A recent experience with a patient helped me realize some of the dramatic differences in the treatment of opioid dependence, in an era of buprenorphine.
I drug-test patients who are treated with buprenorphine or Suboxone. The point of testing is not to catch someone messing up, but rather to determine when a person is in trouble. It would be great if we could simply rely on the word of our patients, but once a person is using opioids, his/her own ability to know what is true falls apart. All of us who treat addiction have heard patients rationalize relapse as something they ‘had to do’ for one reason or another, for example. The effects of active using on insight are why I like the use of ‘DENIAL’ as a mnemonic for ‘Don’t Even Notice I Am Lying.’
The effects of relapse on telling the truth are part of the profound impact of using on a person’s insight. Insight disappears very quickly during active using, as the mind abandons the broad view and becomes focused on one goal. Before buprenorphine, drug testing was in some ways more, and other ways less important. It was more important because after relapse, the person was immediately thrown back into the world of desperate scrambling, where risks for consequences are high. On the other hand, testing was less important—or maybe necessary– because experienced addictionologists (and spouses) could see the effects of using, including the loss of insight, in the active addict’s eyes.
I was one of those people who experienced that rapid loss of insight after my relapse, back in 2000. For years I had attended AA and NA; hundreds if not thousands of meetings over seven years. I remember comforting myself that ‘if I ever get off track, at least I now know where the door is to get back.’ I didn’t realize that at the instant one relapses, that door becomes nowhere to be found.
In retrospect, I don’t know if the door actually disappeared. I suspect that with the right attitude, that same door would have opened for me. But the honesty and humility that I needed, in order to ask for help in finding and passing through the door, were suddenly replaced by the need for secrets—secrets about everything. As soon as I relapsed, nobody could be trusted. Nobody would understand me. I was on my own.
Contrast that with the experiences of patients on buprenorphine who relapse with opioid agonists. As I compare their experiences to mine, I realize that I am using the experiences of a couple people to make broad generalizations. But I have seen a number of examples that support these generalizations, that have consistently followed the paths that I’m about to describe.
One patient—call him ‘Paul’—told me about his relapse before I even mentioned that I would be asking for a urine test. In fact, he was eager to tell me about his experience, as if he looked forward to getting it off his conscience. “I have to tell you that I really screwed up last week,” he said. When I asked him what happened, he said that a friend who he hadn’t seen for several months came through town and stopped by his house. With little warning, his friend pulled out a bag of heroin and a couple clean needles, tossed them on the table, and said ‘let’s fire up.’
After shooting the heroin, Paul immediately felt disappointed in himself. Unlike in the old days, he felt nothing from the heroin. While his old friend nodded off next to him, Paul wondered what the heck happened—and immediately wanted to talk to me about the situation.
His desire to talk is an amazing thing—and worth noting. Without buprenorphine, a person who relapses is not generally eager to speak to his/her sponsor, let alone counselor or physician. In those cases, the mind reels from an avalanche of shame, and the need to keep secrets—even from one’s own awareness—becomes paramount.
There are many buprenorphine programs that would discharge a person for one relapse—and in such cases, I would not expect the same type of honesty from patients. I don’t get the logic of those programs, and I become angry when I think about them. As I’ve said before, if a person relapses, that person NEEDS help—not abandonment! I believe that the proper approach to treating addiction can be found in almost all cases simply by considering opioid dependence to be another chronic illness. And if someone with heart disease overexerts himself and comes in with chest pain, we don’t boot him from treatment!
Paul made an appointment to talk about his experience. He explained how he felt when his old buddy contacted him, and we discussed ways to avoid meeting up with ‘old friends’ in the future. He discussed the urge to escape when he saw the paraphernalia—to escape from life’s responsibilities—and we talked about how difficult it can be to simply tolerate life sometimes, and the powerful effects of triggers and cues. Most interesting to me, as a psychodynamic psychiatrist, he talked about a complicated set of thoughts and feelings that came up when he saw the drugs—questions about who he was, about shame, about the heavy load that comes with doing the right thing, and about the pressure of not letting people down. Those are all big issues, I said as I agreed with him. How much easier, at least for a few moments, to just be ‘nothing’—to have no expectations about one’s self!
We talked about the challenge of being ‘someone’– of being proud of one’s self. It feels good to do the right thing– but it may also feel bad. Am I letting my old friends down, if I do better? I suggested that he might watch the old movie, Ordinary People, where a younger brother struggles after surviving an accident that claimed the life of his brother.
Before buprenorphine, people struggled with opioid dependence largely on their own. Yes, we had twelve step groups—and still do—but twelve step groups place the responsibility to get one’s act together squarely on the back of the using addict. Many people in AA or NA will say that “AA is a selfish program.” It has to be. When one relapses, one is left with his own distorted insight, accumulating consequences until, hopefully, he finds his way back to the pathway established by the simple program of the steps.
On buprenorphine, relapse doesn’t necessarily cause instant loss of insight. I don’t mean to minimize relapse, as bad things can always happen. For example, I have had patients stuck in a pattern of chronic relapse that was difficult to straighten out, even though there was little or no psychic effect from the drug being abused. But from an optimistic standpoint, relapse on buprenorphine stimulates a deeper investigation into what is missing from the person’s life, and a renewed effort to gain what is missing.
This assumes, of course, that the person is not simply tossed from treatment for the relapse. In that case, other people are left trying to figure out what happened—when the obituary appears a few months later.