opioid dependenceWhen 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 knots, sweating profusely, and in a deep, dark depression. I was ashamed for what I had done to end up there, and believed that the staff viewed me with disgust.   I remember one nice person, maybe a nurse, who didn’t seem to hiss at me while checking my vital signs! I was not even allowed laces in my shoes, because of fear that I would use them to fashion a noose.  Yet even with all of these horrible, obvious consequences from using opioids, there was a part of me, deep inside, that wanted more.  And if the unit had not been locked, especially in the middle of the night when the cravings were at their strongest, I cannot honestly say that I would have stayed!

In my next post, I’m describe the next part of the treatment process– and ask an important question.