addicts with less than one year of addiction (daily use or near daily use). This is a somewhat arbitrary cut off, and the OTP physician can ask for an exception to this regulation if needed. Even if the OTP wants to treat the patient with buprenorphine (Suboxone), which is usually much easier to taper off of than methadone, permission must be sought from state and federal authorities before enrolling a patient who has used opioids less than one year.

If buprenorphine is prescribed in the office setting, the prescribing physician can use her best judgment about who is appropriate for treatment, without needing government approval.

4. The opioid addict has the ability to go to a prolonged inpatient residential treatment program for his addiction.
This is controversial, because some doctors think medication-assisted treatment should be given to everyone because of its success rate compared to abstinence-only treatments.

But who gets the best of medical treatment in our country? Possibly it is medical professionals like doctors and dentists, airline pilots, politicians, and celebrities. They usually get the gold standard of treatment for whatever disease ails them.

If such people have opioid addiction, they are treated with inpatient medical detox, using buprenorphine to ease withdrawal, followed immediately with prolonged inpatient residential drug addiction treatment. I know doctors and dentists who spent six to nine months in treatment. After treatment, they must sign monitoring contracts with their licensing boards in able to go back to work. These contracts usually involve a mandated number of group sessions per week and random drug testing. With this kind of support and accountability, these medical professionals have excellent outcomes. Studies show that more than 80% are still off all drugs and alcohol at five years after entering treatment.

If only everyone could get that kind of treatment!

If this kind of treatment is available to the addict…take advantage of it. But most opioid addicts can’t access this kind of treatment, with post-treatment accountability. Insurance companies might pay for a one-week stay in detox, which won’t help. Even if the addict gets a few weeks of inpatient treatment, it’s usually not enough. What I’m talking about is months of quality inpatient treatment.

5. An opioid addict who is also physically addicted to alcohol, benzodiazepines or other sedatives. These drugs can be deadly when mixed with methadone or buprenorphine. I prefer such patients enter a medical detox unit to get off these sedatives prior to entering treatment in an OTP.

Of course this is a complex issue, and there may be times when starting methadone or buprenorphine can be done, perhaps keeping the patient at a relatively low dose, while the patient undergoes a gradual taper from benzos. The OTP physician should be free to use her best judgment about how to treat these complex and high-risk patients.

6. The opioid addict also has acute, severe mental illness. An actively suicidal patient is too sick for an outpatient opioid treatment program. So is an acutely psychotic patient who is having hallucinations and delusions. These patients often can’t to understand what is real and what isn’t. Ideally these patients need inpatient treatment at a facility that will treat both mental illness and addiction. Sadly, it’s getting ever harder to find such facilities for patients who need them.

7. A patient has behavior that interferes with treatment.
OTPs have an obligation to all their patients to maintain a safe and orderly treatment environment. Patients who start physical fights, threaten staff or other patients, or sell drugs shouldn’t be kept in treatment. I know that sounds harsh, but OTPs have a hard enough time maintaining good standing in their communities without having to face accusations about illegal behavior on premises.

Patients need to be emotionally stable enough to conduct themselves in a non-threatening manner to be able to remain in treatment. Some patients, after being counseled about acceptable behavior, are able to comply with requests for behavioral changes. Some patients have erratic behavior due to mental illness, and shouldn’t be blamed, but their behavior still may be too disruptive for the OTP setting.

8. The patient has serious co-existing physical health problems.
Actually, I can’t think of any physical health problem that would make the treatment of opioid addiction with methadone riskier to the patient than untreated opioid addiction. We know for sure that untreated opioid addiction produces high risk of death and disability.

Issues like severe lung disease and specific heart rhythm problems do increase the risk of medication-assisted treatment, especially with methadone. I try to contact the patient’s other doctors and consult with them before the patient goes above a low dose of methadone.

Ideally, I’d like to talk to the other doctors on the day of admission, before methadone is started, but that can’t always be done. With the time pressures doctors are under, it’s getting ever harder to claim some of their time for a patient consultation.

Some of these patients could be started on buprenorphine instead of methadone, which is safer with these health conditions, and has fewer medication interactions.

9. The patient has transportation difficulties.
Some patients can’t get a ride to their treatment program every day, which interferes with delivery of quality treatment. With buprenorphine, federal requirements for daily dosing were lifted, but states still have varying regulations. With methadone, the patient must come for treatment daily. During the first two weeks of stabilization, it’s important for medical personnel to be able to evaluate the patient every day, to assess the effects of dose increases.

