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Personal responsibility is needed to treat drug addiction

| Patient | August 24, 2011

A 44-year-old man came to my office to begin Suboxone in hopes of stopping his injecting heroin. He was raised well by married parents, whose other four children have not indulged in narcotics.

He lives with a friend, unable to contribute to rent while “not working” yet somehow he affords $50 per day for narcotics through (self-admitted) hustling (comprising: working as one tentacle of the drug-dealers’ network, shoplifting, borrowing with no intent to repay, and under-the-table jobs).

He casually mentions having been treated in more than 70 previous detoxification-attempts: none of which he has paid for. Does he value the detoxes, not having any investment in them? He pays nothing for his insurance (which is free, via state-largess: Medicaid), which endlessly cycles him through these detoxes.

There is no specific incentive to stay clean, knowing that someone else will perform this task soon enough, with no personal repercussion, responsibility, or fee. Trying to relate this situation of lack-of-seriousness to him in understandable terms: I thought up an example of having an eternally-valid “free car wash” card. If such a thing existed, would the bearer take great care in keeping his car clean?

If only of the price of a car wash were involved, this might not be so great an issue or problem, but, in reality, each individual detox-effort costs (the rest of us) a price more in line with a top-shelf, luxury paint-job on that same car. To continue the example, he’s not just getting a car muddy, he’s graffiti-spray-painting it (70 times over!) with the rest of us (via a leaden state-apparatus) giving “free refills,” on multi-thousand dollar paint jobs.

This free refill policy, aside from not helping beleaguered taxpayers, doesn’t even help this man’s addiction, by avoiding teaching any personal responsibility. The longest he has been free and entirely clean from narcotics, in the last 18 years, has been during a three-year episode in prison. Invariably, within a few days after any detox (or release from prison), he will restart narcotics,most often because he is “bored”.

A carrot-and-stick approach would be eminently sensible. Certainly, make attempts to help someone get clean, but at a certain point if people are showing up addicted to illegal drugs, there should be repercussions. Implicit in heroin-usage and obtaining drug-money are criminal activity.

In pursuing and prosecuting such criminal activity, remember that this man’s most effective “detox” occurred during his prison-days. While walking “free,” our cost in detoxes alone has been close to $1 million.

This dollar price doesn’t begin to reflect a price incurred through the diminution of others’ lives he has “touched” adversely in pursuit of his own drug-money: aiding and abetting drug dealers’ “outreach” for new customers, as yet virgin to drug-addiction.

Randall S. Bock is a primary care physician who blogs at Withdraw to Freedom.

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  • http://doctorfoodtruth.wordpress.com/ Eric Marcotte, MD

    Wow, honesty is refreshing. I’ve felt similarly but never been able to express nearly as well. Thanks for the bitterness-free, blunt approach. As another primary care doc, I have learned that personal responsibility is required for nearly every cure, no matter how eminently medical or psychological. My passion has become obesity and dietary diseases but even simple infections require the willingness to do what is needed (take antibiotics on schedule) or else treatment failure will occur.
    Just yesterday a state-insured family came in for the third visit in 2 weeks for a tobacco-exposure related middle ear infection in an 8-year-old. The last visit was purely because the kid rules the family and mom wouldn’t enforce phishing high-dose amoxicillin regimen. So, I gave the only can’t-refuse therapy I know of: a free (~$100) but painful shot of ceftriaxone.
    The kid’s 8, he gets a pass on being responsible for a couple more years but mom… Rather than enforce rules and deal with her son’s refusal, she used about $200 of government resources and allowed her son to get a truly painful shot of an excessively broad-spectrum antibiotic. Ugly now that I think it through.
    We truly do need a carrot-and-stick model – our current, carrot-only version is completely imbalanced.

    • Anonymous

      That is brilliant and simple-instead of all out saying addicts  are just lacking willpower-you are saying people have to do somethings prescribed to help ourselves with ANY chronic illness.

      • Randall Bock

        I tell my narcotic addicts that I can’t cure them, but only can act as a conduit, channeling their own desires for sobriety.  Much as you would land an airplane, you can glide your narcotic dose down comfortably (without crashing!).

    • Randall Bock

      Tough situation, but may I suggest copayments as a percentage of the bill.  While some see that as draconian, would play out as far less than overall (say) cigarette-costs, and would guide use, avoid misuse, invite participation in the health care decisions.

      And thank you for the kind words.  Good luck in your practice.  I grazed over to your blog, should check out your book.  Perhaps we should talk.

