Stigma surrounding Medication Assisted Treatment is preventing many people that need treatment for their addiction from seeking it. Opioid overdoses are killing people in record numbers. We need to get these people the help they need. Clink the link below to listen to my podcast now to learn about MAT, what it is, how it works, common myths about MAT, and how it saves lives.
People are dying in record numbers from opioid overdose. According to NIDA (National Institute on Drug Abuse), overdose deaths involving an opioid rose from 8,048 in 1999 to 47,600 in 2017. Despite these alarming statistics, people desperately needing treatment fail to seek it. The reason? Stigma. Need proof? According to the 2018 National Survey on Drug Use and Health, there were about 21.5 million people in the U.S. over the age of 12 that reported having a substance use disorder, but only 2.5 million of those actually sought out medical assistance and treatment for their issues. To clarify, 19 million people that needed treatment did not seek it because of the stigma associated with addiction and treatment. Stigma and judgment are killing people.Despite all of the data showing that Medication Assisted Treatment (MAT) is the gold standard for treating Opioid Use Disorder, and the related success rates of MAT, judgment abounds. The widespread myth that patients in MAT are simply “trading one drug for another,” or “trading one addiction for another” creates a substantial barrier to treatment. As an addictions therapist working in MAT for over 11 years, I have been relentlessly advocating for MAT, and educating patients, their families, counselors, medical professionals, and the general public regarding MAT in order to break the stigma that MAT has been so firmly entrenched in. Now serving as both the Program Director over two MAT facilities in Upstate SC, and as the Region 1 Representative for SCAADAC (South Carolina Association of Alcoholism and Drug Abuse Counselors), and due to the continuing reports of the ever-rising rates of opioid overdose deaths, I feel the need for an urgent call to action. Please allow me to educate you.
The first and most common misconception of MAT is that these patients are simply trading one drug for another. That’s not the whole story. After years of using and/or abusing opioids, a person’s opioid receptors become dysregulated. Methadone and buprenorphine work on a patient’s dysregulated receptors to normalize the patient. Patients are not getting high in treatment, they are getting normal. You wouldn’t tell a diabetic person, “Just lock yourself in a room for ten days, tough it out, and you’ll be fine. You won’t need that insulin anymore.” Nor would you say something similar to someone on medication for chronic high blood pressure. I can hear you saying, “That’s different.” It isn’t. Insulin normalizes the system of the diabetic person and keeps him/her from being sick. Blood pressure medication does the same. Methadone and buprenorphine normalize the system of the person with Opioid Use Disorder and also keep him/her from being sick …with withdrawals. You say, “But the opioid addict did that to themselves; he/she shouldn’t use medication.” Okay, then, I suppose then that you also believe that someone who smokes like a chimney for a lot of years and gets lung cancer shouldn’t get treatment either then? …Thought provoking, isn’t it?
Methadone Maintenance Treatment is for people that have been dependent on opioids for at least a year. That does not mean using opioids for a year; it means dependent on opioids for a year and exhibiting observable signs of opioid withdrawal. Opioid withdrawal symptoms include sweating, hot flashes, chills, watery eyes, runny nose, excessive yawning, goose bumps, muscle pain, headache, nausea, diarrhea, vomiting, crawly skin, irritability, anxiety…the unpleasant list goes on. Suffice it to say that opioid withdrawal is like the very worst case of flu you have ever had multiplied by a factor of 12, and it doesn’t relent. Imagine feeling that way and knowing that you could feel better in a matter of about 15 minutes if you could get your hands on a few pills of Vicodin, or Percocet (or whatever other opioid you have access to). Hmm, let’s see…flu symptoms…or…take a couple of pills and feel normal again? No brainer, huh?
This is the dilemma people with Opioid Use Disorder face daily. They can be hellaciously ill and in bed, unable to be a parent, or employee, or functional anything, or they can score a few pills (or fentanyl, or heroin) and be normal…for a few hours anyway. If you are in this situation, therein lies the rub: you have to amass enough medication to keep you normal. That’s what the “chase” is all about. You chase more pills in hopes of having a sufficient amount to keep you functional so that you can be whoever it is you are required to be. That is what keeps you using. You want to stop, but you don’t have the time or the inclination to be sick for very long. So you get a few pills, or grams, or whatever “just to get you through the day.” Then you’ll quit…later. The problem is, tolerance builds and the amount you used to take to be fine, no longer works, and you need more at a time to keep you fine. This costs more money, and more of your time. Then, the more you use, the more your tolerance builds, and the more you need to keep you fine. The other problem is, at some point you’ll reach your fatal dosage.
