Abstinence=20
has become somewhat of a dirty word in the treatment =
field in=20
the past several years. A month or =
so ago,=20
I read an opinion editorial in the Washington Post =
written by=20
the chairman of the University of VA Psychiatry=20
Department. This man is an eminent=20
researcher. The editorial =
downplayed the=20
usefulness of 12-step support groups and, to some =
degree,=20
suggested they may be harmful. The =
last=20
sentence in the editorial stated, "If addiction is a =
disease,=20
let's treat it with medicine like any other=20
disease." I think that probably the =
eminent=20
doctor has not had enough face time with actual =
addicted=20
patients to have an understanding of what the disease =
is about=20
and how it must be approached. I =
relate=20
this history because there are a number of drugs that =
have=20
come out in the past ten years and more will be coming =
out to=20
treat addiction.
There=20
also has to be some misunderstanding of medicine in=20
general. I spent my early career as =
a=20
critical care internal medicine physician. =
Through my training, I always assumed it was my =
responsibility whether a patient did well or =
not. =20
I have several groups of patients that I would =
put in=20
the "non-compliant" category. =
Patients with=20
chronic heart disease, heart failure, diabetes, =
hypertension,=20
and chronic lung disease, came in and out of the =
hospital over=20
and over again. Each time I would =
go back=20
and ask them why there weren't either taking their =
medicines=20
or adhering to the lifestyle regimens I had=20
prescribed. I did not, at that =
point, see=20
them as having any responsibility for their=20
illness. After treating addiction =
for 23=20
years, my opinion has changed greatly. =
I=20
would like to counter what the imminent psychiatrist =
above=20
said by saying that at the current time we have =
wonderful=20
medications available for diabetes, hypertension, =
ischemic=20
heart disease, chronic heart failure, and chronic lung =
disease. I like to say that there =
is not=20
one person's blood pressure I cannot control on the=20
medications available today. Why =
then do we=20
continue to have so many strokes, so many readmissions =
for=20
heart failure, chronic lung disease, and myocardial=20
infarctions. Granted, the death =
rates have=20
dropped over the past ten years but we have hit a =
certain=20
level that we seem to be unable to go =
below. =20
We have come to realize that patients have=20
responsibilities for their recoveries in these =
diseases, much=20
as they do in addiction. If we =
allow a=20
patient who undergoes coronary artery bypass grafting =
to walk=20
out of a hospital and continue to eat butter, smoke=20
cigarettes, refuse to exercise, stay obese, not have =
their=20
cholesterol under control, and not appropriately take =
their=20
medications for hypertension, then we are accepting a =
social=20
burden that is not really our =
responsibility. =20
Consequently, we have come to mandate that our =
patients=20
with these chronic disorders make "lifestyle"=20
changes. We send patients to =
cardiac rehab=20
to take care of all the above factors after their =
bypass=20
surgery. "Lifestyle changes" have =
become=20
the new catch word of medicine. We realize that =
patients must=20
do a certain set of things to maintain their health in =
relationship to any chronic illness in addition to the =
wonderful medicines we have. =
Medications=20
cannot do it alone.
The=20
Drug Treatment Act of 2000 allowed for a medication to =
treat=20
opiate dependence called Buprenorphine. =
We=20
have long had Methadone clinics, which were very =
restrictive=20
because the opiate dependent patient had to go to the =
clinic=20
every day for a long period of time. =20
Methadone is a powerful and risky medication =
and is=20
used for what I call a harm reduction =
strategy. =20
It was aimed at decreasing social costs to the=20
patients' families and society of the opioid dependent =
patients' addiction. About six =
years ago=20
when the Methadone clinic right across our border in =
Louisiana=20
closed, we had a flood of opiate dependent patients =
who had no=20
where to get their Methadone. I =
took care=20
of a lot of those patients while they were getting in =
another=20
clinic. It was my observation at =
that time=20
that a few had done well long-term but that most had =
not.=20
Many had been in and out of the=20
clinic. I do emphasize that there =
were a=20
few long-term patients whose lives had =
improved. =20
Buprenorphine came out in approximately=20
2002/2003. When I was practicing =
internal=20
medicine, I considered Buprenorphine to be a bad pain=20
medicine. It was an =
agonist/antagonist and=20
did not seem very strong. There are =
many=20
qualities about Buprenorphine that made it a good =
candidate to=20
be an opiate replacement therapy that could be handed =
out by=20
any physician that had been trained in its =
use. =20
There was low chance of overdose and =
respiratory=20
depression, it caused little euphoria, it had a =
ceiling dose=20
where it occupied all the opiate receptors and above =
which=20
more medication would not help, it would negate the =
effects of=20
other opiates taken on top of it, and would cause =
withdrawal=20
if it were taken on top of other opiates. =20
Buprenorphine, like Methadone, was a harm =
reduction=20
strategy. It was meant to decrease =
the=20
social cost of opiate dependent patients, and they =
could get=20
it at their family doctor. It was =
felt to=20
be especially useful in light of the ever increasing =
epidemic=20
of prescription drug addiction. =
I=20
initially thought that Buprenorpine, in addition to =
intensive=20
residential therapy, might be effective. =
I=20
decided to place a group of patients who met certain =
criteria=20
on Buprenorphine. They had to have =
failed=20
two treatments. They had to have =
severe=20
consequences for their opiate addiction, which, if =
unchecked,=20
would probably cause severe illness or =
death. =20
In most cases they were IV opiate users, =
especially=20
heroin. They had to agree to stay =
in the=20
Jackson, MS area for a year so I could follow them and =
see how=20
they did. There were many things I =
found=20
out from this group of patients over the two years =
after we=20
initiated this program. My first=20
observation was that the results were =
poor. =20
The young people that went on the medication =
