Like many people with opioid dependence, I did not progress to a severity of illness where I decided that I needed addiction treatment.  It would have been less burdensome for my family, of course, had I come to such a realization.  But I needed stronger ‘encouragement,’ in the form of life falling apart and having nowhere to turn, except treatment.

The nature of opioid dependence leads the addict to cling to the illusion of power, believing that if he tries one more time— just a little bit harder, or perhaps using some special technique—he will find the will power to taper off drugs on his own, and then avoid them forever.

Of course any person addicted to pain pills desperate enough to walk into a psychiatrist’s office has tried to stopping dozens of times, if not more.  That doesn’t prevent cold feet at the prospect of surrendering to the treatment of some doctor, and patients often scramble to reverse the actions set in motion by spouses, parents, and other family members.  ‘I really think I can do it this time,’ they say.  I’ll cut back by a tiny amount every few days, and THIS time I’ll REALLY stick to the schedule!’

The relationship between doctor and patient are already distorted at this point; the patient forgets that he/she is there for help, and treats the doctor more like a parole officer trying to trap him than like someone who can help.  I often remind patients that whether they do well or whether they do poorly is on them– not me.

It is exceedingly rare for a person who has been stuck on pain pills for months or years to find the ‘will power’ to stop taking them, with or without the assistance of a physician or treatment professional.  But that does not keep patients— and doctors– from trying.

Doctors will give instructions to decrease the dose by ‘this much per day,’ and are left with the impression that their tapers are successful when patients follow their instructions to the letter—while replacing opioids no longer prescribed by that doctor with opioids from another!  In the rare cases that patients are successful in stopping opioids, relapse is more common than not.

Relapse after a period of sobriety is particularly maddening to family members, who buy into the idea that withdrawal is the main barrier to sobriety.  Withdrawal from opioids IS horrible—it is difficult for someone who has not been through the experience to understand the unique combination of pain, depression, and anxiety that torments the opioid-tolerant person when stopping or reducing daily opioids. But those who do manage to complete withdrawal and get back among the living eventually find a reason to use again, and the pattern of promises, hope, and relapse leads to greater and greater shame and demoralization.

‘Tapering’ pain pills is not only rare, but also illegal.  According to the Harrison Act, Doctors are not allowed to prescribe an opioid narcotic in order to treat addiction or prevent withdrawal, the exceptions being through tightly-regulated methadone treatment programs, and more recently in outpatient buprenorphine treatment. I will be talking about both of these medications in due time, as they are largely the reason for the new role of physicians in the treatment of opioid dependence.

Until 2003, people seeking treatment for opioid dependence had two basic options after the going through the futile exercise of outpatient treatment.  One was to enter medical detox— hospitalization in what was often a locked ward, that provided safety and some minimal level of comfort but that mainly functioned to keep patients away from drugs.  After several days, the patient entered residential treatment; a high-intensity combination of therapeutic modalities lasting from 30 days to over a year.

Residential treatment is viewed not as a means of curing the addiction, but rather as the first step of a life-long process, including aftercare, attendance at recovery meetings, and the adoption of a new way of living, one that many addicts will claim is a significant improvement over the life they were living while actively using.

The second option for treating opioid dependence has for years been deemed most appropriate for inner-city intravenous heroin addicts, or for others who lack the tens of thousands of dollars necessary for residential treatment. Methadone, a medication with properties similar to other opioid agonists, is administered to addicts initially on a daily basis, and then at less frequent intervals if the addict avoids other opioids.

The methadone satiates the addict, and also increases the addict’s tolerance, making an intoxicating dose of heroin much larger—and more expensive.  This type of treatment, called ‘methadone maintenance,’ is a type of ‘harm reduction,’ with the goal of reducing intravenous drug use, the spread of blood-borne diseases, and street criminality related to heroin addiction.  In recent years many methadone clinics, after being bought out by business interests, have cleaned up or even rebuilt their facilities, and shifted their business model from treatment of inner-city heroin addicts to the treatment of Oxycontin-addicted suburban Generation X-ers.

Over the past ten years, medications have been developed that dramatically reduce addictive cravings and behavior in patients with opioid dependence.  One would think that the advent of medications that curb addiction to opioids would be welcomed by all who work in the addiction field.  But for reasons that I will do my best to describe, the welcome mat for this medication, in some geographic and professional regions, remains tightly rolled and tucked behind the door.

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    Last reviewed: 3 Nov 2010