      • http://doctorfoodtruth.wordpress.com/ Eric Marcotte, MD

        Dr. Bock-
        Thanks for your response, I’d very much like to connect. I’m fairly new to blogging/social media and value the advice of more experienced folks. I’d send you my email but not sure if this is private or not :-) If it is, let me know and I’ll send you my email Eric

  • http://twitter.com/PersonalFailure Personal Failure

    Addiction is a disease. By your logic, we should make diabetics and those with cancer pay through the nose, because responsible people don’t have diseases.

    The real problem is the it’s much easier to get suboxone than a 6 month to 1 year stay in a residential treatment facility, which is really what’s needed to break addictions.

    • Anonymous

      Well, his parents were married so he should not have gotten a socially unacceptable “disease”.

    • Randall Bock

      Long-term stay in a residential treatment facility does not really (and can’t) teach sobriety in the face of actual life circumstances, much as this gentleman ‘s prison-stay sobriety did not help him once free.

      Cancer and diabetes don’t begin by “hanging around with the wrong people”, “getting high” or “partying”; nor can they be abruptly stopped by a prison term.  I’m not arguing that addiction is easy to get rid of, but there is no genuine disease which yields solely to good behavior, mental focus, maturity, and putting up with short-term aches and pains (withdrawal symptoms).

    • http://profiles.google.com/molly.ciliberti Molly Ciliberti

      Watch out Dr. Bock has a slap on your hand for even thinking this coming.

      • Randall Bock

        prefer to think of it as conversation

    • Randall Bock

      Thought experiment:
      === a type I diabetic and an IV drug abuser get thrown in a draconian prison (“No needles!”  “No drugs!”). 
      === Come back one month later: the diabetic has died, the IV drug abuser looks much improved.
      === Which one had the disease?

  • Anonymous

    To make matters worse, now people are seeking “treatment” in order to get suboxone to sell or use for snorting/abuse.  

    • Randall Bock

      True: many physicians write Suboxone at the maximal recommended dose of 24 mg/day  (or above: 32 mg/day!),  whereas when we start patients up, tailoring the dose to match and ablate their symptoms, ordinarily our starting dose is in the 10-14 mg/day range.  Patients have found it quite easy to purchase Suboxone “off the street”.  This does not help patients in treatment, when they know they can flaunt guidelines and still get a dose.

  • http://twitter.com/eddunkle Keith Alt

    Legalize it.  The price plummets, the junkie gets his fix, no more crime.

    • Payne Hertz

      Short. Sweet. True.

    • Randall Bock

      Drug legalization or decriminalization is opposed by a
      vast majority of Americans and people around the world.  Illicit drugs have been made illegal because of their
      intoxicating effects on the brain, damaging impact on the body, adverse impact
      on societally-reinforcing behaviors, and addiction-potential.

      Legalization would decrease price and increase
      availability, and imply society’s imprimatur.  Availability is a
      leading factor associated with increased drug use. 

      Much
      as the legalization of gay marriage (independent of one’s opinion of
      same) has (secondarily) brought about the teaching of homosexual acts in
      elementary and middle schools– “harm reduction” would bring IV-methods
      to similar age groups as anticipation of “proper” (now legal) drug-use
      methods.

      Nor would legalization eliminate the black market, which would still exist unless all psychoactive and addictive
      drugs in all strengths were made available to all ages in unlimited quantity.

      The answer to inundation is not acquiescence.

      • http://twitter.com/eddunkle Keith Alt

        The answer to medical problems are medical solutions.  A scientist should head the DEA, not a policeman.  Incarceration just makes damaged people more damaged.

        • Randall Bock

          1. Let’s say that somebody has a binge night of drinking, and is hung over the next day.  On the one hand, this isn’t a medical problem — and on the other, even if you presume it is, there is not
          a “medical solution” in response.   Ditto, in the realm of injuries: you should question how the injury occurred, but the incident itself is not medical, nor the response.

          2. “DEA” = “Drug Enforcement Agency”, perhaps you are thinking of “Health and Human Services” or “National Institutes of Health”

    • http://profiles.google.com/molly.ciliberti Molly Ciliberti

      Yes, legalize all drugs and use the “war on drugs” money on helping people manage their addiction. We waste tons of money on this stupid war on drugs and accomplish nothing. I sure got a deep seated sense of Republican holier than thou attitude in this blog.

  • Payne Hertz

    It’s pointless to talk about personal responsibility in a system in which there is no personal autonomy. This man is simply doing what he has to do to deal with his addiction in a system that was set up to enrich you, not benefit him.

    Do away with the medical monopoly on drugs and prohibition and let him make his own decisions about what he does and does not put in his own body and you will never see him in your office again.