Methadone has been around for a really long time, and has been intensely studied and tested, and retested. Can it be abused? Yes, like a lot of helpful medications, it can be abused. Does that mean it isn’t suitable for use? No. Methadone is a miracle drug for many, many people suffering from Opioid Use Disorder. When patients come into a clinic for treatment, they are evaluated for their appropriateness for the program, and if appropriate, they see the clinic physician, and are started on an initial dosage, which cannot exceed 30 mgs on their first day. They are required to attend the clinic daily to have the effectiveness of their dosage assessed and adjusted up or down as needed, to be monitored for signs of sedation or possible over-medication, and to begin treatment planning and counseling.
Buprenorphine has a different protocol and depends on the program being used at the facility. OBOT (Office-based Opioid Treatment) patients are seen the way patients at any physician’s office are seen. They see nurse for their monthly urine drug screen and then see the physician and walk out with their prescription of buprenorphine to have filled at their local pharmacy. OBOT patients are strongly encouraged to use the counseling provided at the facility, but are not required to. DATA 2000 (Drug Addiction Treatment Act 2000) patients may be seen as OBOT patients are seen, or, depending on the clinic, may be required to attend clinic daily and earn their takeout medication privileges after showing progress in treatment and continued compliance, and after meeting time-in-treatment requirements, as is done with methadone prescribed patients. (Please see: https://www.buprenorphine-doctors.com/what-is-data-2000.cfm for further information on DATA 2000.)
What’s the difference between buprenorphine and methadone then? Why choose one over the other? That is a great question. Buprenorphine and methadone are both very long acting with a very long half life. The main difference between the two is that Buprenorphine works best on patients with mild to moderate withdrawal symptoms. I have heard arguments that both medications work equally well on all patients. That is simply not true, at least not in my 11 years of experience in MAT. Patients with “heavier” and longer-term use tend to do better when prescribed methadone. Of course each patient is individual and his/her treatment should also be individual, but in general, this is true. Buprenorphine also has a “ceiling” effect, meaning that once you reach a certain dosage (usually 24 mgs), it is pointless to increase it, as there is no additional benefit or additional relief from symptoms. Buprenorphine has less risk of overdose when taken on its own, but still has significant potentiation risk. Buprenorphine is also more widely covered by insurance. Overall buprenorphine is viewed as the “safer” medication, but if a patient is not getting adequate relief from withdrawal symptoms and submits to the urge to supplement his/her medication with other drugs, then it really is not any safer. The other safety issue with OBOT patients, because the program works like a regular physician’s office, positive drug screens are only addressed once per month, and are done so with the physician and not with a counselor. The other difference is that, as previously mentioned, depending on the program and the clinic, the patient may not be required to engage in counseling at all while in treatment.
The initial goals of treatment include harm reduction and stabilization of the medication. Stabilization refers to the point at which the patient’s dosage keeps him/her from craving the drug of choice and alleviating withdrawal symptoms for a 24 hr period. Stabilization takes time. Methadone stays in the system (i.e., will keep a patient from withdrawal symptoms and cravings) for 24-36 hours. (It may stay in the system regarding showing positive on a drug screen for much longer than that.) This is the reason for the initial dosage not exceeding 30 mgs, and the reason that the dosage has to be adjusted slowly, in order to avoid overdose. It is also crucial for a patient to be educated on the dangers of potentiation. Potentiation refers to two or more substances increasing the effect of each other when consumed together. Certain substances potentiate each other, including opioids, benzodiazepines (like Xanax, Valium, or Ativan), alcohol, and barbiturates (like Phenobarbital, or Fiorocet). Basically, it means that taking two of these together leads to an equation of one plus one equals six, or eight, or ten. The amount of medication in the system is exponentially increased, and this substantially increases the risk of overdose and death. The risk of overdose is highest during the stabilization period because a patient who may not yet be getting 24 hours of relief can be tempted to supplement his/her methadone with other substances in an attempt to get additional relief. This is why most clinics require a new patient to see the counselor daily in order to learn about what to expect to feel physically, emotionally and psychologically while they are stabilizing, and to learn how to manage symptoms without resorting to illicit substance use.
