Should Addiction Treatment Include Shame?

Originally Posted 3/23/2013

I generally write positive articles about the use of buprenorphine for treating opioid dependence, and my articles have been reflective of my attitude toward the medication. The field of psychiatry encompasses more conditions than it does effective treatments for those conditions, and my initial experiences treating people with buprenorphine were strikingly positive.

Is All Shame Bad?

My first buprenorphine patients were extremely desperate after multiple treatment failures, and they responded to buprenorphine the way a person with strep throat responds to penicillin.  Their lives improved so dramatically that I wondered if we needed a new understanding of ‘character defects’; whether the shortcomings should be seen not as semi-permanent flaws, but rather as dynamic, maladaptive personality traits, fueled and sustained by active obsession for opioids— and lessened when that obsession was reduced, using buprenorphine.

I still have a number of those patients in my practice, people who have done very well on buprenorphine and have little interest in discontinuing the medication.  As much as I would like to take on a few new patients, I won’t force these people off buprenorphine in order to make room under the cap.  They have worked hard, done well, and have earned the right to a medication that helps keep their illness in remission.

But I’ve noticed a change over the past couple years in the attitudes of patients coming for treatment.  I’ve been slow to specifically identify the change, but when I do an honest assessment, a clear pattern emerges.  To be blunt, young people don’t do as well on Suboxone or buprenorphine as their older counterparts. Maybe they have a harder time accepting the limits to their own mortality; maybe insight requires a longer time to accumulate life experiences.  Maybe they haven’t suffered enough consequences.   But after starting buprenorphine, instead of tearfully expressing disbelief over the lifting of cravings for opioids, younger patients are more likely to take the effects from buprenorphine in stride and continue to engage in addictive behaviors.

I always consider each new patient’s history of ‘consequences’.  I believe that consequences are what eventually spur recovery, providing the patient lives long enough for that to happen—which is certainly not a given with opioid dependence.  I note that consequences impact people similarly in some ways, and differently in other ways.  For example, most people have trouble imagining just how bad things are likely to become until they actually get to that degree of severity.  People who’ve never used a needle believe they will never do so, and people who haven’t been arrested can’t see themselves in that position.

But once consequences occur, people react to them in widely different ways.  Some people react to felony charges with horror, while others appear indifferent.    A near overdose might cause warning bells to go off in one person, yet cause little reaction in someone else. One person will be ashamed and humiliated the first time in jail, while another seems to simply adapt, as consequences move from bad to worse.

Are ‘consequences’ the missing piece of the puzzle for patients who don’t do well on buprenorphine?  If so, are the differing reactions that people have to consequences clues to helping poor responders? Should counseling efforts target for elimination those attitudes of ambivalence or indifference toward negative consequences?

In general, shame is viewed as a hindrance toward recovery.  The cycle of shame is well-known by everyone who treats addiction; the idea that ‘shame’ serves as a trigger of using, which in turn generates more shame, and so on.  But when I see a 20-y-o patient who is addicted to heroin shrug off another relapse, I wonder if in some people, a little shame would be a good thing.

Some comments from readers of the original post:

1. Lg

Interesting article and noteworthy to me in the sense of shame being a big motivator. Mostly I think is the personal shame I feel for having let opioids kick my arse. In my case the amount of guilt/shame is unbelievable. I’ve been around the block many times and really don’t think I have another one in me. I hope and pray these younger guys get and stay with the program. The other choice just might be the last one they ever make. BTW C&S 5yrs

2. devin91

Jeff, I think a little shame is probably a good thing. William Moyers (one of the guys running Hazelden and coincidentally Bill Moyers’ son) addresses the issue of shame head-on in his book “Broken” about his own battle with cocaine addiction (which, unfortunately, there is no medicinal treatment currently available for). His view, as I remember from reading the book, is that shame is an intensely emotional recognition of consequences, and one’s responsibility for those consequences. Obviously, too much of it can be bad – as you note. But a measured amount of shame is probably the appropriate response to a negative consequence or relapse.

On an another note, I think your observation about a positive correlation between age and response to buprenorphine is very interesting. However, it also highlights the fact that the opioid epidemic afflicts younger demographic groups with greater severity (by almost all measures) and in greater numbers than it does older age groups. Opioid addiction is growing faster among younger patients, and (according to SAMHSA data) female patients, and it is also killing them faster. Older patients therefore, *may* be statistical confounders, in the sense that they have already survived a lethal illness for longer. In other words, there may be some additional factors that make older patients “better responders” to buprenorphine, and to recovery in general. They are “better patients” overall, perhaps?

I agree that patients who don’t seem to acknowledge or care too much about “consequences” are extremely frustrating. But I think this phenomenon begs the question of WHY patients suffering from addiction seem to ignore consequences in general. In fact, the disease of addiction often seems to be the disease of IRRATIONALITY – taking actions against one’s own interest. It is my hope that medications like buprenorphine can give these younger patients a break from the cycle of relapse/shame/relapse, and give them time to develop a RATIONAL perspective about consequences. But I agree that a patient who blithely shrugs off a relapse IS FRUSTRATING, and perhaps IS a little bit “blameworthy”. But I hesitate to tread down that path of thinking, because then you come full circle to blaming the patient for their disease.

As the opioid epidemic continues to rage in the US and across the globe, I would rather see “shameless” patients ALIVE (to have a chance at developing an appropriate sense of consequences and shame) than see a trend towards the view that patients who don’t develop a rational perspective are somehow less deserving of treatment. In short, I’m hoping that your clinical frustration with these patients will not dim your passion for saving the lives of opioid-addicted patients, ESPECIALLY THE YOUNGER ONES. Yes, a little shame would be good, but I don’t find it terribly surprising that the younger cohorts have less shame, more “resilience”, more “arrogance”, and are harder to treat as patients. But that doesn’t change the fact that the opioid addiction epidemic is killing FAR MORE OF THEM than it is older patients.

This comment should not be taken in any way as a detraction from your commendable work, both at the clinical level and the policy level (e.g. lifting the caps, etc.). I’m just musing on these issues, and thinking out loud here.