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