Helping ‘Them’: Our Role in Recovery From Opioid Dependence

Dear Dr. Noon,

Thank you for your thoughtful comments in response to my essay. As you are keenly aware, the problem of addiction cannot be solved with one pill, one approach. Suboxone is only part of the solution: the rest is up the patient. We are all frustrated to see a bright, healthy, talented child slip below the water line.

Those of us who care for chemically dependent patients should share our stories, our limited successes, our unmitigated failures. And be honest, to the extent that those in need have a place to rest.

Please stay in touch.I am always interested in knowing what my colleagues find to be most helpful.

Sincerely,

David Loxterkamp

Competing interests:   None declared

I liked the term "Invisible addicts" that was used in the article.Yes we as primary care physicians should be more careful while writing these pain medication prescriptions.I feel suddenly overwhelmed when a patient walks in my clinic demanding certain drugs for the pain releif fired by some other doctor.I want to treat him /her how I feel is right .But is that option acceptable for that patient?Who's disability check comes due to that pain syndrome he /she has.Its a shame that we as a caregivers dont identify that problem sooner until they become a burden to society using resources and abusing the system.We want to help them but on the other hand they need to help themselves too .I dont judge my patients but pointing out a problem and possibly treating the problem of addiction sometimes is not an option for some of them.Our hands are tied too ,we can only "offer" them help we cant force them to get help.Many of those patients will simply change the doctors so what a caring doctor can do then?

In the article mention of " Dont judge "probably comes from a patient who wants to get out of the addiction.Most of them will walk away saying "I dont need help "I just need my prescription refilled.What we will do then?Is that Suboxone a magic pill? Will that change the attitudes and solve all the problems .I think not.In the fifteen minutes that we get to see any patient, a patient addicted to pain pills is the toughest one.We don't have time to discuss the options and even if we make time they do not want to listen. The whole system of rewarding addicted patients wilh medical cards,food stamps and disability checks months after months is making them more addicted to these medicines than anything else.I think there is a need to filter more thoroughly who qualifies for these benefits and who does not.Younger patients should not be on disability for their OA(Osteaoarthritis) when they can lose weight and probably work if they wants to.Not only he/she has OA (Osteaoarthritis) They have a much bigger problem of addiction.For which I am not sure what magic pill would work.The bigger picture is not so rosy .I do have some patients who refuse the pain meds so they dont get addicted to them.But I can count them on my fingers,as number is so small.

Competing interests:   None declared

Dear Ms. DiNatale,

Thank you for the kind response to my essay "Helping Them."

I look forward to reading more about NAOMI, Safe Injection Sites, and the 4 pillars approach. It is always important to compare treatment models so that we can refine our methods and adopt the best.

I agree with you that health care is, or should be, a right. And providers must not forget our privilege to care for society's most vulnerable and needy.

I cannot agree with you that the ability to purchase drugs from a local pharmacy represents any REAL freedom. Dependency is, in part, defined as the loss of rational control over one's decision-making. Some substances cause almost immediate dependence while others take years. Some substances are dangerous or lethal in very small amounts, "natural" or not. Agreed, the use of a substance is not the same as dependence, and some people are happy and productive living with their dependencies.

But many are not. It would seem to me that education and prevention strategies would be most effectively applied to populations that are not yet addicted. Here the United States and Canada have much work to do, together.

Sincerely,

David Loxterkamp, MD

Competing interests:   None declared

Hello Mr. Loxterkamp,

I am a professional researcher at the BC Centre of Excellence for Women's Health.

In Canada, more specifically British Columbia, we are so far ahead in regards to the treatment of opiate dependence.

Currently we have NAOMI (North American Opiate Initiative) conducting their research to allow physicians to treat severe opiate dependence with the real deal instead of synthetics that are harder for the body to metabolize.

We also have a Safe Injection Site which is saving the province millions of dollars. At the site we have RN's who teach, save lives, and are non-judgemental.

Reading your article I can't help but think of how far behind the United States is with regard to issues relating to opiate dependence.

I hope you look at some of our harm reduction models and the four pillars approach. Take a look at our Safe Injection Site stats and NAOMI.

It's time to start accepting that people can be dependent on so many things and there is nothing wrong with being dependent. Drugs are not BAD. The policies are what makes them BAD.

I can't wait for the day when our natural substances can be bought at the local pharmacy, taxed, and that money put into all sorts of things, including education for those who want to made informed choices.

That is indeed REAL freedom.

Diana A. DiNatale

I am curious about one remark you made in your article. Towards the end you say 'privilege' of the regular doctor.

