When I started treating opioid dependence, I began with high expectations. I was frustrated with what had become a mindless, ineffectual exercise in providing medication for chronic pain. I saw too many patients “circling the drain” on opioids. Most admitted they still had chronic pain despite their high consumption of opioids. Many patients needed their medication just to feel normal and avoid withdrawal. Others wished they could stop taking opioids but were unable to tolerate severe cravings in addition to withdrawal. Getting off opioids seemed impossible. Instead of being part of the solution, I felt like I was part of the problem. I wasn’t really helping these patients achieve a higher quality of life. Then I was introduced to Suboxone (buprenorphine/naloxone), and I thought perhaps this was something that showed promise, something I could wrap my arms around. Maybe we had finally discovered the “magic pill.”
Now after twelve years of using buprenorphine and hundreds of patients later, I have made two significant observations. One of those observations is that although most patients vocalize a sincere desire to be completely free of opioids and stay that way, the sad reality is that most will not be successful. Many patients are unable to completely wean, yes, even from buprenorphine. For those who do wean, relapse rates are high. So although a complete weaning from opioids plus long-term abstinence is a worthy goal, it is not something most patients achieve.
Given the dismal statistics, we may want to reconsider our treatment goals for this population. With complete abstinence as the current measuring stick for success, not only are we not succeeding — but we justify futile interventions and management schemes all in the name of achieving the drug-free patient. Although I have seen improvement recently, it is not uncommon for pharmacy benefits managers to require detailed weaning plans as well as documentation of ongoing counseling as a requirement for medication authorization. The assumption is that all patients will be weaned from opioids. That expectation ignores reality, increases expense and is a setup for failure.
This leads to the other important observation. Despite being unsuccessful in completely weaning a particular patient from opioids, I have seen significant improvement in mood and function. The miracle of buprenorphine is that it returns the patient to a state of normalcy. Patients are happy and smiling again. No longer are patients suffering from cycles of craving and withdrawal. Most of the time patients return to being productive members of society. Fathers return to being fathers. Mothers return to being mothers. Workers return to work with better focus and concentration. The streets have fewer people seeking to support their habit.
Some will point out that while all of the above may be true, the patient is still dependent on and receiving medication. That is true. However, utopian ideals rarely work in the real world. Life is often a choice between two less than ideal options. In the case of opioid dependence, the choice is not between long-term abstinence and ongoing dependence or addiction. The real choice is between improved function while on something more manageable like buprenorphine or a continual struggle with the demons of pain pills or heroin. That is an easy choice to make. Buprenorphine has not been the “magic pill” I was hoping for; nevertheless, I remain impressed with the results. We celebrate those who are able to achieve long-term abstinence, which remains the ideal. However, for the majority of patients, returning to society as a fully contributing member is not only a worthy goal, it is an achievable one as well.
Layne Kamalu is a family physician.
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