I’ve written this blog article several times. I deleted one version because it sounded too mean, and another version because it was too shallow and unrealistic. It’s a difficult subject. Talking about people with substance use disorder who lie has potential to feel accusatory and judgmental, but lying is part of the behavior of people in active addiction.
Some medical professionals see lying as a character flaw and prefer not to treat patients with addiction because of this trait. They feel patients with substance use disorders lie more than patients with other disorders. I’m not sure that’s necessarily true, since I remember lies of patients I treated when I worked in Internal Medicine: “Yes, I always take my blood pressure medication,” stated by a patient whose pharmacist called me to say she hadn’t picked up her refills for several months. Then there’s me: “Oh yes, I floss every day,” said to my dentist, who can clearly see I don’t floss daily.
We all lie. If we say we don’t, then we are…lying, at least to ourselves. Most lies are based in fear. We’re afraid we’ll appear to be irresponsible, or careless. We don’t want others to think we are bad people. We lie because we’re afraid we won’t get what we want. We’re afraid of the consequences that may occur if we tell the truth. We lie because we don’t want to disappoint other people, or because we feel shame.
With addiction, fear is amplified. Patients with addiction are afraid of so many things: running out of drugs, running out of money to buy drugs, physical consequences of using drugs, what friends and family will think if their drug use becomes known. Many addicts fear they are becoming bad people because they act in ways that violate their own values. They find themselves doing things like neglecting family or stealing in order to satisfy the addiction. So they lie.
Addiction needs lies to survive. A person with an addiction can’t get money for pills from a loved one if he says it’s going to purchase drugs, but he may be successful if he says it’s for food. If he tells family and friends how many drugs he is using, it’s likely he will encounter some opposition, making it harder for him to keep using drugs.
Lies are part of substance use disorders.
Sometimes what appears to be a lie is really denial. Denial occurs when a person has convinced himself something is true when it isn’t. In addiction treatment, denial is common. Here’s one example:
I was seeing a patient in one of the opioid treatment centers about her urine drug screens. Six out of the seven since admission to the methadone program were positive for cocaine.
“I’d like to talk about your cocaine use. Can you tell me a bit about why you use, what triggers cravings to use?”
“I don’t use cocaine. I hate it. I hate the way it makes me feel, all tired and depressed when I wake up the next day. It’s awful stuff. It’s from the devil.”
“OK, you’re saying you don’t use cocaine?”
“I don’t. I don’t use it at all. I stopped using it.”
“Um…, but how long has it been since you stopped?”
“I quit years ago, but I did slip up and use just a little bit the other day.”
“I’m getting confused. You’re saying you quit years ago, but used cocaine the other day. Let’s look at your drug screens. Almost all of them have been positive over the last six months, and I see where you have talked to your counselor about it four or five times. In her notes it says you denied any use. We sent off one of the urine samples for a second, more exact test, and it still showed cocaine. How can you explain this? Is it possible you’re really using more than you think you do?”
“That one time I was helping my boyfriend package it. He’s a coke dealer. I don’t agree with all that. I’m going to break up with him.”
I don’t think this patient was lying. I think she was in denial, and a part of her couldn’t accept the extent of her cocaine use. Denial needs to be treated as part of substance use disorders.
Addiction isn’t the only disease with denial. When I worked in primary care, I’ve seen advanced cancers in patients who were in denial about the severity of their symptoms. Patients with serious chest pain ignored their symptoms until having a massive heart attack. With any problem, one of our defenses against facing a difficult situation may be to deny it exists.
A few decades ago, harsh confrontation was felt to be necessary when dealing with denial in drug addicts. Now we know we get better results with gentler, more positive counseling approaches. For example, I’ve read Motivational Interviewing: Helping People Change, by Miller and Rollnick, third edition. I loved the second edition, which gave me ideas about how to change my goal from confronting to collaborating. This edition is even better. It’s giving me tools to help move patients from denial at their own pace. This feels more humane than old methods of yelling at patients, who already are turning away from unpleasant truths.
This method can also be used with patients who are intentionally lying.
Just because a person with addiction enters treatment, lying doesn’t automatically stop. Habits are hard to break, and people in treatment may lie when it’s just as easy to tell the truth, merely out of habit. Then there are incentives to lie in treatment settings. For example, if treatment is court-ordered, a patient in treatment may face jail time if she admits to a relapse. If a patient’s children have been taken by social services, admitting to continued drug use or even to a relapse may delay getting his children back.
Particularly in opioid addiction treatment, patients have incentives to lie in part due to the extensive regulations put in place by the state and federal governments. Some of those regulations are in place to keep the patient safe, and some are to protect against diversion of methadone onto the local black market. Patients in treatment may lose take home doses if they are truthful about drug use.
Even if take homes aren’t at stake, many patients don’t like to talk about relapses, and lie about their drug use. Patients may fear their counselor will belittle or shame them for using drugs. Again, methods like Motivation Interviewing can help the counselor be more collaborative than confrontational. The counselor can have the approach of let’s look at this relapse and learn from it what we can, in order to help you in the future. When a patient admits to drug use, that’s a good thing. Now we’ve got something to work on. That means the patient is facing their disease, and we can now work on relapse triggers. We can track the events leading up to drug use, and the patient can decide if they would do anything differently the next time, if in the same circumstances.
Some patients cleverly say that if they always tell the truth about drug use, they should be rewarded for their honesty by not having any consequences for drug use. For example, a patient who had been in methadone treatment for about three weeks told me he was drinking his Sunday take home bottle on Saturday. I was alarmed, because I feared he could have an overdose death. I told him I was glad he told me, but that I couldn’t give him a take home dose for Sundays in view of that. He was angry and felt he was being punished for being truthful, while my main concern was a possible overdose death if he continued to get take homes.
I use a phrase from Ronald Reagan in my work with people in treatment for addiction: Trust, but verify. I can’t take everything that is told to me at face value. I’d prefer to believe all my patient all of the time, but they have this disease which leads them to lie. When patient safety is at issue, I have to confirm what the patient tells me with other facts, like clinical observation, patient history, and drug screens.
I’ve learned I can’t reliably tell when someone is lying. Years ago I foolishly thought I was really good at detecting lies, but I’ve been wrong so many times that I no longer make that assumption. Even lie detector machines are often wrong, which is why they aren’t admissible in court.
I’m learning not to take lies personally. Lying is part of addiction, and old habits don’t stop right away. How I react to a patient’s lie is more about me than about the patient. Lies sometimes still make me angry, and this happens more often when I’m not in a good place myself. I try to pay attention to my own physical, mental, and spiritual health. When I’m healthy I’m more likely to view people who lie (not only my patients) with more calm and acceptance.
I understand lies because I understand fear. If I come from a self-righteous place in my own heart where I believe I never lie, I am likely to judge another person who lies. So I’m no paragon of truthfulness myself, but I am a work in progress, as we all are.