Patients in Methadone Maintenance Treatment are required to submit to random weekly urine drug screens to monitor whether they are still using other illicit substances or alcohol, until they show compliance in the program as evidenced by having an observed urine drug screen whose results indicate no illicit substance use. (An observed drug screen is one where a counselor of the same sex as the patient goes into the restroom with the patient to ensure that the urine sample given is authentically that of the patient, and that the urine has not been obtained and brought into the facility.) An alternative to the observed urine drug screen, for patients who might have a history of sexual trauma, is to have the patient submit to an oral swab drug screen done concurrently with the (unobserved) urine drug screen to rule out falsification of drug screen results. If they show compliance for a period determined by the facility (usually for a minimum of 30 days), the patient is then placed on a random monthly drug screen schedule, where he/she is asked at a random and unannounced point once each month to provide a sample. If he/she continues to test positive for illicit substances after the 30 days, he/she is required to remain on a random weekly drug screen schedule to closely monitor the illicit use and to provide more interventions as needed. Patients that have shown compliance in MAT and have earned takeout privileges are subject to random unannounced medication callbacks at least twice per year, whereby a patient is phoned by the counselor or a nurse in the middle of a pickup cycle and told to come in the next day to take that day’s medication at the dosing window in front of the pharmacist, and then to have his/her bottles checked and counted by the pharmacist to ensure that the medication is being taken as prescribed and that it has not been sold, tampered with, or taken in any way other than as prescribed. In addition to the medication callback, a urine drug screen is also done, either observed, or with an oral swab drug screen to cross check the results, in order to ensure compliance and rule out falsification of drug screen results.
It is worth mentioning that, aside from the monitoring being done by the MAT clinical and medical staff, MAT facilities are accountable to many outside agencies, moreso than other non-MAT treatment facilities. MAT facilities are monitored by DHEC, the DEA, the Board of Pharmacy, CARF, and the Joint Commission, to name a few. Audits by these agencies happen regularly and may be announced or unannounced. They monitor for compliance in all areas from recordkeeping and documentation to storage and administration of the medication, and in every area that falls in between. This is notable especially because of the number of reported deaths that are attributed to methadone. MAT facilities are automatically assumed to be the source of the originating prescriptions, but it might surprise you to know that the majority of those deaths are related to methadone prescribed by pain management physicians and not by MAT facilities. This is partly because pain management facilities do not monitor patients as closely as MAT facilities are required to do, and because many physicians are not trained adequately regarding methadone and the prescribing of methadone.
There are many MAT facilities in the Upstate for people seeking treatment. The facility at which I am Program Director, Clear Skye Treatment Center in Clinton, SC offers MAT, and has a unique collaboration with Gateway Counseling, which greatly benefits patients in ways other MAT facilities cannot. Gateway Counseling is the sole Laurens County authority for alcohol and drug abuse services, and is a quasi-governmental nonprofit agency that offers a variety of services related to the prevention, intervention and treatment of substance use disorders. Charlie Stinson, the director of Gateway (and all-around awesome human being) worked diligently with the owners of Clear Skye to develop a collaboration in which Gateway obtains state funding to assist low-income patients in affording treatment services. These patients get the assessments, care, and higher-level counseling they require, and receive medication and case management services at Clear Skye. Clear Skye also offers regular MAT treatment services and counseling for those that can self-pay, have Medicaid, or that have private insurance. If regular MAT patients require higher levels of counseling, they are referred to Gateway, and once Gateway patients are stable and are able to obtain employment, they are referred to Clear Skye and transferred to the regular MAT program. This unique collaboration allows for increased access to treatment services for more individuals suffering from Opioid Use Disorder.
I know that I have given you a lot of information. I have attempted to sum up for you what MAT is, what it isn’t, and how it is (properly) done. I am hopeful that this article may assist in the stomping out of stigma and judgment related to MAT, that it may increase patient access to treatment services, and that it will, ultimately, save lives. To that end, you should know that some reported studies show MAT success rates as high as 80%, which is more than any other treatment option can boast. That’s pretty impressive. How ya like MAT now? (insert wink here)
New Year’s brings many challenges for most people, but can be especially challenging for those suffering from a Substance Use Disorder. The holidays are typically a time of increased stressors, and, subsequently, a time of increased risk for relapse. This is true whether one is new to treatment or has been in treatment and recovery for years. Usually there is a high risk for relapse is when a person first enters treatment, but in fact, relapse can be dangerous, even deadly, for those who have been “clean” for a long time, as, they can mistakenly believe that they have the same tolerance that they had before entering treatment, and thus, when they use, they take the same amount of the substance they would previously take and end up overdosing (and dying). The point is that relapse can kill people regardless of their time in recovery, and that the increase in risk for relapse is especially high during times of increased stress, as occurs during the holidays.
There are ways to minimize the risk for relapse during the holidays. The first step is realizing and acknowledging that there will be additional stressors, and plan for increased support accordingly. This may sound simple, but the holidays are extremely hectic, and when people are crunched for time, they frequently cut things out of their schedules that they deem able to be put off til a later time. RECOVERY SUPPORT DOES NOT FALL INTO THIS CATEGORY! For people that are in recovery, there is a need for increased counseling and therapy, and engagement in recovery services and treatment activities during the holidays. The importance of this cannot be stressed enough.
