I worked for several years as the medical director of a residential treatment center in Wisconsin, leaving the position several weeks ago because they were angry about my support for buprenorphine. On my last evening in the place I took a moment to look around and think about how addiction treatment has changed in the past decade. I looked at the pictures of the patients in their charts, who were mostly in their late teens or early 20’s. The most common class of ‘drugs of choice’ were opioids, including oxycodone, heroin, methadone, morphine, and hydrocodone. I thought about the different but similar program that I attended ten years ago, filled mostly with addicts and alcoholics in their 30’s and older. I wonder if Bill W would have come up with the same twelve steps, had his target been not 50-year-old alcoholics, but teenage heroin addicts!
On the walls around me were posted sheets of paper, and on them were lists of ideas from a brain-storming session about how to remain competitive in the modern era of addiction treatment. I scanned the 20-some pages for mention of buprenorphine, and found the medication mentioned only once, under ‘challenges.’ On the other hand there a number of ideas related to marketing, endowment funding, and public image. What I saw in that room essentially summarized the problems with traditional treatment in an era of buprenorphine. It also validated my decision that it was time to move on.
When I was an anesthesiologist I went through a period of frustration over the American Heart Association’s ACLS treatment guidelines, or more specifically over how they were implemented by the hospital where I worked. The guidelines provide easy-to-remember steps to use when treating victims of cardiac arrest. As an anesthesiologist, my education and training taught me to think ‘physiologically;’ if my patient on the OR table went into cardiac arrest, my training allowed me to quickly decide the likely cause, the appropriate medication for that problem, and the proper dose of medication based on body composition, patient age, other medications, medical history, fluid balance, etc. ACLS guidelines were not initially devised for anesthesiologists, but for paramedics and other medical professionals who had less critical care training and experience. To keep things simple enough to remember, the ACLS guidelines provide general medication and dose recommendations based on averages, not tailored to specific conditions or patients. The dose of epinephrine listed in the protocol is 1 mg, whether the patient is a 20-y-o male athlete or a 95-y-o woman. That dose may or may not be appropriate for either a 20-y-o or a 95-y-o– but it is certainly not the correct dose for both! But that’s OK, because we were just talking ‘guidelines,’ not hard and fast rules.
The problem began when nursing educators started teaching ACLS classes not only to paramedics, but to physicians as well. I attended those classes—I had to, just as most physicians who are part of networks are required to do every three years. In most courses I attended, physicians who asked about optimizing doses based on patient characteristics were told to stick to the algorithm so that people didn’t get confused. The result, of course, was to dumb down the classes, and to dumb down the people taking the classes. The issue comes down to whether to trust that individual doctors will be able to think and get it RIGHT, or to assume that they will get it wrong and therefore give them easy-to-memorize instructions. I could go off and extrapolate to modern society as a whole, but I’ll try to control myself! The problem with telling docs to avoid thinking and to instead just follow the protocols is that the guidelines are SO generalized that they almost guarantee failure.
Successful resuscitations are relatively uncommon, making it difficult to come up with treatment guidelines that are clearly good or clearly bad. Over the years, ACLS guidelines have changed in drastic ways. Some interventions recommended as beneficial were later found to make things worse. It is hard enough to decide if standardized, dumbed-down guidelines are beneficial, so you can imagine how hard it would be to determine if a single doctor’s care was good or bad.
What I took issue with was the push for consistency, and the effect of that push on patient care. After a cardiac arrest and resuscitation in the hospital, the chart was reviewed by quality assurance and by a committee that included the people who taught the ACLS courses. No problem so far. But if a doctor deviated from the ACLS protocol, things got silly. The doctor would be asked to provide reasons for deviating from protocol, including support from the literature for the deviation. But the literature focuses on whether the ACLS protocols themselves are of any value, so there are few studies of non-ACLS approaches. There are no studies of the effects of using 750 micrograms of epinephrine instead of 1 mg in a cardiac arrest in a 54-y-o man on beta-blockers, having hernia surgery, who is slightly dehydrated and has a history of mitral stenosis!
Initially the ACLS protocols were designed to help people with less knowledge of physiology provide adequate treatment. But over time, the protocols became the final authority on treatment. So if a patient with an intelligent physician has a heart attack in the cath lab, the doc now has to make a decision. Is the doctor going to give medications and doses of medication specifically geared toward this one patient—and then be hung out to dry by the hospital QA department (which is run by nurse educators who don’t understand this issue)? Or should the doctor just turn his brain off and follow the ACLS protocols, guaranteeing that there won’t be any calls for explanations? The irony is that a doctor who never successfully resuscitates a patient will never run into trouble, provided that the ACLS algorithms are followed—he/she may even get an award! But the doc who saves an occasional patient by THINKING and figuring out the perfect treatment is likely to run into all kinds of trouble! If you were the patient with that smart doctor, and you were facing low odds of survival, would you rather have the standardized, one-size-fits-all approach that rarely works? Or would you want your doc to risk getting written up by using the new medication that he read about that he thinks would fit your condition, but that isn’t on the protocol sheet?
