Every now and then I hear about a therapist or addiction doc who is doing such a disservice to the practice of addiction medicine as to deserve special mention.  This week’s award goes to a certain counselor at a treatment program in Oshkosh, WI, who I’ll refer to as ‘This Jerk.’
I’ve made no secret, over the years, about my hope for addiction to eventually be treated with the same respect for patients and attention to medical principles as for any other illness.  I certainly try my best to work according to those ideas, and find that doing so really helps when it comes to making treatment-based decisions.  In other words, I’ll ask myself—if this person had diabetes, what would an endocrinologist do?  Or better yet—if I had diabetes, what would I want MY endocrinologist to do?

Some Jerks advocate punishing patients who struggle.

This Jerk Counselor

We all know that certain professions attract certain types of people.  Some of us have been pulled over by the cop who was the kid subject to playground taunts, now all grown up, determined to make life a living Hell for anyone with a loose seat-belt.  When I worked in the state prison system, I worked with guards who belonged in the same category; men and women who loved to carry keys to cages that held real people.  It’s the power trip, I suppose.
This Jerk apparently loves the power trip of ‘treating’ people who are sent back to jail for ‘failing’ his treatment.  He doesn’t have to worry about being a lousy therapist; he has a captive audience, and likes it that way.  One difficult aspect of being a therapist is treating patients who don’t like us for one reason or another, or who don’t kneel every time we enter the room.  But when This Jerk feels disrespected, he picks up the telephone and calls the patient’s PO to report ‘noncompliance with treatment’– then gloats about sending the patient to jail.
Treatment professionals who are in a position of unusual power over a patient must be particularly careful to empathize with their patient’s position.  In medical school, we were placed on gurneys and wheeled around by fellow students, to emphasize the vantage of patients coming to the emergency room.  We were taught to sit at the same or lower eye-level of our patients, as speaking down to people creates an unsettling power differential.
The power to prescribe or withhold buprenorphine (let alone the power to send to prison!) comes with an obligation not to abuse that power.  Withholding buprenorphine causes patients to go into withdrawal—something dreadful to people addicted to opioids.  Worse, withholding buprenorphine places patients at very high risk of relapse—which in turn places them directly in harm’s way from overdose and legal repercussions.
This Jerk, I’ve been told, takes issue with psychiatrists who continue to treat patients on buprenorphine who struggle with sobriety.  He considers it ‘good care’ to withhold buprenorphine from an addict who uses, supposedly to punish the patient into sobriety.
In case This Jerk (or a similar ethically-challenged counselor) is reading, I’ll point out the obvious:  when a doctor pulls the rug from under a patient by withholding medication, that patient might easily join the ranks of other dead addicts.  On the other hand, when I work with a patient who is struggling with sobriety, keeping the person on buprenorphine and working to identify triggers for using, that person almost always ‘gets it,’ eventually.
I’ve been working with people addicted to opioids, using this approach, for so long that the other approach—the punitive, ‘cut ‘em loose for struggling’ approach—seems barbaric.  I don’t understand how people identified as healthcare workers (nothing professional in his behavior!) rationalize the dismissive approach.  I suppose, if This Jerk views addicts as the scum of the Earth, or as people with weak characters, or people who lack ‘will power,’ punishing relapse by withholding treatment feels about right.  But most of us leave that world behind when we commit to helping people suffering from illness.
What’s This Jerk’s excuse?  Is it that he just doesn’t get it?  Or are there other motives at play?  With the current cap on patients on buprenorphine, the most lucrative way to practice is to keep turnover high, rewarding practices that hire therapist-idiots like This Jerk.
Or is it the power trip– that people with difficult addictions are an affront to therapists?  I’ve met therapists with this attitude before, who seem to have a form of codependency with their patients. They take credit for any success by their patients, but think the patients who fail are not worth their time, and should be dumped, expunged, or kicked-out to relapse and die.  I suppose This Jerk would say ‘not my problem!  I did MY job!’
Readers may suspect that this topic irritates me—and they’re right.  Maybe I’ve seen more death, up close, than the typical counselor.  I’ve attended autopsies; I’ve reviewed post-mortem photos from overdose scenes; I’ve pushed IV fluids into people with fatal injuries who presented for emergency surgery.  I have spent hours with the parents of young patients who died from overdose.  I’ve seen the parents’ faces as they struggled with the thought that they could, or should, have done something else—just one more thing to save their child.  Death, to me, is not ‘theoretical.’ It is not something to toy with, and certainly not something to invite into the life of a person who made me angry, for not recovering at MY pace.
I suspect that the Jerks of the world will continue to justify their sadistic approach to ‘treatment.’ But patients—at least SOME patients—don’t have to put up with that behavior.  People like This Jerk hold power over an individual with an addiction history, but there is power in numbers.  It is not appropriate to use one’s power vindictively, or to gloat over a patient’s struggle.  It is not appropriate to humiliate a patient in front of others.  If you see that behavior, collect witnesses, and bring it to someone’s attention.  Maybe that ‘someone’ will write a blog post about it!
Doctors in particular should treat patients with ALL diseases—including addiction—with respect.  It is not respectful, or ethical, to deprive a patient of life-sustaining medication—especially out of spite.  I look forward to the day when the thought of ‘kicking someone off Suboxone’ is viewed as similar to kicking a poorly-compliant teenage diabetic off insulin.
Would THAT make sense— even to This Jerk?


nathans · February 13, 2012 at 11:13 pm

Your a good man, Dr. Junig, a genuine ‘mensch’; too often a lone voice barking in the wilderness, but the message is necessary so please keep it up. Reason and right are on your side, so, hopefully sooner than later, they will come around.