10. A patient who enters treatment expecting to be completely drug free in the near future.
I try to make sure patients entering treatment with methadone or buprenorphine understand that I am not switching them from illicit opioids to these medications because tapering off of them is easier. Particularly with methadone, it is not. But both methadone and buprenorphine are so long-acting, they can be dosed once per day, giving the patient a steady level of opioids. This allows the addict to function normally, without withdrawal or impairment, once the dose has stabilized.

Both medications give the opioid addict time to regain physical and mental health. Once on a stable dose, the recovering addict can make changes in his life, with the help of counselors and other OTP workers. The addict can get back to work, stop a life of crime, form better relationships with his family and himself, and recover a better quality of life.

Will that addict ever do well off methadone? There’s no way to be sure about this. Some patients can taper off methadone, as long as they address all of their issues prior to the taper, and if they bring the dose down slowly enough that they don’t feel intolerable withdrawal. Some, perhaps most, recovering addicts find they will do better if they stay on methadone.

All this is to say that the goal of entering an opioid treatment program isn’t necessarily to
get off the treatment medication.

So if a patient seeks to enter methadone treatment but also expresses a desire to be off buprenorphine or methadone within weeks to months, I tell them their expectations aren’t realistic. These medications don’t work like that. If the patient wants to get off all medications quickly, they need referral to an inpatient program. This way, patients can’t later say they were mislead, and they feel like they have liquid handcuffs, chained forever to methadone, with its many regulations for treatment.

New Form of Suboxone: Dissolving Film

Yesterday the FDA approved a new delivery system for the medication buprenorphine. Reckitt Benckiser, the drug company that makes the brands Suboxone (a combination pill of buprenorphine and naloxone) and Subutex (containing only buprenorphine), is now approved to manufacture and sell Suboxone in the form of a thin film that is placed under the tongue to be absorbed. According to early studies, patients think the film tastes better, dissolves more quickly, and is easier to use. I don’t yet have any information on the relative cost of this new film.

Since it was just approved, it’s not likely that a generic form of the film will be available for many years.

 This film of buprenorphine, the active ingredient, can’t be obtained as a generic, and it may be a few weeks before it appears in retail pharmacies.

 I’m hoping the sublingual (under the tongue) film will be harder to snort or inject, because there are reports of addicts misusing the Suboxone and Subutex tablets. And every addict misusing the name brands or the generic of buprenorphine who comes to the attention of law enforcement endangers the existence of the buprenorphine program.

 In the past I worried about prescribing Subutex, the form of the drug that doesn’t contain naloxone, or the newer generic buprenorphine, which also doesn’t contain naloxone. But apparently, some addicts are able to inject Suboxone, and the naloxone in it doesn’t put them into withdrawal. At least, they don’t go into intolerable withdrawal.

 It just shows me again that people are so different in the way they react to medications.

Which is better, Suboxone or methadone?

 

Patients often ask which medication is better to treat opioid addiction: methadone or Suboxone? My answer is…it depends.

 First of all, the active drug in Suboxone is buprenorphine, and I’ll refer to the drug by its generic name, since a generic has entered the market. We’re no longer just talking about one name brand.

 The principle behind both methadone and buprenorphine is the same: both are long-acting opioids, meaning they can be dosed once per day. At the proper dose, both medications will keep an opioid addict out of withdrawal for 24 hours or more. This means instead of having to find pain pills or heroin to swallow, snort, or shoot three or four times per day, the addict only has to take one dose of medication. Addicts can get back to a normal lifestyle relatively quickly on either of these medications. Both methadone and buprenorphine are approved by the FDA for the treatment of opioid addiction, and are the only opioids approved for this purpose.

Buprenorphine is safer then methadone, since it’s only a partial opioid. A partial opioid attaches to the opioid receptors in the brain, but only partially activates them. In contrast, methadone attaches to opioid receptors and fully stimulates them, making it a stronger opioid. Because buprenorphine is a partial opioid, it has a ceiling on its opioid effects. Once the dose is raised to around 24mg, more of the medication won’t have any additional effect, due to this ceiling. But with methadone, the full opioid, the higher the dose, the more opioid effect.

 Because buprenorphine is a safer medication, the government allows it to be prescribed in doctors’ offices, but only if the doctor has taken a special training course in opioid addiction and how to prescribe buprenorphine, or can demonstrate experience with the drug. This office-based treatment of addiction has a huge advantage over treatment at a traditional methadone clinic. Treatment in a doctor’s office doesn’t have to follow the strict governmental regulations that a methadone clinic must follow. Methadone clinics have federal, state, and even local regulations they must follow, and patients have to come to the clinic every day for dosing, until a period of months, when take home doses can be started for weekends.