The second step is to plan one’s time wisely, being sure to incorporate sufficient time for self care activities. Self care activities are unique to everyone, but can include anything that reduces stress, such as taking a bath, listening to music, reading, or engaging in a hobby. “Me time” is important, especially during periods of increased stress. Planning one’s time wisely also includes saying “no” when one needs to. It is completely okay to decline invitations if it protects one’s recovery. It is also okay to decline doing favors for others, if it may undermine one’s recovery efforts. One needs to give oneself permission to put one’s recovery first, because if one’s recovery fails, everything else follows.
Step three includes maintaining awareness of potential triggers for relapse, especially in social situations. Recovery is a very precious gift, it must be guarded as such. If one is celebrating with friends and family, and suddenly finds himself/herself having thoughts of using or of wanting to use, it is important to recognize the thoughts and address them using the techniques taught during therapy, and, if necessary, to leave the situation. Staying in a potentially dangerous-to-recovery situation for the sake of appearances is simply not wise.
It is important to note that emotions can be triggers as well. Obviously, holidays are replete with emotion. Sometimes the emotions feel good, sometimes, not so much. Holidays can bring up problems related to feelings stemming from unresolved trauma or grief. Unfortunately, this is common. It is important to recognize this, and to realize that these feelings are temporary. It is also important to let one’s therapist or counselor know what one is feeling in order to get the proper assistance, and the proper referrals, if needed.
For people with a Substance Use Disorder that are in recovery, the holidays can be especially stressful and high-risk. With the proper care, planning and support, they can be made less so. Please remember life is precious, and each of us has value regardless of the mistakes that have been made or the current problems being experienced.
You who are taking the time to read this are here for a reason. You are precious, and you have great value. Find and live your purpose. Make your new year great.
So…Medication Assisted Treatment (MAT) has been getting the Stank Eye for years. With the Opioid Epidemic getting so much attention, I truly feel that a fair shake is long overdue. MAT continues to be misunderstood by both the general population and professionals in the field alike. It really makes no sense, especially when you consider the number of patients that are actually successful in treatment with MAT.
Statistics show that MAT can cut the mortality rates among those suffering from Opioid Use Disorder by HALF OR MORE! That in and of itself is huge. MAT has been extensively studied and shown effective for the treatment of Opioid Use Disorder, with some statistics showing success rates as high as 80%. That is significantly higher than any other treatment for any other substance abused across all modalities. So why does the stigma persist? Why do people continue to believe that MAT is just replacing one drug with another? Why are there still people in the field of addictions that continue to insist on any other form of treatment BUT MAT?
I’m afraid the answer is both simple and complex. Old habits die hard, as they say. The same is true for old beliefs. Education is the key. There is an abundance of accurate information about the benefits of MAT. Unfortunately, there is also an OVERabundance of information that is…well…bullshit regarding MAT. Until people start being more discerning about the source of their information, misinformation will reign.
Rampant misinformation is the main reason I began this blog. Generally speaking, people do not want to know when they are erring. They are usually quite content to remain ignorant. As I have been saying for years, “There is no cure for stupid (or asshole) that doesn’t end in prison time.” People will continue to cling to false ideas and information until someone or something catastrophic changes their thinking and shows them, beyond any doubt, the truth. Unfortunately in the case of Opioid Use Disorder, that usually means overdose deaths.
Matisyahu. (n.d.). AZQuotes.com. Retrieved November 08, 2017, from AZQuotes.com Web site: http://www.azquotes.com/author/37624-Matisyahu
If I hear just one more “professional” in the mental or behavioral health field (or worse, in the field of substance use disorders) state that Medication-Assisted Treatment (MAT) becoming more available and having to be covered by insurance companies is some horrendous thing, I’m going to lose it! I don’t understand, with all of the information so readily available via the internet, why the idea that MAT is simply replacing one drug with another persists. Why do these “professionals” continue acting like these people suffering from opioid use disorder are just coming into treatment to continue getting high. Are you kidding me? Do you HONESTLY think that ALL of the people working in these clinics are no better than DRUG DEALERS?? Wouldn’t we HAVE to be if that was the case? Your information is decades behind…PLEASE catch up!
I wonder how many of the people knocking MAT have prescriptions in their medicine cabinets for some chronic medical issue or another. High blood pressure meds, insulin…these keep an individual from having the symptoms of his/her illness. Guess what? So do MAT medications. In MAT, we aren’t getting patients high, we’re getting them normal. The medication keeps these patients from having the flu like symptoms that occur when they do not have the substance acting in their system. Let me be clear, opioid withdrawal is not like some mild flu, it is like the worst case of flu you have ever had…multiplied by a factor of 12…and it is UNRELENTING.