LBB · February 16, 2012 at 10:39 am

I wish there were more like you in the treatment world, Dr.J.
Something similar happened to me in April of 2011. After using heroin for 6 months, I looked for help. Finding a doctor covered by my insurance was very difficult. Long story short, after I was on Suboxone for 3 weeks, and my life was totally turning around for the better, I had a one-time relapse. The doc I was seeing immediatley dismissed me when I went to see him. I confused my drug use to him even before he saw the results of my urine screen, trying to use my new honesty skills I was picking up in AA/NA. Nope. Done. I begged for even a few Suboxone to tide me over till I could find a new doctor. Nada. Long story short, I went into withdrawals, went back to heroin, and continued to use for 9 more months (with a few futile attempts at getting clean) before I found my current provider who is a wonderful doctor. I’m in group therapy, AA/NA, and I’m now 23 days clean, the longest I’ve been in over a year. I very well could have died or gone to jail in those 9 months of using. I’m not blaming the doctor for my relapse or my return to drug use, that’s not my point. But he also blatantly said to me that he usually treats people who “get themselves into trouble with prescription opiates, not heroin users” so I guess he had a stigma against a junkie off the street like me. Dr.J you are so right on about them having all the power. I’m a white, middle-class mother & homemaker. On the outside I look like your typical “soccer mom”. Then I mention I’m addicted to heroin and the stigma clouds everything, sadly so often even in the medical community where you’d hope they would be more compassionate, understanding, and caring. I pray for the day that buprenorphine is more widely available to those who need it, and the stigma against all alcoholics & addicts is replaced by an understanding that we all are fighting against a vicious disease.

    SuboxDoc · February 17, 2012 at 11:45 am

    So many heroin users were started on opioids by physicians– who found, after getting cut off, that heroin was cheaper and easier to find– especially after the new formulation of Oxycontin. I have nothing good to say about heroin, but it is just another opioid agonist— and a legal medication in the UK. Thanks for sharing your story.

gabagool · April 12, 2012 at 2:52 pm

At first, I thought it was all in my head. I USUALLY communicate pretty well with people, I speak nicely to them, and, in return, they speak nicely to me. But, when I started recieving my Bupe, the same nice, friendly pharmacists at my local CVS seemed to be…..well, not so friendly. No smiles, I waited LONGER than usual for a script to be filled, they won’t fill it 3 days earlier once when I was going on vacation. Then it hit me……they think Im a junkie……AND I AM A JUNKIE……it really hit home. Made me realize what a mess I made of myself…..but you know, they were STILL Fargin Aceholes, just the same.
I wonder if any other person has ever gotten the same treatment from their pharmacy.

cory hudson · May 18, 2017 at 9:52 am

Doc u truly a caring, professional, and wonderful physician and its a HUGE shame there aren’t more like you. As an addict I see and deal with the negative stigma persons such as myself deal with on a daily basis. Addiction IS a medical condition, like diabetes, hyper/hypotension, etc….. I have yet to see a diabetic be refered to as scum because they state they can’t eat a bag of M&M’s when seeking medical care. Yet when I refuse narcotics and inform physicians I had a severe opiate addiction for over a decade & I’m NOT comfortable taking anything with the potentional for abuse. I got the same reaction 99 times out of 100 no matter how long I have been clean. A very short, rude, demeaning bed side manor as if I DON’T actually need medical attention, I’m just working some kind of angle and I’m med-seeking. The proper education regarding addiction just isn’t there so I love it when I see an MD such as yourself fighting the good fight along side all of us addicts. You truly the answer to the answer to countless addicts prayers and I can’t put into words how much it means.

    Jeffrey Junig MD PhD · May 18, 2017 at 5:03 pm

    Thanks! I appreciate your comments, and of course, I have my own bad days. But I know the attitude you’re describing, and I’ve witnessed it myself, a number of times. I think that it comes in several forms. There are the docs who perhaps led relatively-sheltered lives, who see the use of illicit substances as a crime, meaning that anyone using them is a ‘bad person’ or criminal. Other doctors believe that people with addictions are weak-minded for being unable to control their impulses. Some doctors have a divide in their mind between doctors and patients, with them on one side and patients on the other side.
    I remember my own experience of passing from one side to the other. I was head of the anesthesia department, and attended meetings of the executive committee with other department heads…. nobody knew of my brief addiction history 7 years ealier, when I went to AA/NA and left opioid behind. But then I relapsed, and after several months in treatment I was ‘allowed’ to speak with the executive committee. They all say in a circle around the table, and listened as I confessed what had happened. The CEO then winked at me, shook my hand, and said ‘thanks Jeff.’ But I could see on the faces in the room that I had moved from their side, to the other side– and their eyes were not communicating with me, but rather looking AT me, as one of THOSE people. I got home and called the CEO, who said ‘thanks for coming, Jeff– we’re letting you go.’
    I have to say it…. what a douchebag. The nice smile, the nice suit, the guy who said I was ‘such a friend’– and then ‘sorry’.
    Frankly, the experience was painful, but was also an important part of my personal and professional growth ever since. I would encourage you to do the same– and when you see those attitudes, keep the truth intact in your own head– the truth that these idiots should be ashamed of themselves for trying to judge you.

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