Opiate use disorder is increasingly common, and it is important to develop a systematic approach for treating it. In this article, I will discuss some of the more important elements of treatment, starting with the need to address patients’ denial and moving on to some of the nitty gritty aspects of medication-assisted treatment.
Acknowledging the problem
In asking patients about their opiate use, I have encountered many forms of denial. Here are two of the more common ones.
“My problem isn’t very serious.”
Even people who acknowledge that they have a problem are very good at compartmentalizing—using both ambivalence and denial. They may say, “Well, I just need help with the physical part of my addiction. If I could do a quick detox I’d be fine. I don’t need to do anything else beyond that.” But in fact, most patients are unlikely to be successful without other support and will quickly relapse.
“I don’t have a drug problem, I just use it sometimes to deal with stress.”
Self-medicating is very common. People will use what they have at hand to self-treat their depression or anxiety symptoms without recognizing they are doing so. They may use their Vicodin in the same way others would “drown their sorrows” in alcohol.
I often use motivational interviewing techniques during my initial evaluations (for details on the approach, see our interview with Dr. William Miller in CATR, October 2014). I start by helping people to recognize that there might be a problem. This usually involves helping them to see the discrepancy between where they are now and where they would like to be. Then I help them understand some of the things that they can work on to successfully achieve their goals.
One of the main challenges is to help people acknowledge what sort of pain they are using the drugs to address—physical pain, emotional pain, or both. Patients commonly end up abusing opiates after having received a narcotic prescription for a pain issue and then continuing to use it for other reasons. I try to help them recognize that there’s a difference between emotional pain and physical pain. The medication may temporarily alleviate some symptoms of both of those things, but there are also negative aspects of using an opioid this way, and I help them to think this through.
Some patients readily admit that they use an opiate daily for emotional issues. If so, I might respond with, “Is this strategy giving you the kind of emotional stability that you want? After all, there are other ways to get through tough days. Have you really considered the potential consequences, including to your health, legal issues, and how others would perceive you for doing this sort of thing?” This will often lead to a discussion of alternative treatments, like counseling or psychiatric medications.
People often overestimate how much control they have over their use of opiates. Things may appear relatively stable from their point of view, but something unexpected may happen, causing more stress, and they escalate their use temporarily—only to realize they can’t reduce their dose back to what they were taking before. And if they keep increasing the dose, tolerance and withdrawal symptoms appear. Such symptoms may drive people to do more egregious things to obtain their fix, and they may start to recognize that this is not how they want to live their lives.
Effective treatment of any substance use disorder involves psychosocial interventions at the least, often with the addition of medication-assisted treatment. In this section, I’ll focus on how to use medications such as methadone and buprenorphine to help your patients who are abusing opioids.
While we often think of detox as a short-term process, the official federal definition allows for up to a 6-month taper. Such a long detox can often be done on an outpatient basis. Some patients will opt for detox, while others will do better with maintenance treatment (defined as staying on a prescribed opiate for greater than 6 months). Some patients require inpatient detox, and the American Society of Addiction Medicine (ASAM) criteria can help clinicians make that decision (see CATR, November 2015 for an entire issue explaining the ASAM criteria). In general, inpatient detox works best for patients with more severe addictions, those with psychiatric or medical issues, and those with challenging psychosocial situations, like homelessness and/or continued availability of substances at home.
Some patients are able to gradually taper down their use of oral opioids without a specific detox protocol. For the most part, these are patients who have been able to obtain the medications legitimately. For example, patients may have started taking opioids because of some dental work, but later found that they became dependent, first psychologically then physically. They may have been obtaining it by going to multiple providers or perhaps one provider has continued to provide refills. In this context, it would be reasonable to try a therapeutic taper. In my experience, the taper will be most successful if you taper more slowly both at the beginning and at the end. For example, if a patient has become dependent on taking 8 to 10 Vicodin per day, you might reduce the dose by a half pill every few days initially, speed up the taper to a full pill per unit time, and then slow it back down to a half or a quarter pill at the end.