Physicians are a Problem, part 2

My last blog (Physicians are a Problem) pointed out many of the shortcomings of our current system of outpatient treatment for opiate dependence using Buprenorphine.  There are positive aspects as well for the availability of Buprenorphine in the outpatient setting.  Buprenorphine provides an option that can be widely available, and great success

is possible for this devastating epidemic, but only if the medication is provided with all needed components.   There must be concrete accountability and a real program of recovery.  Most of the problems I pointed out are not due to unethical Docs trying to make a buck although there are too many of these.  Most of the Docs prescribing Buprenorphine are very sincere in their desire to appropriately offer treatment for a bad disease.  Unfortunately, the system that was set up for them gives a false impression that what they are doing is adequate.  A piece of the puzzle missing is referral in every patient treated with Buprenorphine to an addiction professional specializing in addiction treatment. This might be a counselor or an addiction physician, but it would facilitate complete evaluation and integration of the needs for a fatal disease that is totally unforgiving of any missing pieces.

When outpatient Buprenorphine is used for the treatment of opiate addiction, it can provide treatment for many that otherwise never could or would be able to participate in a more intensive treatment setting such as Rehab or residential treatment.  A typical patient I might see as an outpatient is a twenty-thirty-something person without insurance, a new baby is at home cared for by a neighbor or relative while at work, and they have no healthy relationships.  This might be a single parent, or both parents are working minimum paying jobs and barely making ends meet.  This potential patient would end up losing their child, their job, and eventually their life before they could ever have the means or ability to go to residential or full time program. Addicts usually have a heartfelt desire to change. I have yet to meet the honest addict that desired to continue what they were doing.   It is too often almost impossible for them because of a lack of resources or other support.  There is no one for the child if they go to treatment.  They have no financial support if work stops for treatment.  These patients become hopeless, lose their child and job, and when they finally die, it is a relief.  There are dozens of scenarios that make the hurdle of starting treatment perceived to be just too high.  This does not have to happen.  If this patient can be treated as an outpatient allowing them to continue to work, it just might happen.  A local Doc that provides an affordable real alternative can provide non-threatening access.  This can be the oasis they see as they feebly crawl over one more dune across an endless desert.  Hope.

Simply exchanging an opiate for Buprenorphine bought from a primary care physician too often does not lead to successful treatment though.  The initial promise fades as reality continues to show up.  Appropriate management of this patient must address the biological, behavioral and spiritual components of this disease.  Otherwise, the denial, compulsion and craving that are the pillars of this malady soon reemerge.  “Go to meetings” is instructed as the Rx is handed to them and this is woefully lacking.  Buprenorphine then is diverted for financial gain, used in between other drugs to prevent withdrawal, and otherwise enables disease progression rather than recovery.  All of this takes place while faithfully returning to the well-intentioned but ill equipped “Suboxone Doctor.”   There must be an end-point.  “Maintenance” becomes perpetuation.  There must be steady progress propelled by accountability and leveraged with the need to regularly return to the physician.  Yes, the same dependence we are treating becomes power in compelling the patients to put up and show up.  All of this is easily and often wasted, but it does offer real drive if used as it can be.  Buprenorphine can actually be a life-saving tool achieving the relationships first with a physician, then with life and love and eventually Peace.  This is the real answer.  It cannot be stumbled upon.