    Everything you describe was predicted by opponents of prohibition 100 years ago. Why people still react with surprise that addicts behave the way they do within the context this system is beyond me. You can’t change the nature of addiction, but you can change the system.

    • Randall Bock

      Feel free to attempt legislation of whichever drug you choose; however, in the interim, the law is quite clear, and there is no reason why those who become addicted to narcotics should be exempted from law-abiding responsibility.  The mere act of endeavoring to begin illegal narcotics belies your statement of  “no personal autonomy”.  In fact perhaps there is too much: keep in mind that this gentleman’s longest period of sobriety occurred during his prison term, in the absence of such autonomy — naturally, and conversely, his period of making his own decisions have led to his unhappiness and that of others around him.

      • Payne Hertz

        I didn’t say there is no “personal responsibility” but that it is pointless to talk about it in this context.

        A wise man once said “the law is an ass.” There is nothing inherently criminal about using drugs, as there is with rape or murder. If there was, you’d be the first person we’d have to arrest and send to the Gulag.

        It is “criminal behavior” because it has been arbitrarily declared as such to protect profit. I believe there are more humane and efficient ways to help people cope with addiction than locking them in a cage to be raped and brutalized for years at enormous expense. Don’t you? Wouldn’t it be better to just let addicts take the drugs they need to cope and let them sort their own lives out?

        It is always easy to tell people what they should and should not do and demonize them for failing to meet your demands. But the demand for sobriety is not realistic given the hundreds of years of historical evidence that most addicts simply can’t beat their addictions, so to demand that they do at the risk of brutal punishment is barbaric. To blame addicts for doing what they have to do to cope within this system to cope with the reality of their situation is morally wrong.

        • ambrosia hafen-hayes

          the “personal responsibility” argument at this point in treatment is moot. His brain has now been changed chemically (some studies would argue, permanently). His behaviors are simply manifestations of those changes. This is a medical issue that should be treated in a medical fashion by the MD. The inability to manage his disease on his own is indeed impacted by extraneous psychosocial factors, including decisions made earlier in life (the choice to try the drug he is addicted to), as well as current circumstances. It is easy to point blame at the patient as drug and alcohol addiction is still a topic that remains a mystery: it has not been explored as much clinically as other diseases, and as such, has not easily been resolved. As difficult as it may be to not do so, it is always best to try to treat patients objectively for their medical issues with clinical solutions, and leave the psych/social aspects to us social workers ; ), This is a complicated problem that warrants interdisciplinary approach.

          please review this helpful info:

          http://www.drugabuse.gov/infofacts/understand.html

        • Randall Bock

          “Payne Hertz” presents a very limited/ false choice: endless rehabs or “brutalized in prison”; certainly there are other options.  People actually do well with encouragement, training, and the idea / possibility of leaving this maze.

          Low expectation is a self-fulfilling prophecy.

          • Payne Hertz

            I am not presenting a false choice, but reality. This is the reality of our system now is endless rehabs, an endless struggle to obtain drugs or jail. Most addicts do not have the choice of continuing to use in a controlled manner through harm reduction programs, which have been shown to be effective at minimizing the personal and social dysfunction arising from drug use, most of which are due to prohibition, and not the effects of the drugs themselves. The majority of narcotic addicts can live full and functional lives if they are allowed to obtain a reliable, adequate daily dose of narcotic drugs. Using brutality and social stigma to try and force them to stop clearly hasn’t worked, but accommodating the addiction until such time as the individual himself is ready to undertake the monumental effort needed to quit at least minimizes the harm involved to that produced by the drug itself.

            Countries that have liberalized their drug laws, such as The Netherlands and Portugal, have seen a drop in the use of drugs overall. That may seem a paradox, but remember that drug users use drugs to escape from physical or psychological pain. The easier you make their lives, like by not brutalizing them or forcing them into a daily Darwinian struggle for obtaining drugs, the less they need those drugs to cope with life and the more likely they are to muster the psychological resources needed to quit.

            Encouragement is certainly desirable, but realistically it isn’t going to do much to help people quit.

          • Randall Bock

            Increased state-sanctioned methadone supply, and overall liberalization of attitudes toward narcotics have led to lower street narcotic prices. During the same period narcotic-related deaths have multiplied enormously here and abroad. Just two generations ago, opiate-usage was a thousandfold less than it is now.  Was the human race worse off then?

  • R Gladwin

    “Personal responsibility?” Most people aren’t even familiar with that terminology.

  • http://twitter.com/AddictionSuport Ned Wicker

    Boy what a good point this article makes, free treatment is worthless treatment. If I’m not paying for something why do I care if it works, why do I commit to it.

