Below is a direct cut and paste from an email I recently received from a colleague who feared his drinking had spiraled out of control. He managed to get a friend to lend him a few days-worth of the prescription medication naltrexone, proven to reduce cravings.
“The bottom line is that the cravings were making me uncomfortable and I can’t believe how they have vanished. Is Naltrexone used as a preventative measure for people like me? The first order is figuring out who will give me a prescription. My doctor is lovely and smart but I REALLY don’t want to have this conversation with her. Uh huh. Hello shame. I’m not even sure she would support it, which could be even more humiliating.”
I cannot tell you how often I’ve received emails or had conversations like this. Naltrexone is rarely prescribed, even though it’s proven to help at least 1 in 10 people with drinking problems, probably a lot more. Yet doctors routinely write presriptions for heart medications aimed at preventing 1 in 50 heart attacks. Full disclosure, I received a series of Vivitrol shots (the 30-day extended release injectable version of Naltrexone) a few years ago when I had a brief episode of drinking. That medication, in tandem with trauma therapy, helped me enormously.
We live in wondrous times, where medications ease the pain and suffering associated with thousands of conditions. So why do we withhold access to medications scientifically proven to help those battling substance use disorders?
Using medications to treat substance use has a complicated history. People are justifiably skeptical of an industry that makes billions on getting people addicted in the first place by fraudulently marketing drugs like Oxycontin – only to turn around and heavily promote an anti-craving medication like Vivitrol. But let’s not demonize all pharmaceuticals. Anti-craving medications such as Naltrexone and Gabapentin, need to be part of a broad tool kit to treat problematic substance use.
Then there’s the stubborn belief in AA and 12-step circles that you don’t “use drugs to get off drugs.” This thinking is incorrect, not supported by the evidence and is actually counter to what the founders of AA said. Confirmed by Stanford University’s Dr. Keith Humphreys, a former senior advisor on addiction to the Obama administration.
“AA has a little pamphlet about medications and says to members, “Don’t play doctor, don’t tell anyone to stop taking their medication.” Yet you find members of AA who think true recovery means you’re not allowed to take your anti-depressant.”
In fact, according to Humphreys, one of the founders of AA asked the developers of methadone, to help alcoholics. “Bill Wilson asked, “Could you please develop a medication like that for alcoholics?” That’s the guy who founded AA. A lot of people today don’t know that.”
We are gripped by the deadliest opioid addiction and overdose crisis in history. I live in a community (Vancouver, Canada) where we had a record number of overdose deaths in 2016, and it looks like 2017 will surpass it. To quote Nora Volkow, Director of the National Institute on Drug Abuse (NIDA), it’s time for all “scientific hands on deck,” if we are to beat back this scourge. And that means embracing medications as an integral part of the solution.
According to a 2016 report by the surgeon general, just 10 percent of Americans with a substance use disorder obtain specialty treatment, in large part because of the kind of judgment my colleague fears he’ll face when revealing his problem drinking to his doctor. In fact, The National Center on Addiction and Substance Abuse (CASA Columbia), considers the lack of most doctors’ understanding of how to treat addiction, “malpractice.”
Family doctors schooled in state-of-the-art substance use treatment could do a lot more to help their addicted clients. Starting with a brief screening to discern whether a substance use problem is present and whether it is mild, moderate or severe. Then doctors could work with patients to design a treatment plan within the community. If my friend could access naltrexone early, perhaps he’ll never need rehab. Studies to date show those who engage in some form of evidence-based psychological therapy, combined with medications proven to reduce discomfort of coming off substances or promote sleep, have the most success.
Just last month, a National Institute on Drug Abuse (NIDA) funded randomized clinical trial “found that primary care patients with opioid and alcohol use disorders who were offered a collaborative care intervention were more likely to receive evidence-based treatment and refrain from using opioids and alcohol six months later, compared to patients receiving usual care. The authors suggest the findings indicate that treatment for Opioids and Alcohol Use Disorders can be integrated into primary care settings effectively. These meds – in tandem with desperately needed trauma therapy, would save countless lives on Vancouver’s notorious downtown eastside, where people die every day from overdose.
I’m heartened to see thanks to efforts of organizations like the Peter Dodge Foundation, big rehab is finally coming on board. Hazelden Betty Ford and the Dodge Foundation have teamed up to deliver a conference this December called “Integrated Approaches and Practical Applications,” for primary care doctors. This kind of collaboration is long overdue.
I wish I could send the doctors of some of my clients; one who told me his family doctor who actually delivered him, when he revealed he had a heroin problem said, “I don’t treat addicts.” Others routinely refuse to prescribe naltrexone, because “I don’t know enough about it.” To that end in Canada, the Centre Addiction & Mental Health, the gold standard in treatment, has created a series of one page fact sheets that patients can take to their doctors.
Making meds and psychotherapy widely available in the community will have an impact on our substance use crisis. As will more provocative ideas like prescription heroin programs like those in Europe. We are so far from embracing prescribed heroin because our culture is addicted to demonizing people struggling with substance use disorders. These programs have proven to reduce street drug use in Europe. We continue to rely on prisons. We need to open our minds to all innovations that are evidence-based and, bottom line, will save lives.
I give the final word on this subject to Bill W, the founder of AA.
“Let’s bring to this floor the total resources that can be brought to bear on this problem…Let us think of unity among all those who work in the field…Let us stand together in the spirit of service.”
