I generally write positive articles about the use of buprenorphine for treating opioid dependence, and my articles have been reflective of my attitude toward the medication. The field of psychiatry encompasses more conditions than it does effective treatments for those conditions, and my initial experiences treating people with buprenorphine were strikingly positive.
My first buprenorphine patients were extremely desperate after multiple treatment failures, and they responded to buprenorphine the way a person with strep throat responds to penicillin. Their lives improved so dramatically that I wondered if we needed a new understanding of ‘character defects’; whether the shortcomings should be seen not as semi-permanent flaws, but rather as dynamic, maladaptive personality traits, fueled and sustained by active obsession for opioids— and lessened when that obsession was reduced, using buprenorphine.
I still have a number of those patients in my practice, people who have done very well on buprenorphine and have little interest in discontinuing the medication. As much as I would like to take on a few new patients, I won’t force these people off buprenorphine in order to make room under the cap. They have worked hard, done well, and have earned the right to a medication that helps keep their illness in remission.
But I’ve noticed a change over the past couple years in the attitudes of patients coming for treatment. I’ve been slow to specifically identify the change, but when I do an honest assessment, a clear pattern emerges. To be blunt, young people don’t do as well on Suboxone or buprenorphine as their older counterparts. Maybe they have a harder time accepting the limits to their own mortality; maybe insight requires a longer time to accumulate life experiences. Maybe they haven’t suffered enough consequences. But after starting buprenorphine, instead of tearfully expressing disbelief over the lifting of cravings for opioids, younger patients are more likely to take the effects from buprenorphine in stride and continue to engage in addictive behaviors.
I always consider each new patient’s history of ‘consequences’. I believe that consequences are what eventually spur recovery, providing the patient lives long enough for that to happen—which is certainly not a given with opioid dependence. I note that consequences impact people similarly in some ways, and differently in other ways. For example, most people have trouble imagining just how bad things are likely to become until they actually get to that degree of severity. People who’ve never used a needle believe they will never do so, and people who haven’t been arrested can’t see themselves in that position.
But once consequences occur, people react to them in widely different ways. Some people react to felony charges with horror, while others appear indifferent. A near overdose might cause warning bells to go off in one person, yet cause little reaction in someone else. One person will be ashamed and humiliated the first time in jail, while another seems to simply adapt, as consequences move from bad to worse.
Are ‘consequences’ the missing piece of the puzzle for patients who don’t do well on buprenorphine? If so, are the differing reactions that people have to consequences clues to helping poor responders? Should counseling efforts target for elimination those attitudes of ambivalence or indifference toward negative consequences?
In general, shame is viewed as a hindrance toward recovery. The cycle of shame is well-known by everyone who treats addiction; the idea that ‘shame’ serves as a trigger of using, which in turn generates more shame, and so on. But when I see a 20-y-o patient who is addicted to heroin shrug off another relapse, I wonder if in some people, a little shame would be a good thing.
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Last reviewed: 23 Mar 2013