I can hear naysayers arguing, “but high blood pressure and diabetes aren’t the same as opioid addiction. Those addicts do it to themselves!” Well, some people with high blood pressure cause it by having a not-so-healthy diet….do they not deserve treatment? Someone that acquires lung cancer because he/she smokes like a chimney for his/her entire life…should we deny those patients treatment as well, because they “did it to themselves?” Opioid Withdrawal IS a medical issue, and if medication can treat it, why do some people act like people suffering from opioid use disorder have some kind of moral defect for taking advantage of the fact that it is offered? Not all opioid “addicts” start taking opioids for some mental escape. Many of the people in MAT end up there because they become dependent after being in treatment for chronic pain management, and get kicked out because they begin to abuse it because tolerance makes the dose they are prescribed not as effective. I wish people would stop and think about what these opioid “addicts” face when they decide to seek treatment. Many of them do not seek treatment because of the stigma attached, a stigma which behavioral and mental health workers, and substance use disorder workers SHOULD BE trying eradicate, but make worse by their JUDGMENT-Y posture on MAT! SHAME! You people SHOULD know better. If you don’t, you SHOULD–do your job and get current on the latest research! Being Mr./Ms. JudgeyMcJudgeyPants helps NO ONE, and actually DETERS people who desperately NEED treatment from seeking it. So…get off your high-horse, damn!
It is extremely disheartening as an addictions therapist to read articles on social media and mainstream media regarding society’s view of “drug addicts.” It seems that there are many people that are okay with giving up on that population. Every day there are articles covering The Great Opioid Epidemic, where topics discussed include the associated death toll, the negative effects of addiction on society, the financial cost of addiction… I recently read an article where someone was quoted basically asking how many times a first responder should keep reviving an addict who has repeat instances of overdosing, as if a person’s life wasn’t worth the cost of more than one or two doses of Narcan. My heart suddenly became very heavy, and I just shook my head.
I’m guessing that those people that express such feelings have personally never had their lives be touched by addiction. I’m glad for them in that regard (and more than a bit jealous of them). Addiction can do awful things to the family members of an addict, and the family as a whole. The addict asserts, “It’s my body; I’m not hurting anyone else.” How very wrong the addict is who says that. I know from personal experience. I grew up with family members that suffered, and continue to suffer, from addiction. Watching the things it did to those family members, to me personally, and to our family was the reason I’ve never used any drugs and don’t drink alcohol. It was also the reason I became an addictions therapist. How many times have those addicted family members asked me, “What is so special about YOU? Why are YOU not as screwed up as WE are? Why does YOUR life get to be so good?” I laugh a little sarcastically to myself and think, “So GOOD? Yep. FABULOUS! All of the instances that cops were called to the house, the embarrassment when “things would happen” when I had friends over, the drunken fistfights between those family members when they had too much to drink–that ended with a hospital visit, the constant worry over one of them being arrested or dead, the walking in on one of them slitting his wrist and not being able to wake anyone to help because they were all passed out…Yep! I had it SO good.” My answer was, and is, always the same, “If I watch you touch a hot stove and burn the sh*t out of your hand, I don’t need to touch it to see if it’s hot.” I believe the saying goes “A wise man learns from his mistakes, a still wiser man learns from the mistakes of others.”
Every addict is someone’s brother, son, sister, daughter, husband, wife… someone’s loved one. People are NOT disposable just because they have a problem that affects others and is difficult to solve. People should NEVER be disposable. First responders should revive someone who has overdosed as many times as it takes. Maybe such people are asking the wrong question. Maybe they SHOULD be asking, “How can we get these people the help they need after we revive them, to prevent a recurrence of overdose?” Maybe the first responders should keep a list of referral places to send these overdosed people. Maybe states should have a look at the possibility of mandated treatment if someone overdoses more than once or twice. Clearly that person is a danger to himself/herself if it continues to happen. Just as clear is the fact that treatment is less expensive than housing the addict as a prisoner, when he/she starts committing crimes to fund his/her habit and gets caught.
I am hopeful that with all of the attention on The Great Opioid Epidemic, a truly open discussion will begin, and the great minds in the field of addiction will begin to educate society on what opioid addiction is, what Medication-Assisted Treatment (MAT) is and what it isn’t (namely “just replacing one drug with another”), why it has the highest success among the treatments for Opioid Use Disorder, and how to get people who need treatment into treatment. I am also hopeful that MAT will begin to be more widely covered by insurances, if for no other reason than that people who are functional members of society can work and thus pay their insurance premiums. (Hey, however I have to pitch it, I will; whatever works!)
