An Open Letter to Addiction Treatment Providers

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An Open Letter to Addiction Treatment Providers

By Elizabeth Brico 09/26/18

There's something wrong with addiction patients feeling the need to ask for medical advice from their communities because they don't trust their providers.

Image: 
Young woman writing in a notebook and sitting outside.
This is a common, treatable disorder with a robust body of solid research behind it. You need to read that research.

Maybe you're a psychiatrist. Maybe you're a dosing nurse at a methadone clinic. Maybe you're an inpatient counselor. Maybe you work in an emergency department, or you're an OBGYN; maybe you don't specialize in addiction at all, but you regularly come into contact with people who are struggling with the condition. If you're a medical professional, and all or some of your clients have a substance use disorder (SUD) diagnosis, this letter is for you.

I am a person in remission from a substance use disorder. I'm here to tell you that addiction patients need you to understand our condition. That sounds basic, I know. It is basic. But here's the thing: too many of you don't understand. I'm not trying to attack you. I'm not saying you're all misinformed. There are unquestionably many caring and well-informed providers doing excellent work in this arena. But it's also true that enough of you are misinformed to be causing major problems for SUD patients. And that needs to change. Like yesterday.

Right now my husband is white-knuckling his way through methadone withdrawal while his clinic works on getting him safely back on his therapeutic dose after one of you, a behavioral health doctor, rapidly dropped him 100 milligrams without consent, for no medical reason, while he was in the hospital for mental health reasons. And in 2014, my newborn daughter went through over a month of neonatal withdrawal from my prescribed methadone, which could have been prevented or lessened if my pre- and postnatal providers had made a few small changes to their protocols; sadly, this kind of medical treatment is still provided to mothers and infants across the country.

Every damn day SUD patients crowdsource medical information from social media communities and online forums, often due to mistrust in the medical community when it comes to addiction care.

Sara E. Gefvert, a certified recovery specialist who runs the Methadone Information Patient and Support Advocacy (MIPSA) Facebook group, says that she created MIPSA because she saw members of other communities receiving unreliable responses to medical questions. "Many MAT sites and groups I saw were not monitored frequently for correct and accurate content or were only adding to the misinformation and stigma that persons in recovery face, especially being on medication-assisted treatment."

In just one day, questions asked in five separate addiction treatment-focused Facebook groups included: 

What kind of pain relief options are available during labor while I'm on buprenorphine?
Should I raise my methadone dose if I have psychological but not physical cravings?
Is it normal to lose my sex drive while on methadone?
Am I still in recovery if I drink alcohol occasionally?
Can cold-turkey opioid withdrawal kill you?
Is it safe to detox while pregnant?
Can you combine buprenorphine and methadone?
Should my methadone be making me nod out?

And others along those lines.

These are all medical questions with real world consequences—some dire. The answers to these questions should be coming from trusted providers with medical expertise. Sure, people crowdsource medical information from the internet all the time, but it's usually about pretty mild concerns, or trying to squirrel out whether they should go to a doctor. On the other hand, these addiction specific questions are often accompanied by complaints that the patient couldn't get a straight answer from her treatment provider, or that the information she received was the opposite of what she read in a research study or an online article. There's nothing wrong with people seeking community input on issues they're facing, especially when the answers are reviewed by knowledgeable and professionally trained administrators like in the MIPSA group.

There is, however, something wrong with addiction patients feeling the need to ask for medical advice from their communities because they don't trust their providers.

This seems to be an especially prevalent issue for medication-assisted treatment (MAT) patients. I was on methadone for about a year in 2013 and 2014, and on buprenorphine from 2014 to June of 2018 (with a short break of about five months in 2016). Before starting methadone, I was actively addicted to heroin for close to five years. In all of that time, I heard a lot of different things from a lot of different doctors, nurses, counselors and detox staff in virtually every region of the country. For example:

Buprenorphine is only good as a detox aid.
Buprenorphine works best as a long-term treatment.

Methadone is more addictive than heroin.
Methadone creates a dependency but effectively treats addiction.

Breastfeeding while on methadone is unsafe.
Breastfeeding while on methadone can help ease neonatal withdrawal.

I can't count myself sober if I take medication
I'm at an increased risk of relapsing and overdosing if I detox.

Addiction is a disease.
Addiction is a spiritual malady.

How was I supposed to tease out the truth from all that?

With all the confusing and contradictory information that patients receive about addiction, it would be easy for someone to assume that the medical science is still out. In reality, there's quite a lot of straightforward, peer-reviewed data about substance use disorders. Frankly, there is no excuse for a medical provider to ignore these facts. For example, decades of research have shown that methadone (a long-acting opioid agonist) and buprenorphine (a partial opioid agonist), help deter opioid misuse, decrease the risk of fatal overdose, and may help to correct neurochemical changes that took place during active addiction.

To quickly address some of the other misinformation I've encountered:

  • Both methadone and buprenorphine treatment are appropriate, and in fact designed, for long-term use. Patients who choose to taper from these medicines can do so safely, but there is no generalized medical reason why someone with an opioid use disorder should be forced off either medication.
  • Breastfeeding while on methadone or buprenorphine is considered safe as long as the mother is not using other substances.
  • If a patient is using these medicines as prescribed and is not using other substances in a compulsive manner, they are in remission from their substance use disorder. In other words, they’re sober (though defining oneself with the term "sober" is a personal choice).
  • Addiction is medically defined as a disease. Which means that the onus is on our medical providers to stay informed about the science of this disease.

Ultimately, you can't be held responsible for everything your patient does. But you do have a responsibility as a treatment provider to give your patients accurate and informed medical advice.

According to the Substance Abuse and Mental Health Administration (SAMHSA), about 20 million adults in the United States have a substance use disorder. So we're not talking about some rare condition that only a handful of specialists can be reasonably expected to understand. This is a common, treatable disorder with a robust body of solid research behind it. You need to read that research. You need to stay informed. If you don't have an answer to a patient's question, you need to refer them to an accessible colleague who will. You took an oath to do no harm. Staying informed about addiction medicine is part of keeping that oath.

Sincerely,

Elizabeth Brico

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