My favorite patients are drug addicts

April 23, 2010

Medical school taught me little about drug and alcohol addiction and treatment, and residency taught me even less.

Key Points

Addicts cause their own miseries, I thought. And since these were the Reagan years, they should "just say no" when offered drugs. My attitude mirrored those of the attending physicians in my residency program. When an addict was admitted twice for endocarditis, needing an artificial valve on the first admission and its replacement on the second admission for reinfection, I was just as irritated as the attending and the rest of the house staff. I remember discussing whether we could ethically refuse him treatment if he came in a third time. We were so self-righteous, though we had offered him little in the way of treatment for his disease.

I knew nothing about medication-assisted therapies for opioid addiction. Now I know better.

I was working part time in primary care when a colleague, the medical director at a local drug treatment center, asked if I could work for him for a few days while he was out of town. He was a good friend, so I agreed. I thought it would be easy money-and fun, doing admission histories and physicals on addicts entering the inpatient residential program, and I was right.

But I also saw patients entering the clinic's methadone program. This appalled me. It seemed seedy and shady, a fringe area of medicine. I told myself I would work those few days, tell my friend politely when he returned that I didn't "believe in methadone"-as if it were a unicorn-and could not work there again.

But when I talked to these patients, they surprised me. Some were intravenous heroin addicts, but most were addicted to pain pills like oxycodone, various forms of hydrocodone, and morphine. Most of them had jobs and families, and expressed an overwhelming desire to be free from their addiction. I was most intrigued by how they talked about methadone treatment, how "it gave me my life back" and "now I don't think about using drugs all the time." But with methadone, weren't they still using drugs?

My curiosity was piqued, and I started reading everything I could find about methadone. I discovered that the treatment of opioid addiction with methadone is evidence-based with 40 years worth of solid data proving its efficacy. So why had I never heard of it? I could have referred many intravenous heroin addicts during my residency for effective treatment of their addiction.

Because of methadone's unique pharmacology, it blocks physical opioid withdrawal symptoms for more than 24 hours in most patients, and it blocks the euphoria of illicit opioids. At the proper dose, patients should not be sedated or in withdrawal, and are able to function normally, working and driving without difficulty. Therefore, methadone maintenance is not "like giving whiskey to an alcoholic," as some ill-informed people-like me-have claimed.

Buprenorphine, a partial opioid agonist, is a milder opioid, and there is a ceiling on its opioid effects, making it a safer and better choice for many patients than methadone. It is particularly good for addicts with relatively short periods of addiction and fairly stable lives. Since it is a milder opioid, it is relatively easier to taper, if appropriate.

I started prescribing buprenorphine from a private office. I did notice that the demographics of office patients were different from the methadone clinic. Unfortunately, buprenorphine is expensive, at a minimum of $6 per 8 mg pill, and some patients needed up to four pills per day. It became evident that only people of financial means or with specific types of medical insurance were able to afford the office visit, the medication, drug screens and other lab tests, and individual counseling. At methadone clinics, most patients are self-pay and could pay a day at a time, usually a fee of $10-$15. All services were bundled into that one daily charge.