I have described the epidemic of opioid dependence that has killed thousands of young people throughout the US over the past few years. I’m sure that the claim sounds overstated, but during the past six years over a thousand people have died from overdose—mostly due to opioids—in Milwaukee County alone.
I have described the traditional approach to treating addiction, pointing out that for many years the treatment of the disease of drug dependence has been relinquished by the medical profession to other professions. I have pointed out something that everyone in the treatment business knows, but that is rarely admitted; that for opioid dependence, traditional treatment rarely works.
It is important to understand the difference between physical dependence and addiction, two phrases that are sometimes used interchangably but that may or may not refer to the same thing, depending on the context.
Tolerance and withdrawal are signs of ‘physical dependence’ on a substance. Addiction, on the other hand, is a complicated term that has different meanings in different contexts, but generally refers to an obsession or attachment to a behavior, person, or substance.
Many people mistakenly consider physical dependence and addiction to be the same thing.
I saw a patient from up north earlier today, and we talked about the economy in his part of Wisconsin and in the Michigan Upper Peninsula. From what he had to say, things are the ‘same old same old;’ i.e. jobs are few and far-between. Seems as if it has been that way for a long time now. And it’s hard to imagine any industry doing well enough in the current economy to make a dramatic change up there.
One change that HAS become apparent over the past year is the increased availability of heroin, now easily found in small towns throughout the upper Midwest.
I’ve seen the same trend closer to my practice, where heroin use has grown from a Milwaukee phenomenon to just another high school temptation. Along with the use of heroin comes something not as often associated with high school; intravenous drug abuse, or IVDA. And a troubling comment pops up more and more during my discussions with people actively addicted to opioids: “Now that O-C’s are abuse-proof, we gotta’ use heroin.”
Addicts in and out of treatment can face a frustrating ‘catch-22’ * when confronted over whether they are in good recovery, or whether they are instead sliding in the wrong direction.
The dynamic is exemplified in sinister form in the movie One Flew Over the Cuckoo’s Nest; if a person is considered ‘insane,’ nothing the person says or does will prove his or her sanity. In the case of addiction, every addict with a beef can be accused of using self-centered ‘addictive thinking.’ And every comment by an addict about a perceived injustice can be used by a patronizing authority to show that the addict is unreasonable.
The louder the complaint and the more egregious the injustice, the more unreasonable the recovering addict appears. Such is the case for an addict in treatment; every opinion that an addict expresses about his or her progress is taken as evidence of a lack of insight or humility.
My third patient of the day today was Tom, a 22 year old young man who I’ve been seeing for the past four years for treatment of addiction to opioids. We started out the session by talking about how good things have been going in his life since starting buprenorphine, a medication that efficiently eliminates cravings for opioids and that has been available by prescription in the US since 2003.
For several years now, Tom has been working full time. He has regained the trust of family members. He has become more confident in his own goodness, one component of the pathway toward greater self-esteem. The only stumbling block of the past few years was dealing with the attitudes of one family member who would tell him at family gatherings (whether or not she was asked) that because he took buprenorphine, he was not really ‘clean.’
Such an attitude is born of ignorance and can be dealt with over time by letting one’s recovery speak for itself, which is exactly what Tom has done.
Near the end of our appointment Tom shared his sadness over the loss of an old friend from his ‘using days,’ who died last week from an overdose of heroin. “It is sad that he never decided to get better” Tom said. “And I owe it all to you.”
According to the traditional paradigm, opioid addicts entering treatment leave detox after about a week, still experiencing a great deal of fatigue and depression but able (and expected) to participate in the various components of the treatment program.
The program where I was treated ten years ago was ‘open-ended,’ meaning that patients stayed in residential treatment until deemed ready to leave by their attending addictionologists. The average length of stay was a little over two months, but I was not discharged until after more than three months in treatment.
When I mentioned in a prior post that outpatient treatment of opioid dependence is generally unsuccessful, I was referring to the results of the ‘old paradigm’ of treatment. Since 2003 new approaches, using new medications, have revitalized outpatient treatment efforts and spurred physicians– in the past, only bystanders of the treatment process– to become active members and even leaders of treatment efforts.
Before 2003, patients who eventually recognized defeat in their struggle with opioid dependence would enter residential treatment. The first stage of residential treatment consisted of ‘detox,’ a medically-based process usually performed in hospitals or in locked psychiatric wards. One purpose for detox was to help addicts as their bodies were cleared of the addictive substances, a process that usually results in varying severity of withdrawal symptoms, depending on the substance. Withdrawal from some substances, for example alcohol or benzodiazepines, can be life-threatening. Opioid withdrawal on the other hand is very unpleasant for the addict, but is not generally life-threatening. As the saying goes, opioid addicts in withdrawal only WISH they were dead!
The main role of detox for opioid addicts is to keep addicts away from opioids. Even after realizing that opioids are destroying their health, lives, families, occupations, and finances, most opioid addicts cannot stop taking them and continue to go to great lengths to get them. I have known physicians with medical licenses on the line, who knew that taking opioids again would mean losing the ability to practice medicine for the rest of their lives– who returned to using and lost everything. When I worked for the prison system I had patients who were as innocent as anyone could be before their addiction to opioids, who robbed pharmacies, broke into homes, or became prostitutes in order to get opioids. I would never have completed my own detox in 2001 if not for the locks on the doors of the facility. Although by about four days of withdrawal, I was too weak to walk the length of the hall, spending what seemed like endless days with my limbs shaking involuntarily, my intestines in …