 The law allowing buprenorphine to be prescribed for opioid addicts from offices instead of clinics was passed in 2000. It was hoped that relatively stable opioid addicts would get treatment at doctors’ offices, and addicts with higher severity of addiction would still be treated at methadone clinics.

 But it hasn’t worked out quite like that. Because buprenorphine is relatively much more expensive than methadone, addicts with insurance or money go to buprenorphine doctors’ offices, and poor addicts without insurance go to methadone clinics. Rather than form of treatment being decided by severity of disease, it’s decided by economic circumstance. This means that some of the opioid addicts being treated through doctors’ offices really aren’t that stable, and have been selling their medication, making it a desirable black market drug. Most of the addicts buying illicit buprenorphine have been trying to avoid withdrawal or trying the drug before paying the expense of starting it.

 Treating opioid addicts for the last nine years, I’m continually surprised at how people’s physical reactions to replacement medications are dissimilar. Some patients don’t feel well on buprenorphine, but feel normal on methadone. For other patients, it’s just the opposite. For many, either medication works well.

 Addicts (and their doctors) tend to assume that all opioid addicts will be the same in their physical reactions to these replacement medications, but they aren’t. For example, last week I saw a lady who insisted she’s never had physical withdrawal symptoms from methadone. But most patients find methadone withdrawal to be the worst of all opioids.

 And sometimes I have a patient I expect will do very well on buprenorphine, but they don’t. they feel lousy.

 So the answer to question of which medication is best – buprenorphine is safer, and not as strong an opioid, so it’s the preferred medication. It’s also more convenient, but much more expensive at present. But a great deal depends on the patient, and how she reacts to medications.

 Neither medication is meant to be the only treatment for opioid addiction. Best results are seen when these medications are used along with counseling, to help the addict make necessary life changes.

Interview with a Suboxone Doctor

The following is an interview with one of the first prescribers of Suboxone in Charlotte, North Carolina. Dr. George Hall is an experienced physician, board certified in both Family Practice and Addiction Medicine, who has worked in both fields for many years and helped countless addicts and their families:

JB: What have your experiences been, treating opioid addiction with buprenorphine, or Suboxone?

GH:   It’s been pretty incredible from day one…….watching people, and the difference it’s made in their lives, when they come on buprenorphine.

JB: Of the patients you’ve started on buprenorphine, what percentage would you say improved on it?

GH: Ninety-plus percent, I would think. You’ll have the occasional patient who doesn’t come back, and an occasional patient who can’t afford it, but there’s not many that stand out in my mind through the years [who have done poorly with buprenorphine].

JB: Can you describe how you decide to do a detoxification with a patient on buprenorphine, versus keeping the patients on it for longer, and what your experiences have been?

GH: The people I detox on buprenorphine are the ones who have to come off of it in a short period of time. They say, “I want off by one month or two months or three,” and generally those people actually change their mind over a period of time, as they see their life getting better.

So, most of the time, it’s patient-driven. As you know, the data for opiate dependency shows that this population just doesn’t seem to do very well. Perhaps that’s the reason I have such a positive feeling about buprenorphine. We’ve used it for maintenance, since day one, in a lot of patients, and those are the people whose lives you see continue to change over a long period of time.

JB: Are there any problems that you’ve seen with buprenorphine?

GH: I think the problem with buprenorphine is similar to the problem with methadone …we see these people getting extremely well. They don’t get euphoric, but they’re not ill any longer. They’re able to function, they’re able to sleep. It’s a long-acting medication that allows them to have a normal day. When they’re out on the street or they’re buying from the internet or they’re going to multiple doctors, they just don’t have normal days.

So is that a problem? Only if you define any sort of recovery as abstinence-based. But, if you’re defining recovery as improvement in quality of life, not using other substances, able to hold jobs, able to have families and interact with families, treat their depression, then these people do extremely well.

But…I think the problem for me is…..once they begin to do so well, it’s just like with anything else, whether it’s an alcoholic or a cocaine addict or a marijuana addict that’s been in recovery for a period of time. The acuity of the disease drops in the patient’s mind, and it seems like they think, “I’m cured,” and “I’m just normal now so I don’t need to do other things. I don’t need to go to NA meetings. I don’t need counseling. Why do you keep pushing me to do this, because I haven’t used in two years? I’m doing great.”  Whether this is the disease talking to them or it’s just part of life…

And that’s what I see with any addiction…the disease itself says you don’t have a disease, whether it’s alcohol dependency or opiate dependency, and perhaps we see that even more with opiate dependency. We see that on maintenance therapy.

