Doctors and patients are supposed to share a therapeutic alliance. This agreement hinges on trust and respect. But what happens when that trust breaks down because of addiction? In a recent On Medicine column, Dr. Siddhartha Mukherjee writes about a patient he treated early in his career, whose deceptions to obtain opioids pulled him into a patient-doctor relationship that he eventually describes as “mutual assured destruction.”
Mukherjee’s struggle with his patient continues a conversation in the medical community on the difficulties and misconceptions of treating opioid-addicted patients. Over 100 physicians and other health care professionals responded to an invitation to share their stories about treating patients like Mukherjee’s. A selection of responses, edited for clarity and length, is below.
Wading in the Dark
Even trained doctors admitted there is much to be discovered about which types of people become addicted and why.
One misconception is the belief that medical science understands addiction. I don’t think that we know why one person can be prescribed oxycodone after surgery and take it for five days and then stop and another person becomes addicted. Opioid abuse seems to be considered by many to be a reflection of a person’s lack of will or a personality defect — not unlike alcohol abuse, tobacco use or even obesity. I don’t think that anybody wants to be a drug addict. I don’t believe in “victimhood,” but if we don’t understand the events that led to a person’s becoming addicted to opioids, we’ll never be able to find solutions to the problem. There is no “one size fits all” model for treatment. Dr. Heather N. Schwemm, Primary Care Internist, Kennebunkport, Maine.
Many respondents noted the gaps in our health care system have further impeded progress in treating addiction.
One of the biggest challenges is helping patients access quality mental-health services and counseling both for the addiction issues and the almost always present untreated mental-health issues. The opioid addiction is never the only problem. But mental-health care, especially for those on Medicaid, is challenging to access. Hours are too often limited to days, when people are at work (and many of my patients can’t afford the unpaid time off that may lead to job termination). The other challenge is funding. Mental-health care and medical care for addiction is expensive. Medications that prevent withdrawal symptoms and block the high (or do one or the other) are excellent for tools for reducing the chance of relapse, but at an out-of-pocket cost of $500 to $700 per month, it is too expensive for many patients. Patients can end up buried under mountains of debt simply because they were responsible and sought treatment for their addiction. Medicaid does a bit better, but when patients bounce off of Medicaid because of a slight increase in income, it can put patients’ sobriety in peril because their benefits for counseling, doctor visits and medication suddenly vanish until, again, that deductible is met. And access to mental-health care can be a serious challenge for Medicaid patients. Sarah Butler, Physician Assistant (Certified), Livonia, Mich.
Our system perpetuates the problem. Patients expect that they will get prescribed opioids because in large part they will. If they don’t, they might respond poorly to the question, “Was your pain well-managed in the hospital?” on patient satisfaction surveys. Reimbursement is in part based on the results of these surveys. They dominate our every interaction with patients. I recently broke a bone and both in the E.R. and in the M.D. office, was offered opioids as a first-line pain medication. I declined, aware that alternating acetaminophen and ibuprofen, and icing and elevating were better, evidence-based options for acute pain like a broken bone. Dolores Flanagan, Nurse, San Francisco
A Lack of Empathy
Many healthcare professionals noted that the way society stigmatizes addicts can jeopardize their recovery prospects.
The emphasis on the opioid epidemic speaks to a societal problem with empathy. As many publications have noted, when the addiction epidemic was concentrated in brown and black communities, it was a law enforcement problem. Now that addiction has moved to the suburbs, it is a public health issue, as it always should have been. Addiction is defined as a chronic, relapsing disease. Many have done bad things as a consequence of their addiction, but that doesn’t mean they are irredeemable. We have known for quite some time now that addiction changes the brains of those who fall to its prey. We need to do a better job at using pharmacotherapies to treat addiction. Diabetics take medicines to address the changes of their disease process, yet in some treatment centers want addicts to go “cold turkey” or accuse them of “switching one addiction for another.” Shannon Dingle, Psychiatric Nurse Practitioner, Bronx
The misconception about opioid use is the belief that it’s a choice. There has been so much research that links opioid addiction with attachment disorder. So you have people who have suffered from poor parental bonding getting hooked on opioids often at the hands of the medical community; they go to jail, lose their jobs, children, freedom, and when they get out they can’t get jobs, they have no emotional support and they blame themselves for their vulnerability. Why wouldn’t they? The rest of the world blames them. No wonder they go back to using drugs. Addicts need love, support, connection. That’s why they got addicted in the first place — not having these things. We need to have compassion. And, we need to understand and respect addiction more generally. Dr. Rebecca Jones, Dermatologist, Brattleboro, Vt.
The emotional tollf required to take care of certain patients has overwhelmed some health care workers.
I started as a therapist treating women in a major city, and over the course of a 10-year career wound up running multiple state-funded women’s residential addiction programs there, with the purest of intentions to provide help for what I know to be mostly traumatized women. I got burned out and left my job about a year and a half ago because I couldn’t deal with addicts anymore. They turn treatment on its head — it becomes a sort of “game on” when they enter programs and proceed to break every rule, in a giant game of distraction, which invariably leads back to relapse. It’s an exhausting and grim business treating addicts because one can’t help but conclude in the end that most of them don’t really want to change. It’s been heart-wrenching for me to become so disillusioned with the whole thing. Name Withheld,Licensed Mental Health Counselor, Brooklyn
I am a doctor, with a brother who was a heroin addict for 10 years. With my help, he got clean twice, both times by leaving the country for a while and getting out of his environment. However, he never admitted that he was an addict, never went to rehab and never changed his addictlike sociopathic behavior. We have not had a relationship for a very long time, and we never will again. I know it is not politically correct to say this, but opioids, narcotics, meth and all these drugs change people in very substantial ways, and it’s a minority who are ever truly rehabilitated. I think we should put our medical efforts into the patients we may truly be able to help. Being an addict can be a choice, and they will get better only if they are really ready to. Meanwhile, I, personally, will not allow them to waste my time. Name Withheld, OB-GYN, New York
Recovery Is Possible
But as rampant as opioid addiction has become, there have been stories of hope too.
The biggest misconception about opioid abuse is that folks cannot get better. I saw with intensive outpatient treatment over a year with Suboxone that miracles do happen. I saw folks get better and become productive members of society. I saw them turn around and give back to other addicts. I saw their families heal with them. But the investment of resources is significant. They also need continuing care for many years — less frequent treatment but they still need to attend groups at least once a week sometimes for years and continue on their Suboxone. Christine, Licensed Clinical Social Worker, Syracuse
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