An excellent question.
Yesterday a saw an email exchange between the head of a group of addiction treatment providers and two prominent leaders in addiction medicine. They were expressing fear that people outside themselves would define addiction treatment now that parity legislation has passed. Their fear is, I assume, that people at federal agencies will define addiction treatment to mean or at least allow it to include, treatment with medication only. I wonder if we should call it addiction treatment when the treatment is focused on keeping medication for addiction out.
One of the participants in this email exchange also stated he wants to define what “recovery” is. Maybe I can’t tell him what it is, but the recovery I’m aware of is associated with enough humility to know that we cannot define what recovery is for other people. If I did define it, would I include this patient I saw yesterday.
Adam is a 45 year old artist who I met about three years ago. He was alienated from his family, suffering in his work and not happy in his life. He was using heroin daily. I started him on suboxone and followed him for about a year in a practice where I did not have access to drug screens on site, so I didn’t have a chance to apply my view of abstinence to his care. His life with his family improved immediately, his work stabilized and he began to enjoy his life. I saw him every month for over a year and watched him quickly return to what anyone would call a normal life. He began to be active in raising his son, became reattached to the religious practices of his childhood, and enlarged his spiritual life as well as his relationships with others. All the while I urged him to join a twelve step program but he refused consistently.
My practice pattern changed and he began to be followed by a colleague who continued to see him. Adam remained stable and maintained the improvements in his life in spite of never having entered a 12 step program. Evidently my colleage didn’t have access to drug screens either or didn’t use them regularly because Adam wasn’t drug sceened during this time either. Yesterday Adam came back to see me because my colleague is no longer available. In my current practice we use drug screens frequently to support patients’ abstinence and I usually get the results by computer about half way through a patient’s visit. When I saw Adam he appeared to me just as he did before, calm, happy, energetic and living a fulfilled life. I saw the message come up for the drug screen results but didn’t pay immediate attention because Adam wsa doing so well I assumed it would be clean. As I was about to end the session, I looked at the result to document it and saw that in addition to bupreorphine, it was positive for THC.
I said to Adam, “So what’s with the pot? When did you start smoking?” He replied that he really had never stopped but had answered no when I asked because i asked “Have you been using anything to alter your mood or mind?” and he never had considered pot mind altering as he had never had a problem with it. I was pretty shocked. My first reaction was to want to get him to stop. He asked me why and my the usual reasons failed me. Here was a man who had manifestly maintained a normal life better than his previous life, with a happy family, full employment, and a large circle of friends all the while smoking pot in social situations when his friends did.
I was really concerned and pretty sure I had to do something, but this had taken me by suprise at the end of the visit and I decided to revisit it when I saw him next time. I thought about it a couple of times later that day. What should I do?
Then I saw the email exchange, and, as it happens so often, I saw in someone else the end result of the path I was on. That gave me a chance to decide that it isn’t the path I want to take. Would I say that Adam has not had treatment for his addiction? Can I say he is not in recovery? He’s certainly not in my kind of recovery, but his treatment goals have been met. If I imposed a “no pot rule” on my treatment of him, that’s one goal of his that would not be met.
Who am I to define someone else’s recovery? Who am I to decide to what extent someone should allow me to treat their illness? Isn’t it their illness? Their life? I’m usually so quick with the advice. Here I was brought up short by a guy who didn’t feel he needed my advice. Everything was going along fine for him just the way it was.
In looking at it I’ve met a lot of people like Adam; he’s just the first one I’ve met who used pot. Most of the other ones have been smoking cigarettes. I try to get them to let me help them stop and some just don’t want the help. Like Adam, it’s not a goal for them. All I end up doing is giving them the information behind my reasons to thinking it would be better if they stopped: that studies show that use of any drug or compulsive behavior makes relapse more likely on the drug they came to get abstinent from.
It’s funny. Writing this I’m remembering I saw a woman yesterday with the same story as Adam except that she smoke a few cigarettes a day with her husband who is a heavy smoker. She doesn’t want to stop. Cigarttes have never been “a problem” for her, and she feels that when she smokes with her husband it enhances their relationship. When she’s not with him she doesn’t smoke. She reminded me of another woman I once treated who continued to smoke cigarettes on Suboxone. She smoked two a day because she felt if she didn’t she wouldn’t be able to stand her husband’s smoking and didn’t want to divorce him. She taught me that it is possible even for addicts in recovery to use something for some reason other than their addiction. I just never considered it could be pot. Why not? Is there a difference, besides legality, between sharing a joint once a week with a friend and sharing two cigarettes a day with your husband?
Deciding what’s right for other people is a slippery slope that I really don’t want to start down. That’s why I think the true measures of the success of treatment should be functional and objective. Where I work now we have a set of symptoms we ask about every week with patients in treatment. They self score these symptoms from 1 to 10. We also ask them a number of questions about the functioning of their life. When we’ve looked at our patients over time these scores improve with treatment. I’ve noticed that not many therapists or people who treat addiction like that kind of measure. Like the person in the email exchange I referenced, we all have our own definition of “doing well” that we apply to our patients. I’m reminded of the famous quote of Oliver Cromwell, “I pray thee, brother, think that you might be wrong.”
© Howard C Wetsman MD FASAM