The Tough Grey World of Addiction Medicine

Pills The New York times recently had a great article about addiction medicine and the controversial drug Suboxone and it’s generic relative buprenorphine used to treat opioid addiction.

The article highlights how addiction medicine is fraught with many controversies –from the drugs used to treat addicts to the controversial clinics to the controversial physicians running them.

Controversial Drugs. The article focuses on Suboxone and the generic, though slightly different, buprenorphine. Suboxone is different from buprenorphine because it has an additional ingredient to help prevent it’s abuse. This seems great, and the clearly superior drug, right? Well, ironically, not for drug addicts who don’t have jobs or money or health insurance, because Suboxone is significantly more expensive. So, it’s a Catch-22. What’s an addiction medicine doc to do? Prescribe a better drug that his or her patients can’t afford and are unlikely to be able to stay on, or prescribe a cheaper drug that knowingly is more addictive?

Controversial Clinics. The article describes several free-standing clinics designed to treat large numbers of these patients with knowingly high doses. Higher doses may be more effective, right? But, how high is too high (no pun intended)? Many facilities have waiting lists and serve as many patients as they can. But, how many patients is too many? What about seeing patients only monthly instead of weekly, again, so you can see more patients and help more people? How do you balance the greater good (serving more patients) vs. the good of the individual patient?

Controversial physicians. It’s no secret that many addiction medicine physicians are former addicts themselves. If you believe that medicine is a calling, addiction medicine might be a calling within a calling: addicts are not an easy-to-treat or high revenue-generating class of patients. And, having addicts treat addicts makes many uneasy. Many of these physicians are facing the same battles as their patients. And, with the potential for relapse high for any addict, trusting that your doctor stays sober might be the ultimate form of trust in the doctor-patient relationship.

This all makes for a very messy picture. Many even wonder if patients on these maintenance drugs can be considered “clean” or “sober.” To that, I’d say, does it matter? As long as they are leading more productive lives, I’d say the treatment is successful. So, while we are not dealing with the “ideal” patients or the “ideal” meds, or the “ideal” outcomes, I think we have to get comfortable with this grey zone.

Understandably, many are not comfortable with this grey area. We tend to judge people with addictions because it is an illness that spills out into the patient’s life and it often results in bad behavior: negligence of work and family and often illegal behaviors like stealing, prostitution, etc. These patients’ lives are complicated and messy and their recovery is just as complicated. It isn’t only about staying sober –it’s also learning to handle life’s stressors, putting relationships back together, finding and holding a job, etc. No other form of recovery in medicine asks so much of its patients –we should all be a little more tolerant of the grey areas to get that done.

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