opioid dependanceI have several blogs and forums, all part of the mission to educate people about opioid dependence and buprenorphine.  Because of my online presence I am frequently contacted by reporters or journalists, and asked to provide my opinion about some aspect of opioid dependence.  The requests have become more frequent over the past year, suggesting that either my name recognition has increased, or that there is greater awareness—finally—that an epidemic of opioid dependence is killing people in large numbers.

Among those who contact me are people who are ‘anti-Suboxone.’  Some people are very heated in their arguments against the medication.  I run the addiction forum for another large health-related web site, and a couple years ago my presence on that site provoked ‘hate e-mail’ from readers, who accused me of being ‘just another drug pusher’ for my advocacy for buprenorphine!

Thankfully, opinions have moved in what I see as the correct direction.  Don’t get me wrong—I LOVE the idea of people becoming completely free from substances, including buprenorphine.  But despite the ridiculously large sums of money that people pay for treatment, lasting sobriety is rare for opioid addicts.  At this point in the argument, advocates of traditional treatment will say ‘oh yeah?  Show me studies that PROVE that!’

I don’t have those studies, and when one ponders the issue it is easy to see why I don’t.  How, exactly, would such a study be done?  The people who do well do not want to provide information to a team of researchers over the years of follow-up necessary to do such a study, and the people who do poorly are often unemployed and without telephone numbers—if not dead or incarcerated.

I know that traditional treatment—i.e. residential treatment, often based in the twelve steps—is a costly revolving door because I have been a part of that world for over 17 years.  I myself was treated in that type of system, and have known many other people treated in residential treatment programs—some will more frills than others.  I have worked as the medical director for such programs, and have supervised outpatient treatment centers.  Like everyone who reads the news, I’ve noticed that most new-making celebrities or athletes addicted to opioids go back to treatment again and again.  I’ve seen people come and go at AA or NA meetings, and heard thousands of stories from ‘around the tables.’

My work as a psychiatrist has allowed me to meet many, many opioid addicts over the years.  There are two essential problems with traditional, residential treatment.  First, nobody wants to go there.  With other substances (e.g. alcohol), the addiction eventually becomes so severe that consequences force the addict to enter treatment.  But these consequences develop over years– for example causing an alcoholic to finally become desperate enough to enter treatment after 20 years of broken relationships and legal problems.  With opioids, the death rate is so high that people die before getting anywhere near the desperation needed to compel treatment!

The second essential problem is even more significant.  For opioids, the traditional approach to treatment simply does not work.  Of course, most of the people who need treatment can’t afford the $5,000 to over $50,000 per month (usually up front) to get in the door.  And many of those who do find the money don’t last more than a week or two, leaving when the withdrawal becomes intolerable.

But perhaps the saddest cases are those who finish treatment, leaving with a ‘chip’ and a hearty round of hugs from the counselors who use the moment to feel good about what they are doing.  When those patients relapse—sometimes by the end of the very day that they leave treatment—they are left thinking that they THEMSELVES failed—rather than blaming the grossly ineffective ‘treatment’ that they received.

Every residential treatment center that has been around for more than a year has a room off a back hallway that contains file cabinets holding the charts of dead people. The counselors don’t open those charts—nobody does.  Even as the obituaries of former patients appear in the newspaper, nobody pulls their charts to ask ‘what happened here?!’, as would happen in the case of any other medical treatment that took so much of patients’ money, implying the ability to help—but instead failing so miserably.

I understand the attitude of these counselors.  There was even a time, maybe ten years ago or so, when their attitudes were reasonable.  There was nothing else effective for treating opioid dependence, so the money wasted on treatment at least reduced the money for buying heroin!   Counselors told themselves that they were ‘throwing starfish from the beach,’ saving the one rare starfish while the vast majority washed back onshore, to die and dry in the sun.  But when effective treatments like buprenorphine are available, those attitudes are no longer reasonable.

Photo by Cielo de Paz, available under a Creative Commons attribution license.