More about counseling and stigma

One of my patients sent me a link to a Kentucky newspaper article that described the recent surge in cases of opioid dependence and treatment with buprenorphine. The article described the increased costs for medicaid programs because of the need to pay for buprenorphine. The reporter said that the problem was that people are being placed on buprenorphine and only ‘maintained,’ instead of receiving ‘definitive treatment’ to fix the problem.
The reporter’s perspective and conclusions are not unusual, but they are, to put it bluntly, a crock– for a couple reasons. The first problem with the story is the reporter’s bias, caused by stigma. I left a comment after the article asking why the reporter wrote about rising costs for buprenorphine, instead of an article about the rising costs for medications for ALL of the many new diagnoses and conditions treated these days? To name a few, we have new medications for bipolar disorder, for elevated cholesterol, for coronary disease, for impotence and ‘low T,’ for diabetes, and for asthma– and all of those medications have resulted in higher costs as well. Why single out buprenorphine?
In fact, opioid dependence has become the second leading cause of death for young adults in many parts of the country, and if you look at the cost of buprenorphine over a denominator consisting of the number of lives saved by the medication, buprenorphine becomes a real bargain! Medications for other fatal diseases, for example chemotherapy for breast cancer, are much more costly than the $5 per day cost for treating opioid dependence. We also spend hundreds of thousands of dollars for EACH victim of a serious motor vehicle accident, and similar amounts for every transplant recipient– even when most transplants eventually fail, just as many addicts eventually relapse. Why is only ONE chronic illness– one with a relatively inexpensive cost per life saved– singled out? Are some lives less valuable than others?
What about the suggestion that buprenorphine is only a band-aid, and avoids ‘definitive treatment?’ I have written about this situation many times, and (thankfully) more and more data lends support to my position. I have struggled with my own opioid dependence for 18 years, and over that period of time have come to know a great many addicts; people who were colleagues, friends, patients, and acquaintenances. I have worked in residential treatment settings, and have referred patients to treatment programs ranging from one month to over a year in length, costing from $4,000 to $70,000 per month. The simple, shocking truth is that for opioid dependence, residential treatment RARELY WORKS. The issue of ‘addiction treatment’ is an incredible, sad, shameful ruse that has been spoon-fed to the lay-public, and even to medical and AODA treatment professionals. On TV, Dr. Drew does his thing with addicts– and yet nobody ever seems to question why his patients KEEP ON USING! We read that Lindsay Lohan just failed another drug test, and people assume she is pathologically stupid– when the truth is that she is only like so many others. She probably has an ignorant doc, pushing her off buprenorphine and blaming her when her ‘treatment program’ failed…. when in reality her DOCTORS failed, and her COUNSELORS failed, by not reading the literature and saying ‘duh– this residential stuff never works!!’ At the residential treatment center where I worked for the past few years, the counselors get excited when the patients look all shiny and clean after six weeks in the program… but completely ignore the fact that almost all of those same patients are using by the end of the next year. And what REALLY angers me is that many of the patients who the counselors consider ‘cured’ end up dead from their addictions… and instead of looking at themselves in the mirror with shame, they blame the ADDICTS for not following the program. That would be fine if a small percentage failed treatment. But when EVERYONE fails, it is the TREATMENT that deserves criticism, NOT the PATIENT.
Sorry for shouting.
Over 600 people taking buprenorphine were followed in a recent study that you can read about here. The study showed more of the same– that patients taken off buprenorphine universally relapse. But the study showed something that I found interesting, but not all that surprising. You see, everyone always loves to say that buprenorphine is fine, but ‘only if there is counseling too.’ I always get a kick out of how many people think ‘counseling’ is a good idea– as long as it is for someone else! This study of people on buprenorphine compared a control group that had a quick med check each week during the study period, with a ‘counseling group’ that had two one-hour sessions per week throughout the period, talking about interpersonal issues, personality problems, trauma and stress in the patients’ lives, and other feel-good issues. Guess what? There was NO DIFFERENCE in relapse rates between the control group and the addicts that received intensive counseling. None. Nada. Zero.
I have stated many times that opioid dependence deserves treatment as a MEDICAL ILLNESS, a chronic illness, a potentially fatal illness that finally has a chronic and effective treatment available. But now that this life-saving treatmennt is finally here, the insurers have the gall to limit access to treatment for only a year?! The newspapers have the gall to whine about the cost of a day’s medication– all of five bucks?!! And AODA counselors and some misinformed doctors have the gall to mislead patients by talking down the medication that will help people, even while knowing that their own meal-ticket/treatment programs are ineffective?!!
It even appears that the docs who ‘get it’ about buprenorphine are not doing what good medical science usually does– which is to keep an open mind about treatments and follow the data, not ‘PC’ assumptions. One assumption has been that addicts are so ‘faulty’ inside that they cannot be treated without ‘counseling;’ that surely they all need counseling to truly get better. Where is that assumption when it comes to treating other illnesses? And now that we have evidence that counseling was of no value in the latest study, will minds be open to change?
One of the study’s authors summed it up like this:  
“Does putting people on a short period of buprenorphine maintenance combined with counseling lead to reductions in relapse? It’s a great idea, and a wonderful hypothesis, because if it does work then this would be a huge win. We would not have to use extended maintenance. Unfortunately, it did not work, but the study needed to be done.”