    Most of the people that write to me on the site say they have no money for treatment, my question is how come they always seem to have money to buy drugs and alcohol?

  • Randall Bock

    in regard to the quote below “Legalize it.  The price plummets, the
    junkie gets his fix, no more crime. “  n.b.: Heroin prices
    plummeted in the decades after introduction of methadone, a quasi-legal
    narcotic, one certainly endorsed by multiple levels of the state
    apparatus.  When it essentially nearly doubled the overall US supply of
    narcotic, prices plummeted, but narcotic-dealers didn’t disappear, just
    worked harder expanding the user-population: making the resulting
    user-demographic younger and socioeconomically broader.  Even under
    “legalization” certain age groups would face restriction, and illicit
    dealers would still be at work.  Is the addition of more narcotic what
    our society needs now?

  • Randall Bock

    Even tattoos are not necessarily permanent. 

    Breakup from a deep and meaningful love affair can present misery (and, yes, “brain changes”) on par with narcotic-withdrawal’s; yet one would not presume no ultimate exit back to equilibrium.

    • ambrosia hafen-hayes

      I would encourage all medical professionals to review the information provided in the link I posted earlier from the Dept of Health and Human Services. Under the “medical and health professionals” heading is informative resources, especially the resource article “Drugs, Brains, and Behavior: The Science of Addiction”. I humbly beg to differ that there is supporting clinical evidence that indicates that heartbreak is comparable to drug addiction with regards to impact on the brain. But I would happy to see this information, as I would find it very helpful. This condition should be approached by scientists, researchers, and medical professionals as objectively as possible, leaving out personal opinions and relying solely upon clinical evidence as well as qualitative research. While drug addiction is indeed preventable and curable, it is still a medical condition, not a moral or character issue.

      • Randall Bock

        1. Narcotic usage ‘s bell curve peak is at (approximately) age 21.  Left to its own devices, it peters out with age.

        2. Heartbreak versus narcotics: hard to prove either way; keep in mind though that yearly suicide attempts are 20 times more common than (and completed suicides are twice as common as) narcotic overdose deaths.  Certainly there is some overlap of causality between the categories, but as likely as not the amount of major stress leading to suicidal attempt from “heartbreak” is on par or greater than that from narcotics.

  • http://twitter.com/USMCShrink Kevin Nasky

    Nothing new here, but this is really simple:
    Legalize everything.
    Take all money saved from waging the “War on Drugs” (billions?) and fund the most bad-ass substance treatment program in the world. Since one size doesn’t fit all, fund all sorts of programs ranging from abstinence-based to harm-reduction, psychologically-based and biologically-based, etc. There will still be a zillion dollars left over, so we can put enormous funding into research substance disorders.
    For those of you hung up on the ‘impact on society’ potential of legalization…I’m not sure use would increase. But let’s just say it does. What does that concern you? Most people get high in their homes. If the concern is that our streets and public places would be infused with intoxicated junkies (I assume that’s what one poster was referring to when he said “adverse impact on societally-reinforcing behaviors), then we can divert law enforcement efforts in the direction of arresting those who are publicly intoxicated.

    • Randall Bock

      millions, billions, trillions, zillions

      >> millions: the amount that one individual addict’s treatment can consume (case in point: as above)
      >> billions: $15 billion for “the war on drugs” an amount dwarfed by our current “most bad-ass substance treatment program in the world”: e.g. ~$6 billion on methadone maintenance alone; and an (un)healthy  percentage of the overall Medicaid/SSDI $600 billion burden; say, lowball $200 billion, not even counting the loss (by absence from production) to the overall economy
      >> trillions:  the amount of our current (and growing) national debt
      >> zillions: (not!) the amount that would be “left over” (despite the growing national debt) if the war on drugs were cut

      Having top-down state-funding of these treatment programs (again without personal responsibility) is part of the problem.  As we have thrown money at this problem (as with others: USPS, public education, you name it) the problem has not disappeared; in fact has grown.  Since the 1970s’ advent of government in drug-treatment, the only palpable gain has been in number of addicts and number of treatment-centers and modalities: a symbiosis in which both parties are invested in continuation rather than cure.

  • Randall Bock

    One recovering patient runs an HVAC service.  His warranty plans don’t include negligence and willful damage. 

    RSB: “What if the warranty plan wasn’t paid for by you or the customer, but by the government?  Would you do it?”    HVAC: “Of course!”

    RSB:   “Do you think that would result in more service calls?”
    HVAC: “Of course!”

    RSB: “Do you think that would result in less user self-maintenance?”
    HVAC: “Of course!”

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