JB: If you had an opiate addicted patient who had unlimited money, time, willingness, and resources, what treatment would you recommend first? If they were addicted only to opiates?

GH: When I think about that question, I think about gold standards of treatment. The people who have the highest recovery rates are professionals. Physicians in North Carolina have over a ninety percent recovery rate at five years. It’s not because they’re physicians, it’s not because they’re brilliant, it’s because they’re made to do a lot of stuff to help convince them they have an illness, and to treat it as an illness on an ongoing basis. They are made to do at least twenty-eight days, to three months, to six months of inpatient treatment, most of them from the beginning. If we had an IV opiate-addicted anesthesiologist, [he would get] probably at least twelve weeks of inpatient treatment, monitoring, and perhaps even a job change. So [addicted doctors] do extremely well. Not that they have unlimited funds, but if they want to remain a physician, they have to do certain things.

So that kind of brings me around to what you’re asking. If money were no object, I would think fairly long term – two to four months of inpatient treatment, with a slow detox with something such as buprenorphine, which is a very soft detox compared to some of the ones we’ve used in the past – followed up by intensive group therapy,  and then getting them involved in 12-step recovery programs. And after we bring them out of inpatient treatment, [they would get] some sort of follow up over a period of one to two years if we are looking at unlimited funds, and the willingness to do that. Which isn’t practical in the general population.

JB: Because of the expense and time?

GH: Because of the expense and the time we have.

Methadone Clinics Behaving Badly

Not all methadone clinics are equal. We know what qualities are associated with the best outcomes, and hopefully every clinic is trying to improve.

First, many clinics should be called “opioid treatment centers,” because they offer more than methadone; they also prescribe and dispense buprenorphine. In the future, buprenorphine will likely be the first line treatment for opioid addiction replacement medication, with methadone saved for people who don’t do well on buprenorphine, usually because it’s not strong enough. In the very near future, buprenorphine may replace methadone as the treatment of choice for opioid-addicted pregnant patients.

Besides the ability to offer buprenorphine, the best clinics have well-trained staff with low turnover. This seems obvious. It’s difficult for a patient to participate in counseling with enthusiasm when they’ve had three different counselors within four months. Sadly, this is an area of counseling that has difficulty retaining counselors.

 And while we always need to be open to learn from our patients, a counselor should already know the basics about opioid addiction and its treatment with replacement medications before he sees the first patient. I’ve heard the occasional counselor voice doubts about the benefits of replacement medications. If the counselor can’t wholeheartedly support their patients, they need to go back and read the basic research, or move on to a different field. An ambivalent and uninformed counselor can taint the treatment milieu at an otherwise good clinic.

Doctors prescribing the methadone or buprenorphine should be willing to give adequate doses. Clinics who were stingy with dosing had worse patient outcomes in many studies. In the past, clinics were reluctant to dose above 60 or 70mg, but we know now that patients do better at adequate doses, and there’s a wide variation between patients as to what’s an adequate dose. Most patients stabilize on between 80 to 120mg, but some need much more and some need much less. Cookie cutter dosing isn’t best practice.

Counselors shouldn’t have overwhelming caseloads. The regulations say each counselor should have no more than 50 patients, but even that’s too many with the growing documentation requirements.

Clinics shouldn’t let a few patients, not doing well and causing chaos in the community, to remain in the clinic, dosing daily with methadone or buprenorphine. The reputation of opioid treatment centers is too important and too fragile. In many communities, laws have been passed to limit the number and type of drug addiction treatment centers, because of the community’s perception that the patients will create havoc locally. In reality, very few patients behave like this, but the ones that do create the illusion that all patients will drive while impaired, or shoplift at local stores. Some patients are too sick or too unwilling to do well at an opioid treatment center. These centers owe it to their other patients and their community to refer patients doing poorly to other options.

Now for the number one most important factor that determines how well a patient will do while in treatment at an opioid treatment center…a warm and empathetic relationship with treatment center staff. This means all staff, not just their counselor. It includes the nurses and doctors and clerical staff.

It appears that behavioral change with addiction is more likely to occur when the people trying to help are caring and compassionate.

What an epiphany of the obvious.