3 thoughts on “More about counseling and stigma”

  1. From one Doc to another (I’m in Australia). You may be interested (or possibly know) how we do things here. Basically, addicts can register at any Dr who’s completed a programme and is then authorised to prescribe what we call Schedule 100 drugs: mainly buprenorphine and methadone. Almost all these Dr’s ‘bulk bill’ ie. are free for the patient. Once prescribed, the patient turns up at a chemist (who’s set up to dispense S100 drugs) daily and receives their dose. After 2-3 months of stability ‘takeaways’ may be authorised by the Dr: up to 3-4 a week. In general terms there is almost NO prescribing of 30 day bottles here – Px need too see the pharmacist daily and their Dr at least once a month. This is free for the patient, however most pharmacies will charge a couple of dollars a day to dispense, and keep patient’s skin in the game. The provision of the drugs themselves is free. ie. done by the Dept. of Health. So..all in all our systems is quite different in that it’s a) pretty much cost-free to the patient and b) requires regular attendance at a pharmacy ie. daily or almost daily.
    In terms of prescribing: Dr’s over here are far less ‘go my own way’ than the US (I have found anyway). There is established practice, and you leave yourself wide open to criticism from your peers if you vary from that. In the case of suboxone, the established standard is to keep patients on suboxone for as long as possible, if not permanently. We are under no pressure to ween addicts off suboxone/methadone, and in general I actively discourage it, except for a very few motivated individuals with stable lives eg. other healthcare workers. A Dr that promoted leaving a programme would face a barrage of criticism, and possibly be reported by his/her peers. This is great in one way, but bad in others: the individual’s healthcare can’t be overly tailored.
    So…that’s buprenorphine et al in Australia…hope you and your readers find it interesting, and keep up the outstanding work of this blog!

  2. I’ve been on 8 mg of subutex for over 2 years. Over a short period of time, I started feeling bad, wher before I was enrgetic, happy etc. anyone experience this? Thhe affect of the drug was great, the dissapated, and it just not working.
    It’s been tia way for months…I can’t figure it out.
    Any comments would be appreciated

    1. I have close to 100 patients in my practice who have been on buprenorphine for a long time– a couple years or more. I do not see this effect– but they are all susceptible to ‘the usual suspects’ in psychiatry, i.e. major depression, dysthymia, bipolar disorder, anxiety disorders, etc. Since active opioid dependence occupies SO much of a person’s life and time, going on buprenorphine and ending the obsession to use opioids has a major effect on the person’s life. Suddenly there is a great deal of extra free time; suddenly the mind is less distracted and more aware of the problems that may have been put off for months or even years; suddenly the problems in a marriage, such as loss of intimacy, become apparent instead of being repressed.
      Buprenorphine does ONE thing– and that is to remove the chemical obsession to use opioids (a ‘conditioned’ obsession may remain for some period of time). Buprenorphine is not a panacaea; life continues to throw challenges each day, and we must all struggle to keep our chins up and trudge forward… and every once in awhile we have a little fun, too. Please check out http://www.suboxforum.com if you haven’t already.

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