What exactly are you trying to say? That it's a priviledge to have a family physician? In Canada, it's a right.

Competing interests:   None declared

Dear Dr. Newman,

Your comments touch upon a divide in addiction medicine between the abstinence model and a harm reduction approach. Anyone who prescribes Suboxone cannot claim that they support “pure” abstinence. Philosophical differences permeate our own opioid dependence treatment program, where the providers support harm-reduction while the therapists preach abstinence. As a result, our “contract” has gotten shorter and shorter, and I have readmitted many of the patients discharged under more stringent guidelines. The goal is to help, when possible; not to judge, always.

We are learning. Even helping a few patients. And the conversation continues. Thank you for being part of it.

David Loxterkamp

Competing interests:   None declared

To the Annals,

The "reflections" by Dr. David Loxterkamp in the Annals of Family Medicine, vol. 4, no. 2, 2006, are to be commended. As the title suggests, it is indeed the role of generalist physicians to help "them" – i.e., opioid dependent patients. Just a couple of comments:

It’s noted that patients and staff "quickly grasp" that buprenorphine works: "it prevents withdrawal symptoms, eliminates cravings, and restores regularity to a disjointed life." Right! And/but precisely the same is true of methadone in appropriate maintenance doses.

Reference is made to a "contract that requires [patients] to abstain from drugs, [and] attend weekly counseling sessions..." While it’s stated that no one has been discharged from treatment for failing to attend counseling sessions or for "a positive urine test," both these requirements are quite extraordinary in the field of medicine. Imagine requiring a patient being treated for Type II diabetes to sign a contract not to eat sweets, and to attend faithfully nutritional counseling sessions. Nice if one can get such compliance, but unthinkable to terminate treatment if the "contract" is not fulfilled, and it is not clear what lesser sanction would be imposed.

The intent of the author, it would seem, is to have physicians treat opioid dependence just as any other chronic illness. Notwithstanding the apparent conflict between this goal and the nature of the "contract," Dr. Loxterkamp is to be complimented for urging colleagues to address the serious, potentially fatal, problem of addiction. As he notes, patients with this illness "have been here all along...." It’s time, as Dr. Loxterkamp says, "to use our power to help the sick to the best of our ability."

Robert Newman, MD, MPH, Director, Baron Edmond de Rothschild Chemical Dependency Institute of Beth Israel Medical Center, NYC

Competing interests:   None declared

To Joel P Laughlin:

Thank you for your careful reading of "Helping Them: Our Role in Recovery from Opioid Dependence," Ann Fam Med 2006; 4: 168-171 (Reflections).

Your "quibble" is at the heart of the essay. "They want what they don't deserve, a second or even 30th chance." My statement was meant to reflect society's judgment, a judgment that the addict often internalizes as a result of shame or depression. I claim no power or authority to sift the wheat from the chaff, nor is it in our job description as family physicians.

David Loxterkamp, MD

Competing interests:   None declared

This is a well-written and worthwhile account of one primary care physician's effort to deal with an exploding problem. My only quibble involves the statement, "They want what they don’t deserve—a second or even 30th chance." What human being on this earth is qualified to make a moral judgement regarding who is and who isn't deserving of help for any disease, be it addiction or diabetes or cancer?

Competing interests:   None declared

This article is a wonderful narrative of the gradual process required for primary care physicians to become as thereputic with addicted patients as they are with all other chronic disease sufferers.

In order for this change to take place, all physicians need: 1)the internal willingness to address addictive issues like we do other bio-psycho-social-spiritual maladies that our patients develop, 2)the necessary knowlege of the natural history / risk factors / response to treatment of addictive disease, 3) the obligate skills to treat this condition including screening skills / brief intervention skills / the ability to assess readiness for change and negotiate treatment plans based upon that level of readiness / and a monitoring strategy or system.

It is always helpful to have addiction psychiatry or addiction medicine specialists available for consultation, but a suprising amount of the treatment can be organized by, run through, and monitored by primary care physicians and their office staff.

Given the widespread un-met treatment need in our communities, and that fact that these sorts of patients are already in our offices for various other conditions, it is only logical that physicians will embrace this new knowlege / attitude / and skill set, agree to become certified to prescibe office based opioid maintenance therapy (eg. buprenorphine), and better meet their patients needs. Sadly, not much in the history of interaction between physicians and addictied patients has been logical in the past, but as the dreary days of Winter begin to fade, hope springs eternal! Our patients and communities deserve nothing less.

Competing interests:   I am a general internist and addiciton treatment program physician, who helps organize Suboxone physician-training courses and who directs and addiction fellowship training program.