Addiction. The American Board of Preventive Medicine certified me as an addiction medicine specialist so how bad can the term be? My patients called themselves addicts. Heck, they called themselves junkies and fentanyl fiends. That’s not a license to stigmatize. Nor does it mean that substance use disorder patients appreciate people outside the clan calling them that. Just treat people with respect. The affliction truly is a disease, not a question of morals, willpower, choice, or weakness.
What does cause opioid addiction? Genetics: Estimates range from 40 to 60 percent penetrance. Other players include chronic pain management, duration of use, co-occurring clinical disorders, childhood abuse, socioeconomic distress. The list of epigenetic factors goes on ad infinitum.
Medically assisted treatment (MAT), not detox, is the cornerstone of care. You are indeed “trading one addiction for another” although I think dependency is the better word here. A myriad of medical problems require medication dependency. Not a perfect solution by any means, but you get your life back.
All the standard pharmacologic treatments work. Despite its drawbacks (see below), methadone shows significantly higher treatment retention rates than buprenorphine. Buprenorphine shows significantly higher treatment retention rates than naltrexone. That being said, methadone is best reserved for “hardcore,” long-time users. The dose can be continually increased to match the incredibly high tolerance levels of such users. My charges (granted, self-selected to get buprenorphine or naltrexone) scoffed at methadone treatment. They disliked having to get up at the crack of dawn every day to stand in line for all passersby to see. It took forever to earn take-home dosing privileges. They also felt the staff at the clinics treated them as cattle if not with outright disdain and found it demeaning to have the staff administer the dose to them as if they were children. They also disliked the stringent discharge policies. They felt that many of their cohorts lied about the dose efficacy in order to get more methadone so they could get high. Even if you wanted to put up with all of that, most parts of the country don’t have nearly enough outpatient treatment programs (OTPs) to meet demand. Nor is in-office methadone treatment coming anytime soon. I’m with my folks. I think buprenorphine and naltrexone are the way to go. Speaking of standard treatments and received wisdom, for buprenorphine higher doses work better. A dose of 24 mg a day outperforms the typical 8-16 mg/day and is just as safe.
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(Non-standard treatments such as ibogaine, psilocybin, and esketamine actually show promise but are not even close to ready for prime time. Wait for credible studies. Kratom really is truly trading one addiction for another and rather dangerous.)
One should, with few exceptions (until something better comes along), take the medicine indefinitely. Contrary to popular belief, there is little harm that comes from long-term prescription opioid use, particularly buprenorphine. In a different context, my boss used to say, “Relapse is reality.” If you stop your meds, you’re going to fall back close to 100 percent of the time within a year.
Cognitive behavioral therapy (CBT) and dialectical behavior therapy (DBT) don’t help. Nearly every treatment guide you’ll see recommends using counseling. It does virtually nothing to help achieve sobriety or prevent relapse. CBT might address co-morbidities some (and addressing co-morbidities is important), but you’ll likely need to use still other medication for success in that realm. Don’t be afraid to use clonazepam, ADHD meds, or gabapentin. Just keep a tight rein on the doses and supply. AA and NA consistently outperform standard psych care at a fraction of the cost. The results are even better when you add MAT to the mix. Although their formal credo touts acceptance of prescribed meds, the higher power advising those peer groups tends to treat medication users like pariahs. Tylenol may pass muster, but Prozac, say? God forbid; the orthodoxy runs that deep. Proceed with caution.
Harm reduction, harm reduction, harm reduction. As noted above, people will relapse, especially at the inception of their treatment. What’s the point of discharging them from care if they do relapse or use other illicit drugs (most frequently cocaine)? The more they refrain from fentanyl and its adulterant du jour the better off they will be. Do repeatedly discuss the dangers of concomitant illicit drug use, but don’t get bent out of shape about it. (I had a colleague who used to punish her patients by increasing the frequency of their visits if marijuana showed up in their urine drug screens. “You know it’s a gateway drug do you not?” Hand to God. If they’re in your office, those wild stallions jumped over or kicked out that gate long ago and are gleefully galloping around the horse prairies. Pun intended.) The only time I discharged anybody was when I could prove they were selling their medications. Even then, if it was buprenorphine they were selling, I thought that in a way it was a community service. Better buprenorphine than the alternatives. Caregivers spend too little time caring and too much time worrying about having one put over on them.
Just treat the patient already.
Walter S. Wightman is an addiction medicine physician.