Each one of us has a purpose. We each also have our own crosses to bear. God put us here for a reason, each of us with different talents and different problems so that we can use those talents help each other. None of us, regardless of the difficulty of our problems, is disposable. When we begin to view even SOME people as disposable, we ALL become in danger of eventually becoming disposable as well.
Okay, I just need to rant for a minute…
Why do some people think that everything revolves around them? When did common courtesy become uncommon? I guess what I’m really asking is…WHAT THE HELL IS WRONG WITH PEOPLE???
That would be a long list, wouldn’t it? I’m not that old, but I do remember a time when people were actually decent to each other. I shi…oops, I mean…kid you not. Imagine… people opening doors for each other, people driving as if they understand that there are, in fact, other drivers sharing the road, people not having a loud conversation in the middle of the movie theater while the main feature is playing, people offering help…with no expectation of a returned favor! Mind boggling, isn’t it?
How did we get here? Is it a result of dumbing-down school curricula over decades–a sort of ignorance of decency? Is this the consequence of everybody-gets-a-trophy entitlement? Did it arise from the ever-increasing popularity of the YouTube-ready clips of people “showing out?” When did that become entertaining, and what does that say about us? When did we begin to stop valuing each others’ humanness?
Don’t have a cow; I’m not making sweeping generalizations. I KNOW there are still kind people in the world, but you have to admit that they are getting more and more difficult to find, and there are many more observable instances of unkindness. It’s unfortunate. I wish that weren’t the case.
I’m no Pollyanna, but there has to be a way to remedy this. I’ve always said, “There’s no cure for a**hole that doesn’t end in prison-time,” but seriously, there has to be something we can do. Maybe a nation-wide movement…Down with D-bags! …Well, that’s not very family-friendly, but…we’ll come up with the name later…in the meantime, I guess I’ll have to do my part by continuing to act right, even when others do not, by taking random and frequent opportunities to show others kindness, even when they cannot return the favor, and by remembering to add to the solution, and not to the problem.
Why? Arghhh…I know, I know…genetic predisposition, environmental factors, nature, nurture…but we’re missing something. We must be. Why the compulsion to take something to feel better? Why do we think that that will fill whatever the void is? And why do we keep taking things even when it didn’t work before?
We humans do things that make no damned sense sometimes. It’s frustrating to me as an addictions therapist to watch patients struggle so hard. Many patients come into treatment earnestly wanting a better life, but when they realize the amount of work involved in actually making a better life, some become less inclined. My response when I see the loss of inclination in their micro-expressions is this: “If your life sucks so badly that you need to be high for all of it, don’t you think it’s time to change your life instead of numbing yourself to the suckage?” Often patients don’t see all of the work that they are doing to get and stay high; and they don’t realize that getting their lives together would actually be less effort. It is usually at this point that I ask the patient to recount an average day’s events for me, and what, exactly, is involved in maintaining their habit. Inevitably, maintaining the habit takes significantly more effort…and risk. Though still reticent, the patient usually concedes my point and agrees to try things “my way” for awhile.
But…getting back to my original point…what’s missing? What are we looking for? Is it a sense of belonging and acceptance? Is it unconditional love? Is it a break in the boredom? Is it something general missing or is it exclusive and different for each of us? I’m sure on some level it’s a unique amalgam for each of us, but it seems to be a general sense of entitlement to something more in life. And this is not true only for “addicts;” it’s true for everyone; “addicts” just have a more dysfunctional way of coping with the associated frustration that causes more problems in their lives.
I guess the inclination to pop something into our mouths in the hopes that it will fix what ails us isn’t so unusual. Hey…it works for headaches and cold symptoms. We get into trouble when we expect it to fix our boredom, though, and our problems or life events, and our…well, our general discontent. For those, there is no easy fix. For those, it takes time, planning, and effort. We have to identify the actual problem, not just the perceived problem, and then work to find an adaptive solution. And we need to realize that instant gratification is not likely, and that we are not promised or entitled…to anything.
When we’re children, everything is magic. We make everything fun, and our “job” is play. There is no sense of entitlement in small children. There is no judgement, either. There is fun, love, and acceptance. There is only here and now. Why do we lose all of that as we grow? There is a wisdom in the way children view the world and in the way they do things. It’s ironic that as we grow and become adults, we think we know better…yet our lives become harder because of the way we begin to view the world and the way we do things. We lose the simplicity and the enjoyment. Where is the wisdom in that?