seemed to=20
do okay for a while but they either dropped out or off =
the=20
medication and went back to using. =
There=20
was no question that there was a group of patients, =
usually=20
middle aged and prescription drug addicted, who seemed =
to do=20
well on the medication. I noticed =
that the=20
focus of treatment became on how much Buprenorphine =
they were=20
taking. There was never a time that =
you=20
could ask one of these patient how they were doing =
that they=20
would not say that they needed more =
Buprenorphine. =20
The focus of their attention in treatment was =
entirely=20
the medication rather than any behavior change of =
their=20
own. Physicians cannot force =
patients to=20
change their behaviors. There is no =
medication that can make a person change their=20
behavior. Learning a new behavior =
takes=20
practice and persistence. Our =
Buprenorphine=20
patients were unwilling to do this. =
In=20
dialectical behavioral therapy, one of the four =
modules is=20
distress tolerance and another is emotional=20
regulation. These are two =
characteristics=20
that 99% of our young addicted patients from 18 to 25 =
do not=20
have. They experience emotional distress as a need for =
the=20
drug and often refer to this as craving. =20
Every time the patients would come and be =
checked by my=20
associates, they would state that they were craving =
and the=20
dose would be increased. While the =
maximum=20
effect is supposed to be felt at 16mg, I noticed that =
my=20
associate had many of these patient on the maximum =
dose of=20
32mg. They would still complain =
that they=20
needed more. The other thing that I =
observed happening was that even though the patients =
were not=20
supposed to talk about being on Buprenorphine that was =
all=20
they did talk about. They compared =
doses=20
and passed between each other key words to say to my =
associate=20
that was checking them, that would help to get a =
higher=20
dose. They were unwilling to go =
through the=20
discomfort it took to be responsible, learn new =
behaviors, and=20
begin dealing with these feelings as opposed to trying =
to use=20
a chemical to get through them. =
With the=20
year period of time, all the younger patients from 18 =
to 25=20
had failed to stay abstinent. =
Seventy-five=20
percent of the rest of the patients had also quit=20
Buprenorphine and gone back to using. =
This=20
was compared to the non-Buprenorphine group in which =
50% had=20
maintained abstinence over that year's period of=20
time. These were again chronic =
opiate=20
addicts who had been through at least two previous =
good=20
treatments and failed.
At=20
this point we realized that Buprenorphine had no place =
in=20
enhancing our treatment. I consider =
it to=20
be a potential treatment for physicians of all =
different=20
specialties in the community who see patients with =
opiate=20
dependence. Again, we just have to =
realize=20
that it is a harm reduction strategy. =
Most=20
of the patients on Buprenorphine do not get counseling =
and=20
have no plan to be tapered off. =
They may=20
have less social difficulties while they are on it in =
that=20
they don't get arrested for trying to pass phony=20
prescriptions, or buying drugs on the =
street. =20
They don't have the significant financial =
burden of=20
buying drugs on the street. But =
this is=20
just a stop-gap to their disease of =
addiction. =20
At some point, it will come back and the social =
cost=20
will go back up. Most of these =
patients=20
quit Buprenorphine after they are out of trouble and =
the pain=20
has gone away. They go back to =
using and=20
experience the same troubles, and come in wanting to =
start=20
Buprenorphine again.
It=20
is very easy, and I want to repeat "it is easy" for =
us, as=20
physicians, to prescribe something like=20
Buprenorphine. We can spend the =
whole=20
session discussing doses and number of mg, and how the =
patient's craving is doing on a certain number of=20
mg. We never have to sit there and =
discuss=20
the situation from which the craving =
arose. =20
We never have to discuss what might have caused =
the=20
patient to be emotionally uncomfortable. =20
Patients lump all of their uncomfortable =
feelings into=20
one category they call craving. =
They expect=20
any medication to take away that anxiety, worry, and=20
distress. If the medication then =
does not,=20
then it does not work. Unfortunately the only =
medications that=20
do this are opiate agonists themselves. =
For=20
years, physicians have tried to treat addiction with =
either=20
maintenance opiates or benzodiazepines such as=20
Xanax. If we could give all the =
opiate=20
addicts in the country an endless supply of opiates =
and, in=20
the bargain, tell them that they must become =
responsible and=20
function as the rest of the human beings in society =
do, it of=20
course would not work. We have =
tried this=20
over the years and it simply just does not =
work. =20
Patients must grow up, so to speak, and learn =
skills to=20
function in society that they either don't have at the =
present=20
or never learned. This is hard and=20
difficult. It is much more =
beneficial to an=20
opiate addicted patient to have him sit through =
distressing=20
feelings and/or use a support system to work them out =
than=20
simply giving him a pill, which erases these=20
feelings.
New=20
medications will continue to be developed and placed =
in the=20
market. They must meet our criteria =
as more=20
than harm reduction adjuncts. If we =
don't=20
see results and I don't hear my colleagues talking =
about=20
results, then I'm not going to use it. =
We=20
decided as a facility that Buprenorphine did not =
benefit the=20
treatment of our patients. There is =
still a=20
very small group, again which are middle age or older =
opiate=20
addicts with multiple treatments, that I feel =
Buprenorphine is=20
good choice and significantly so. =
Still,=20
most of the time, that group does not get much out of =
the=20
treatment process and could just be put on the =
Buprenorphine=20
and followed as an outpatient. We =
believe=20
in abstinence-based treatment and in my mind, it is =
not a=20
theoretical concept. I constantly =
discuss=20
treatment outcomes, medications, and ways of treating =
patients=20
with other medical directors of excellent treatment =
centers=20
across the country. If we don't see =
results, then we don't use the therapy. =20