The death of actor Philip Seymour Hoffman from a heroin overdose has brought about a lot of discussion regarding medical treatment to prevent heroin deaths. I will not “diagnose” Mr. Hoffman in any specific manner, as it is unethical to do so for a person that one has never seen or examined in person. I cringe when I see physician television personalities “diagnose” celebrities whom they have never spoken with.
Buprenorphine is a medication used to treat addiction to heroin and other narcotic pain killers. Buprenorphine is the opioid, or narcotic part of the medications Subutex and Suboxone. It is used for what is called Opioid Agonist Therapy (OAT). It can be thought of as a safer and office based alternative to methadone. Methadone, by law, can only be administered in a methadone clinic. Buprenorphine can be written in a private doctor’s office, and filled at a pharmacy just like any other prescription. Patients that start buprenorphine therapy usually describe themselves as “feeling normal again”. One’s life changes from dysfunctional back to functional. Buprenorphine also blocks the effects of other narcotics, so this provides another safeguard and behavioral reinforcement for not abusing heroin or other narcotics.
Suboxone is taken as either a tablet or a small film that is dissolved under the tongue. I think that it works great for patients that were abusing pills by swallowing or inhaling them nasally. The medication kind of acts as a “one-for- one” replacement. However, in my medical practice, I have noticed that intravenous users can have a harder time remaining abstinent even with Suboxone therapy. This is because taking a tablet or a film cannot even nearly approximate the entire experience of preparing and injecting an opiate such as heroin. The entire process of preparing the heroin for injection is an addictive behavior in itself. Patients have described it to me as being similar to sexual foreplay, but even more pleasurable. The “rush” that people get when injecting heroin is also a uniquely addictive experience, and has been described as being similar to sexual climax, only much more pleasurable. So we have two incredibly reinforcing behaviors at work here, and this makes the addiction more difficult to treat. Taking a tablet or a film pales in comparison to the entire experience of using intravenously.
Buprenorphine only works if you take it. Patients that are prescribed buprenorphine can choose to not take it and go back to their previous drug use. So, buprenorphine can be a “wonder drug” for many, and prevent heroin deaths. However, if someone chooses the euphoric pleasurable rush of intravenous heroin use over buprenorphine, heroin deaths are not always avoidable. The sad truth is like with other diseases, some people do not recover, and they die. The same holds true for the disease of addiction.
The numerous articles about Mr. Hoffman mentioned that he was attending 12-step meetings (Alcoholics Anonymous – AA – and Narcotics Anonymous – NA). There are many things about 12-step meetings that I do like. I consider 12-step meetings to be free group therapy, as well as a source of social support. 12-step meetings and cognitive behavioral therapy basically say the same things. They both teach coping skills, one based in spirituality, the other based in psychology.
However, I also think that 12-step meetings can be dangerous for some people. It is not AA or NA policy to discourage or forbid use of medications to treat addiction and psychiatric illness. However, in practice, there are many people who do this, including rehab programs that do not offer medication, and there can be negative consequences as a result. For example, take a patient who has a history of multiple relapses on narcotics. That person then starts Suboxone treatment, and his addiction goes into remission. The patient then tells their AA or NA sponsor that they are on this medication. The sponsor tells him that he must stop the medication because he is not “sober” or “clean”. The patient then stops his Suboxone, and eventually relapses because of advice from a misinformed layperson. His life goes back into dysfunction, as well as return to a risk of overdose.
In 12-step teachings it is said that “the definition of insanity is doing the same thing over and over again, yet expecting a different result”. Yet advice given by AA or NA members can contradict this. Advising someone to continue to try medication free abstinence, and watch them continue to relapse, IS “doing the same thing over and over again”.
It is also said in 12-step meetings that “medicine and science could not help us, so we formed the fellowship” of AA or NA. However, science and medicine ARE starting to be able to help. Yet, this type of help is being shunned by 12-step group members and some 12-step rehab based programs.
I think that it is hypocritical and does not make any sense.
“Physician Stuart Kloda, an addiction medicine specialist in private practice, notes that those who quit heroin and then relapse are especially vulnerable to fatal overdoses.
This is an excerpt from the video that discusses this:
“If at the end of your initial addiction, you were using, say, five bags of heroin, and then a couple of months go by and you start injecting heroin again, and you decide okay, ‘I’m going to inject five bags,’ your risk of overdose is very high, because your body is not tolerant of that amount of the drug,” he said.
Kloda and Schorr say that deaths like Hoffman’s are preventable, because treatments that combine counseling with opioid replacements like methadone or Suboxone (buprenorphine and naloxone) are highly effective.
But they say not all drug rehabilitation programs are current in their treatment approach.
“They are not offering appropriate medical therapy for addiction, and they’re not offering Suboxone,” Kloda said, calling it “one of the best drugs that has been developed for addiction, in a very, very long time. Basically, in one day, once it’s started, and the person finds the right dose, they’re out of withdrawal, everything is great,” he said. “You’re fine, you feel good, and I consistently see people do well,” both at work and in their personal relationships.
Kloda says traditional self-help groups, like Narcotics Anonymous, are invaluable in offering social support and interaction with other recovering addicts. “It’s like free group therapy, cognitive therapy,” he said. But he said although it’s not official NA policy, “a lot of group members are anti-medications, even anti-depressants. So people have had their peer groups drop them, or they’ve relapsed, because they had a sponsor who told them to go off their medication.”