depressed manA recent experience with a patient helped me realize the dramatic difference in the treatment of opioid dependence, in an era of buprenorphine.

I randomly drug-test for a wide range of substances.  I don’t test because of a lack of trust for patients;  I test because before the era of buprenorphine, insight—a more fundamental character trait than honesty– would rapidly change after relapse.  Almost immediately after the onset of an opioid high, the people using lost insight into the big picture and saw only what needed to be done right then—to cover up evidence of the relapse and avoid experiencing whatever shame-inducing consequences would likely come their way.

I was one of those people who experienced that rapid loss of insight after my relapse, back in 2000. For years I had attended AA and NA, attending hundreds if not thousands of meetings over seven years.  I remember comforting myself that ‘if I ever get off track, at least I now know where the door is to get back.’  I didn’t realize that at the instant one relapses, that door becomes nowhere to be found. 

Where does it go?  I can’t say for sure.  But the humility needed in order to ask for help while passing through the door is suddenly replaced by the need for secrets—secrets about everything.  As soon as I relapsed, nobody could be trusted. Nobody would understand me.  I was on my own.

Contrast that with the experience of a patient on buprenorphine who recently relapsed with heroin.  I realize, of course, that I am talking about a couple people and making broad generalizations.  But I have seen examples that support theses generalizations in several cases, and the examples have consistently followed the paths that I’m about to describe.

This patient—call him ‘Paul’—told me about his relapse before I even mentioned that I would be asking for a urine test.  In fact, he was eager to tell me about his experience, as if he looked forward to getting it off his conscience.  “I have to tell you that I really screwed up last week,” he said. When I asked him what happened, he said that a friend was in town who he hadn’t seen for several months, and the friend stopped by his house.  With little warning, his friend pulled out a bag of heroin and a couple clean needles, tossing them on the table, and saying ‘let’s fire up.’

After shooting up, my patient immediately felt disappointed in himself.  Unlike in the old days, he felt nothing from the heroin.  While his old friend nodded next to him, my patient only wondered what the heck happened—and immediately wanted to talk to me about the situation.

There are programs out there that would discharge a person for relapse—and in those programs, I would not expect the same type of honesty from patients.  I don’t get the logic of such programs, and I become angry when I think about them.  As I’ve said before, if a person relapses, that person NEEDS help—not abandonment!  I believe that the proper approach to treating addiction can be found in almost all cases simply by considering opioid dependence to be another chronic illness.  And if someone with heart disease overexerts himself and comes in with chest pain, we don’t scold him and boot him from treatment!

I found it incredible that ‘Paul’ wanted to talk about his experience.  He explained how he felt when his old buddy contacted him, and we discussed ways to avoid meeting up with ‘old friends’ in the future.  He discussed the urge to escape when he saw the paraphernalia—to escape from life’s responsibilities—and we talked about how difficult it can be to simply tolerate life sometimes.  And most interesting to me, as a psychodynamic psychiatrist, he talked about a complicated set of thoughts and feelings that came up when he saw the drugs—questions about who he was, about shame, about the heavy load that comes with doing the right thing, and about the pressure of not letting people down.  Those are all big issues, I said as I agreed with him.  How much easier, at least for a few moments, to just be ‘nothing’—to have no expectations about one’s self!

We talked about the challenge of being ‘someone’– of being proud of one’s self.  It feels good to do the right thing– but it also feels bad.  Am I letting my old friends down, if I do better? I suggested that he might watch the old movie, Ordinary People, where a younger brother struggles after surviving an accident that claimed the life of his brother.

Before buprenorphine, people struggled with opioid dependence largely on their own.  Yes, we had twelve step groups—and still do—but twelve step groups place the responsibility to get one’s act together squarely on the back of the using addict.  Many people in AA or NA will say that “AA is a selfish program.”  It has to be.  When one relapses, one is left with his own distorted insight, accumulating consequences until, hopefully, he finds his way back to the pathway established by the simple program of the steps.

On buprenorphine, relapse doesn’t mean loss of insight.  Things are not always rosy;  I have had patients who got stuck in a pattern of chronic relapse that was difficult to straighten out, even though each ‘relapse’ caused little or no psychic effect from the drug being abused.  But in many cases, relapse on buprenorphine stimulates a deeper investigation of what is missing from the person’s life,and a renewed effort to gain what is missing.

This assumes, of course, that the person is not simply tossed from treatment for the relapse.  In that case, other people are left trying to figure out what happened—when the obituary appears a few months later.

Depressed man photo available from Shutterstock.