I don’t pretend to know the answer to solving all of the world’s addiction issues. I do know that there is a void needing filling, and that until we figure out what that need is, we will never be able to do so… not adequately anyway. I also know that a good first step is to try to lose the sense of entitlement we inherit as we get older. We need to get back some of our childlike simplicity, to become more present, and to relearn to unconditionally love and accept others as we did when we were small. We must “become as little children.” Hmmm…good advice…I know I’ve read that somewhere before.
Medication-Assisted Treatment (MAT) facilities have struggled for a long time with some patients using their medication as a source of supplemental income. This happens more often than you would expect, and not just at methadone clinics. It happens at pain management clinics, and it happens at regular physicians’ offices. Selling one’s prescribed medications is called diversion, and it is a criminal offense.
You would think that it would be more likely to occur at a place like a methadone clinic. After all, those people are addicts, of course they engage in illegal activity. Well, think again. People suffering from addiction are not, in fact, the only ones engaging in this behavior. In fact, you likely know someone that has done it, or is currently doing it to make some extra cash. It isn’t difficult these days to obtain a prescription for pain meds, or for anxiety meds. These are among the most frequently diverted medications. And, if it is done through a physician’s office, there is little danger of the physician finding out. There really are no safeguards in place to prevent diversion at physicians’ offices, as there are at methadone clinics and other MAT facilities.
At MAT facilities, there are protocols in place to minimize diversion. The first is the inability to come into treatment and leave with medication to take home with you right away. In MAT, it takes time to earn takeout medication privileges. Patients are required initially to take their medication daily in front of the pharmacist at a dosing window. They have to be regularly monitored by various treatment team members for signs of over-sedation, and are monitored via random weekly urine drug screens for at least the first month. They are also required to see their counselor very regularly for addictions therapy and ongoing counseling sessions throughout the treatment episode.
Once a patient reaches a stabilizing dosage and begins testing negative for illicit substances, he/she is eligible to begin doing random urine drug screens once per month. It is at that point (usually after about a month in treatment) that the treatment team examines the patient’s individual progress to determine if he/she is ready to have the first level of takeout medication, one takeout. The patient is instructed prior to the start of each new “phase” regarding the handling of the medication, the dangers of taking it in ways other than prescribed and of taking other substances or OTC medications with the medication, and in the consequences of mishandling or misusing the medication. If the patient continues to be compliant in treatment for the subsequent ninety days, continuing to test negative for illicit substances, continuing to see the counselor regularly, and continuing to have no legal issues relating to drug use and no behavioral issues at the facility, he/she is again examined for eligibility and readiness for the next “phase,” or takeout level, two takeouts. After another ninety days of continued compliance, the patient is again examined for eligibility and readiness for the next “phase,” three takeouts. After another ninety days of continued compliance, the patient is again examined for eligibility and readiness for the next “phase,” six takeouts, meaning he/she attends clinic once per week. After another ninety days of continued compliance, the patient is again examined for eligibility and readiness for the next “phase,” thirteen takeouts, meaning he/she attends clinic once every two weeks.
The purpose of slowly increasing the allowance of takeout medications is twofold: to help the patient to avoid the addictive impulse to take more medication than he/she is prescribed, and to limit the patient’s ability to divert his/her medication. During the “phase-up” process, patients are taught to manage cravings and triggers, and taught how to handle having medication on hand without abusing it. Higher “phase” patients are still required to attend regular counseling sessions, and submit to regular random urine drug screens. It is worth noting that if, at any point in treatment a patient begins testing positive for illicit substances while he/she has takeout medication, the counselor will, depending on the situation, reduce or eliminate the number of takeouts and make the patient attend clinic more frequently for closer monitoring, and the patient will resume a weekly random urine drug screen schedule until he/she begins testing negative for illicit substances once again.
The second protocol is regular monitoring for diversion. To that end, patients having a higher “phase” are randomly phoned at least twice per year for a bottle recall. The patient is phoned in the middle of a pickup cycle and told to return to the clinic within 24 hours of the call. He/she is told to bring all bottles of medication with him/her, both empty and full. An observed drug screen (one in which a counselor of the same sex, or a medical staff member goes into the restroom with the patient) is done when he/she arrives to ensure that the patient is not bringing urine in, or falsifying urine drug screen results in any way. If the patient is selling and not ingesting the medication, the observed urine drug screen results would show negative (or a lower level) for the prescribed medication. After completing the observed urine drug screen, the patient is brought to the dosing window by the counselor, and the pharmacist inspects all of the medication bottles. The patient is then given his/her dose for that day and is instructed to medicate at the dosing window. If the seal on any of the remaining bottles is broken, if any of the medication is missing or appears to have been tampered with, it is considered a failed bottle recall and the patient is required to attend daily and begin the “phase-up” process all over again. If a patient does not answer the bottle recall phone call, does not check any messages left by the counselor, or just does not show up to complete the recall, it is considered a failed bottle recall and the consequences (loss of takeout privileges) is the same. Some MAT facilities will also require a patient to bring in any regularly prescribed medications with him/her to also have a pill count during a bottle recall to ensure that he/she is taking his/her outside medications correctly to monitor for abuse of other prescribed medications such as benzodiazepines for comorbid anxiety issues. Some MAT facilities will do a random monthly pill count for outside meds on an ongoing basis for more thorough monitoring, but will do an extra one during a bottle recall.
