First, let me say that I’m a big proponent of 12-step recovery. I don’t think my field of psychiatry has come up with a tool as effective as 12-step recovery, certainly not one that has worked for 70 years. That said, there are some things I have to take issue with concerning my care for my patients with certain people now presenting themselves as experts in 12-step recovery. Please understand that I’m not taking issue with AA or NA or any other 12-step fellowship. These fellowships do not take a stand on outside issues, and my care of my patients is definitely an outside issue.
Unfortunately, not all members of such fellowships share that view, even some with considerable experience. Here’s an example. A patient of mine had a difficult time staying sober, even on the medication which usually has a great effect. I asked him what was happening, and he told me that he wasn’t taking the medicine after all, because it made him sleepy. Please understand that in my experience this would be a very rare occurrence. Opioids generally don’t make opioid addicts sleepy; they give them energy. This medicine, buprenorphine, is a partial opioid agonist and as such is unlikely to cause an opioid addict to get sleepy.
Now this particular patient is also a compulsive over-eater and is quite overweight. I asked him when he was taking his last dose of medication: 5 pm. His complaint was that he was falling asleep in evening NA meetings. I suggested that it might be his still uncontrolled eating and the binge he had for dinner that was more responsible for his sedation but he thought it otherwise. I thought that he should take his buprenorphine as it would likely decrease his craving to overeat as well as for opioids and, in time, make things better. See, he had talked to other people in NA who saw that he was falling asleep in meetings and told him that buprenorphine was probably the culprit. I told him that was unlikely, but he was sure they were right. He did agree to an experiment though.
I asked him to take his last dose of buprenorphine, not before the meeting, but after meeting. If he was right he’d get a good sedative effect and go to sleep as he wanted to. He’d also get to stay awake in the meeting. If I was right he’d probably still fall asleep in the meeting. Two days later he called and said the buprenorphine kept him up. Was he still sleepy in the meeting? Yes.
This patient’s story illustrates two problems I see a lot. First is that the old wives tale of “one addiction at a time” is alive and thriving in the 12-step community. The second is that there is, concerning some medications for addiction, a rash of “contempt before investigation.”
I don’t know where the idea comes from that we can only deal with one addiction at a time. The concept of one addiction being different from another is so foreign to me that I have a hard time understanding what the phrase means. Does someone who compulsively gambles, compulsively masturbates, compulsively overeats and is an alcoholic and opiate addict really have 5 diseases? We have very good evidence that if someone starts using one drug to stop using another, or even continues using one drug while trying to stop another, it doesn’t work very well. Why would we think it would be different when one is trying to continue a behavior that acts like a drug in the brain while trying to not use another drug? Because overeating is legal and encouraged by the fast food industry? I don’t think our midbrains are aware of congress, food packaging or even what we’re doing to boost our dopamine levels. It only sees that we are or are not getting the dopamine.
The philosophic reaction, without experience with the medications, of some people in the recovering community to medications for addiction is astounding to me. Especially when it comes to buprenorphine. I’m struck with how this medication somehow got a special place in the minds of some recovering people – like the devil incarnate. I’ve heard, “it’s just like heroin,” “I’ll just be addicted to that now,” “he isn’t clean.” I’ve even had the experience with an addictions counselor who said to me, “If you’d only seen the horror stories I’ve seen, you’d never use the drug.” When I asked he’d seen two people who didn’t do well and couldn’t tell me if they had gotten proper addiction medical care or not, but was unwilling to believe that I had seen scores of people who had never before been able to work a 12-step program who could now function well enough to do so.
The whole issue of buprenorphine is too large for this article, but I’m also struck with the number of people in recovery who think it’s okay for me to give a patient buproprion because it’s “an anti-depressant” but not buprenorphine because it’s “a pain med.” Again, I don’t think our midbrains care what words people made up to describe other uses for these medications. The midbrain reward system truly has singleness of purpose and it is this, “Am I getting the dopamine or not?”
© Howard C Wetsman MD FASAM