This is an essay about opiate dependence. I am not an addiction psychiatrist, nor am I an expert on the topic. But I’ve realized I don’t need to be to care about this, and neither do you. I’m learning to understand that what once seemed like a hard leap between do no harm and harm reduction is complex but deserves attention.
Doctors, especially psychiatrists, do need to learn to treat opiate dependence medically as a course of routine so it is widely available in inpatient, urgent care and outpatient settings. I am hoping more doctors will learn to do it, even at a time when we are all overstretched, because it really is an emergency. We can all learn it. Whether we can actually do it in the office is a different story. The creation of a new board exam in Addiction Medicine won’t necessarily help the patients unless we figure out how to make the treatments work. Most of the recent top-down changes in medicine are only going to make things harder for these patients.
General psychiatrists have tended to avoid doing medication-assisted treatment but this needs to change. Buprenorphine has been FDA-approved since 2002 and it really should be mainstream by now. The training should be widely available, free and offered at appropriate professional society meetings and at many sources online. These patients cannot all go away to rehab and many may not need it. The psychosocial support structure for patients getting medication-assisted therapies needs to be built up as well. These patients need chronic disease management, not a fix.
Thousands of people a year are overdosing and this number is increasing. The federal government has come out with new guidelines, laws are being passed to limit prescriptions, prescription monitoring programs are being put in place and naloxone is becoming more available. However, until more doctors begin treating opiate-dependent patients with medication-assisted treatments, we will continue to see large numbers of overdoses. This is because it’s often almost impossible to quit opiates without medication-assisted treatments. People may get detoxed, but they are then at high risk of overdose while abstinent.
There are not enough doctors with buprenorphine training, and, of those that have it, not enough are willing to use it. Even those doctors who are willing still have a cap on the number of patients for whom they can prescribe the medication. The number of hurdles for patients and doctors is high. Patients have an easier time getting into methadone programs, where there are still waiting lists. The system is broken.
In primary care, or anywhere with short visits, EHR, quality metrics and meaningful use, I can see how buprenorphine inductions may be difficult, unless you have enough staff and a trained nurse supervising. These are patients who need a lot of our time, at least in the beginning. The recent value-based payments and quality initiatives have just made everything more difficult, too. In primary care, at the very least, the vivitrol shot should be available for those who have completed a detox.
The questions of how and where these huge numbers of patients are going to get help are hard. The one-size-fits all approach to addictions, i.e. abstinence-based 12 step programs, still espoused in some places are reductionist and really don’t work well initially for opiate-dependent patients. The office-based treatment with buprenorphine, though safe and effective, has not been embraced, and understandably so. It’s partly because of the hurdles and MD time shortage crisis. There is also stigma.
In a way the opiate problem has also exposed our many reductionist thinking about psychiatry in general. There is no infrastructure for dealing with the numbers of patients and depth of need. Reimbursement is so fatally flawed that very few get proper help. There are different kinds of clinics and programs, but the services provided are often so very thin. The MD time is scarce but mis-allocated. In psychiatry we are sadly all accustomed to scarcity and stigma preventing patients from getting real help.
Will outpatient treatment be adequately addressed through a network of specialized programs like the ones at the Harvard hospitals or Alltyr in St. Paul? Can the direct primary care model help these patients? Can the pain management clinics integrate addictions too? The psychosocial supports for patients are vital. Motivational interviewing and the skill set for engaging these patients is challenging. I can see how, as for many of our patients, opiate dependence treatment is the sort of thing that insurance will push to halfway measures and shortcuts like telemedicine or collaborative care because of funding distortions, opportunistic outsiders and the huge shortage of doctors willing to do this work.
Opiate addiction is stigmatized probably like nothing else, which needs to change. A look at language is instructive.
The origin of the word junkie stems from the era of WWI. It is thought to be an association to the scrap metal opiate addicts stole in order to buy heroin. The sources are numerous for that connotation.
- a person with a compulsive habit or obsessive dependency on something:
1920s (originally US): from junk1.
There are 2 main definitions of junk in English:
1.1 Worthless writing, talk, or ideas: I can’t write this kind of junk
1.2 A person’s belongings: I only have an hour to get all my junk together
1.3 US vulgar slang A man’s genitals.
2. informal Heroin: you do anything for junk—cheat, lie, steal
3. The lump of oily fibrous tissue in a sperm whale’s head, containing spermaceti.
Late Middle English (denoting an old or inferior rope): of unknown origin. sense 1 of the noun dates from the mid-19th century.
In the Middle Ages junk was a name for old or inferior rope. By the mid-19th century the current sense of ‘old and discarded articles, rubbish’ had developed. From there came the slang sense ‘heroin or other narcotic drugs’ in the 1920s, the source of junkie [1920s] ‘a drug addict’. Junk food has been making us obese since the early 1970s. The junk which is a flat-bottomed sailing boat used in China and the East Indies is a quite different word. Dating from the mid-16th century, it comes through French or Portuguese from the Malay word jong.
Junk is an interesting word. It connotes waste but, of course, one man’s junk is another man’s treasure.
There is something about junk as a synonym for opiates that makes perfect sense. It seems like society is throwing people in the trash like they are worthless and toxic.
Before possibly junking this word for good, I thought it was worth looking at the cultural associations that go along with this language, which makes the disease so painful and difficult to deal with for all involved. Something that is this steeped in associations to stealing, garbage, dirt, food, sex and treasure has got to be a pretty potent biochemical, emotional and cultural phenomenon. Society is struggling to face it for a myriad of reasons not often discussed. Opiate addiction is a painful, scary phenomenon that destroys people. If only people could just quit. How to help with that?
The ideological hurdle is that for the most part abstinence is a failure as a short-term treatment goal for many patients with opiate addiction, and medicine seems still to be fixated on this outcome of abstinence in an irrational way. But the patients who get detoxed too quickly succumb to relapse and overdose. We don’t know much about how long we need to treat them yet.
Rehabilitation based on the 12 step model of Alcoholics Anonymous was created for alcohol dependence. It draws on a spiritual dimension, which has little science. Some patients benefit. Some of it works- especially the idea of having peer support- but the view that people can’t benefit or go to a program if they are receiving medication-assisted treatment is harmful. It is still the case that programs reject patients who are on medication-assisted therapies, and refuse to discharge them on these medications. No one else gets this kind of terrible care, from what I can tell.
If we don’t want to at least examine how or why we are avoiding and neglecting people being dependent on opiates, when there is plenty of blame to spread around everywhere for this disaster, we too may be part of the problem. Personally, I’m trying to throw ideas I had and wasn’t fully aware I had about this for years in the trash. It took me awhile to read and start to reorient my thinking about this and I’m still pondering. The media is only starting to get a glimmer of the scope of the problem.
More doctors need to take the buprenorphine course. Someday the person may unexpectedly appear who needs help with this. We need to be prepared, to know if there is any way we can help, making use of everything that is available to us. Doctors can at least provide scientific information, referrals and hope, as we would with any other illness.
The patients need us to help clean up this epidemic that is now everyone’s problem. It is our duty to help, if we can, and at very least set aside any bias that could be in the way.
It will take a lot of work to try to address the opiate epidemic and it’s not clear how that could ever happen without more doctors. You don’t need to be a doctor or take a special class to know, as Tracy Helton Mitchell says, that you can’t get clean if you’re dead. (1) I don’t know how I could explain the current situation any better than that.
1. An Addict, Now Clean, Discusses Needle Exchanges and ‘Hope after Heroin.’ NPR Fresh Air published March 8, 2016, updated March 11, 2016.