How do we get back to addiction treatment? About 100 years ago some people came up with the twelve steps. I don’t know the history of early AA as well as many, but the steps were devised for the patients of the time, who were mainly middle-aged alcoholics, mostly Caucasian, and mostly male. The steps have stood the test of time, and are now applied to many different substance addictions, and even to non-substance disorders such as eating disorders and pathological gambling. Do they work for those conditions? Sometimes. Like cardiac arrests, the conditions treated by the twelve steps tend to have very low success rates for ALL treatment strategies, so the steps don’t have to work very well to be as good as anything else. I have great respect for the twelve steps, but some have imparted them almost magical qualities that can be used to fix anything!
Some addiction treatment centers are fixated on the steps not as a treatment tool but as a special entity, so that they seem to favor ‘purity of sobriety’ over saving lives. As a fan of the steps myself, I too see ‘sobriety’ in a biased way, making it all the more difficult to describe this concept. Bear with me—maybe my point will be clearer if I ask a few questions. I encourage you to come up with your own answers, and to discuss this topic at the forum.
What is the point of treatment? When a patient enters a treatment program, how should them measure success? If everyone is hugging each other and going to meetings at the end of 30, 60, or 90 days, is that enough? If 85% of those ‘successful treatments’ are using after one year, should the treatment center feel good about the job they are doing?
At the forum, we try to avoid discussions about ‘who is more clean’ because there really is no answer to the question. Today I surfed past a silly TV program where the Real Housewives of New Jersey were divided into two groups, arguing with each other over who was meaner, who lied first, who said what to who… all shouting over each other. Do they really think that one side will ‘win?’ That’s how I feel about ‘who is more recovered’ arguments. And I am gratified that most of the discussions at the forum show far more class and intelligence than that particular topic! My questions here are not intended to go down that path; these questions are to make the point that there are bigger issues than ‘whose recovery is better.’
Which of the following outcomes should a treatment center prefer? Patient A leaves treatment totally free of all substances after 30 days of a 30-day program. He enters a halfway house and leaves after 90 days, still clean. After six months he stops attending meetings. Three months later his friend from his home town pays him a visit, and after drinking a few beers and taking a couple 80’s for old time’s sake he dies in his sleep. Patient B leaves treatment after 21 of 30 days and against the counselors’ advice finds a doc who prescribes buprenorphine. After a month on buprenorphine he takes a couple 80’s with an old friend, and doesn’t feel anything from taking them. The next month he takes an extra buprenorphine tab every now and then, so that he runs out early. He doesn’t call his doc, and instead gets sick for a day or two at the end of the month. He even takes some methadone to ‘treat’ the withdrawal, but it doesn’t really do anything. After four months he has talked to his doc about these things several times, and is starting to get used to—and enjoy–not feeling high. At eight months an old friend visits and gives him a couple 80’s. He knows that they won’t do anything, so he passes on them. Or maybe he is having a rough day and he gives in one last time—but they don’t do anything.
I am not implying that a patient necessarily does better with buprenorphine (although I do think that it is the case that patients do better with buprenorphine!). My point is to show two types of ‘recovery,’ and to ask, which patient of the two is doing better? MY answer is that the second person is better off, because he is ALIVE. I would think that most people would agree—that it is better to be alive than dead. But some of the attitudes I have witnessed among traditional counselors make me think that they are so intent on a twisted version of ‘perfection’ that they would feel better about the first patient! I was speaking with the CEO of a hospital recently who said that if hospitals had a 15% success rate for other diseases, they would be viewed as dismal failures. But in recovery, there seems to be an attitude that the failure rate is acceptable—as long as someone lives. I hope that buprenorphine prompts movement toward a new paradigm where it is no longer acceptable, accepted, or ‘a given’ that many people die.
The steps were designed, in my view, with the help of divine intervention. They sometimes offer the gift of sobriety to a suffering alcoholic who has reached rock bottom. There have been attempts to use them to achieve sobriety from other substances, including opioids, and they sometimes help a desperate opioid addict. But it is much more difficult, and rare, for a teenage opioid addict to accept ‘powerlessness’ than for a jaundiced, middle-aged alcoholic to do the same. Like the ACLS algorithms, the steps are a ‘one-size fits all’ approach to treatment. Like the algorithms, they can be a valuable tool. But for both the algorithms and the steps, the point should NOT be on the purity of the treatment approach; the point should be whether lives are being saved, and whether an imperfect approach that uses out-of-the-box thinking might save a few more.
The REAL challenge facing traditional treatment centers will be to let go of their old ideas of ‘perfect sobriety’ and to use the treatment tools that have the best chance of keeping addicts alive. Doing so should not be that difficult; all they need do is look at the faces of the young addicts entering their programs, and ask themselves, honestly, how many will be alive after a few years? The honest counselors at traditional, non-buprenorphine programs should be humbled, and even ashamed, by what they know about those numbers.