To further monitor for diversion issues, pharmacists and physicians at MAT facilities may utilize what’s known as the PDMP, which is a pharmacy database. This is the third protocol. The PDMP allows a pharmacist to run a patient’s information through the database to obtain information regarding a patient’s current prescriptions. This assists in preventing dual enrollment of patients, which is illegal. (Dual enrollment is when a patient is either concurrently enrolled in multiple MAT facilities, or when a patient is enrolled at an MAT facility and is also receiving prescriptions for opioids or for MAT medication at a private physician’s office.) It is especially important for MAT facilities to regularly use the PDMP because physicians’ offices cannot access prescription records for prescriptions patients receive at MAT facilities due to CFR 42.2 federal confidentiality regualtions for substance abuse treatment records. That is also the reason it is vital that MAT facilities make every effort coordinate care with patients’ physicians. Coordinating care with a patient’s physician ensures a higher level of patient safety, as the patient will be regularly monitored by both physicians.
Diversion may seem like an easy way to make extra cash, but it isn’t the primrose path it purports to be. Recently some states have passed bills allowing drug dealers and other people diverting their medications to be charged with murder if someone they sold substances or meds to happens to overdose and die. And it looks like similar bills being passed will be more common in the future as the number of prescription drug overdoses continues to increase. With the epidemic of prescription overdoses, it may behoove physicians with private practices to begin instituting protocols similar to those used in MAT facilities to minimize overdoses and diversion. First, do no harm. Where have I heard that before? Hmmm.
Shi…oops, I mean, stuff happens. I’m referring to relapse, specifically. Relapse is a part of the recovery process. It is a crappy part, but a part nonetheless. It is extremely rare to have a patient enter treatment and stay on the straight and narrow without a single relapse at some point in his/her treatment episode. I state this fact not to give patients an excuse to relapse, but to help to avoid the guilt and shame that keep patients using illicit substances once they do relapse. Relapse, like shi…stuff…happens.
Typically when people make the decision to enter substance abuse treatment, they are “gung ho” about making changes and are “all in” regarding their recovery. In the field we call this the Pink Cloud stage. Being excited about recovery is a very good thing; the problem lies in the ennui that comes after the Pink Could stage ends and everyday normal sets in. When that Pink Cloud lifts, everyday normalcy can seem…boring, despite being exactly what they expressed they wanted most when entering treatment.
Education regarding what to expect throughout each stage of treatment is the best defense a patient can have to protect his/her recovery. Any counselor or addictions therapist worth his/her salt will arm patients with adequate knowledge from the very start of treatment. After all, it is easier to handle situations if one is expecting them and has a plan of action to deal with them when they arise. This should include identifying the individual triggers for illicit substance use. Knowing the things that make a patient want to use, and having a plan of action to avoid those things and for how to handle them when they are unavoidable, are important elements of any treatment plan.
For anyone in recovery, it is also important to have support outside of the treatment setting. This entails more than simply finding a sponsor. This means changing the people that one surrounds oneself with, which can be a painful process. It means cutting off people that are damaging to one’s recovery, even if they are viewed as friends. It means not frequenting the same places that led/lead to using, or that contain people that use. One needs to change one’s playmates as well as one’s playground. There are many avenues to finding recovery support. A simple online search can be a good starting point for finding support meetings in one’s area such as A.A., N.A., Celebrate Recovery, etc. Any treatment center should also be able to provide referrals upon request. Regardless of where it’s found, outside support is essential for anyone in recovery.
Recovery is never easy. Few things in life that are worth having are. One of the most awful aspects of addiction is that it is fatal if left untreated, so the choice should be easy, even if recovery itself is not. The choice is yours: life or death. What’s it gonna be? I hope you choose life. There are many beautiful things left to see and do. There are people that need you. You are here on this earth for a reason. You are still here because you are meant to make a difference to someone. That is why we are all here. That is why we all have differing struggles and different talents, to aid each other in this place and on this journey, until we reach our final destination. And we don’t need to do it alone. That in and of itself is a beautiful thing, even when the world is not. Choose life; there is more beyond the struggle.
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