Excerpted from the Preface to my book, Abstinence Kills
I have been a practicing physician since 1985. I thoroughly enjoyed the first three decades of my medical career as a family doctor. Three things had drawn me to family medicine. Firstly, family doctors have the opportunity to see the full spectrum of humanity. I used to treat patients of all ages, from delivering babies to end-of-life care in nursing homes. I was proud of taking care of people from “womb to tomb.” Family doctors also get to see the best and worst of humanity, from the nicest, warmest people to terribly damaged human beings and outright sociopaths. Other specialties tend to see only certain segments of humanity. For example, gynecologists see only women, pediatricians see only kids, internists see mostly the elderly, etc. Emergency medicine is the other medical practice that sees the whole spectrum of humanity, but emergency physicians typically encounter patients only once or twice. Specialists generally only see people when they are sick. Only family medicine sees people from all walks of life, rich or poor, young or old, in sickness and in health.
The second thing that drew me to family medicine was the ability to follow patients over the years. Few medical specialties afford doctors the same degree of relationship with our patients. You might only meet your anesthesiologist behind a surgical mask for a few minutes before surgery; you will probably never meet the radiologist who reads your X-rays or the pathologist who decides if your biopsy samples are cancerous. Specialists only deal with the same patient for a few days, weeks, or maybe months; rarely do they see the same person over the span of years. Only family medicine gets to follow individual patients for years, even decades.
The third feature about family medicine is that, whereas specialists treat diseases, family doctors treat people with diseases. Speaking for family physicians, we get to know our patients as real people, not just as broken bodies. We know our patients as people with personalities, dreams, charm, but also flaws. We see patients when they are sick, but also when they are well. We see our patients through tragedies, divorces, and catastrophic health problems, but also through graduations, promotions, childbirths, etc. If we are lucky, we get to see a baby we delivered grow up and get married, maybe even have a child of their own. It is truly a privilege to share in our patients’ pain and joys.
Yet I gave up this career that I loved to become an addiction physician very late in my career. Why? I had not entered medical school thinking, “When I grow up, I want to treat heroin addicts!” What happened to turn me to addiction medicine? Answer: The opioid epidemic.
How the Opioid Epidemic Changed my Medical Practice
Many readers may be familiar with the story of how the opioid epidemic began with the relentless marketing of the painkiller, OxyContin. This dark time in medicine has been well documented in numerous books, articles, and TV series such as Hulu’s Dopesick and Netflix’s Painkiller. I will not retell the story here, but I would like to paint a quick picture from my personal point of view as a practicing physician at that time. You see, I lived through it and witnessed firsthand how the whole sordid mess unfolded from the very beginning till today.
The late 1990s saw a massive campaign by the pharmaceutical industry, led by Purdue Pharma, pressuring physicians into prescribing opioid painkillers like OxyContin with reckless abandon. Purdue claimed that the active ingredient in OxyContin was released into the bloodstream too gradually to induce feelings of euphoria and was therefore non-addictive.
At that time, most opioids were prescribed by family doctors, such as myself. It isn’t that family doctors were gullible (although many were). The pressure to prescribe more opioid painkillers came not only from pharmaceutical companies, but also from prestigious bodies, such as the Institute of Medicine and the Veterans Administration, among numerous others. Physicians were being disciplined by medical boards for failing to treat pain adequately. At the same time, doctors were also being successfully sued for failing to treat pain adequately.
I remember not being convinced by Purdue’s narrative, because OxyContin was far from the only opioid flying off the shelves. Older opioids such as hydrocodone (e.g. Vicodin), oxycodone (e.g. Percocet), and morphine were also selling like hot cakes, even though they had no claim to gradual release. I had a bad feeling.
There were no guidelines for prescribing opioids available at that time. The CDC did not release its first opioid prescribing guidelines until 2016, whereas the surge in opioid prescriptions had already begun by the late 1990s. In the absence of guidelines, I implemented strict monitoring of opioid prescriptions. I was an early adopter of urine drug testing to make sure patients weren’t taking other drugs not prescribed to them. Drug testing also showed whether or not patients were actually taking the medications they were prescribed rather than selling them. I kept a close eye on medication refill patterns to make sure patients weren’t filling their medicines early or too often, which might suggest they were overtaking their medications. I started counting the patients’ pills at every visit to make sure medications weren’t going missing.
I learned two things through this practice. The first was that most of my patients benefited from opioid medications without ever developing any sign of abuse or addiction. Addiction is clearly not inevitable. To this day, I maintain a sizable practice managing opioid medications for chronic pain patients.
The second thing I realized was that the people who were losing, or had already lost, control of their opioid use needed help. Most of the patients I found who were abusing or losing control of their opioid use unquestionably suffered with legitimate chronic pain. Many of my colleagues would immediately dismiss any patient suspected of abusing medications. That did not seem right to me. To dismiss these patients might wash my hands of them, but what would become of them? Where would these patients turn if they were simply kicked to the curb? If they were already “hooked” on opioids, chances were high that they would end up seeking help from their local drug dealer. It seemed a horrible injustice for me to dismiss someone for abusing pain pills I had prescribed only to push them into the hands of heroin dealers. I had already gotten to know many of these patients, not as bad people doing bad things, but as good people who lost control.
Switching to Addiction Medicine
Reluctantly, I decided I needed to learn how to help these patients of mine. I enrolled in training to learn how to prescribe buprenorphine (including Suboxone, Subutex, among others), a medication approved to treat opioid use disorder. Although I learned about addiction medicine out of necessity to serve my patients, I was amazed at how effective addiction treatments were. I saw the most incredible transformations in some patients. They might have been homeless, jobless, facing criminal charges, and losing their children to Child Protective Services (CPS). Yet sometimes within a few months, they might again become gainfully employed, contributing members of society, and restored to their families.
Before I realized it, addiction medicine had turned into the most rewarding thing I had ever done in medicine. Allow me to explain. As a family doctor, I dutifully kept abreast of medical advances, learning how to treat people with high blood pressure, high cholesterol, and diabetes to prevent heart attacks. However, if a patient I treated did not have a heart attack, I would never know if it was due to my treatments or if the patient wasn’t destined to have one. I would not know if I helped my patient live an extra year or twenty, or made no difference at all.
On the other hand, again for the sake of illustration, if I help a young patient find sobriety, I get to see the transformation happen before my eyes. Patients are genuinely thankful and I get to see my work bear fruit. I share in their triumphs, such as finding a job, getting promoted, being reunited with their children removed by CPS, etc. I don’t just help the patient, but I could potentially also make a huge difference for the next generation, and perhaps even generations beyond that.
Lessons I Learned from my Patients
My experiences taught me several things. First, I became convinced that opioid addiction is a disease. This conviction did not come about through theorizing, studying, or accepting some dogma or ideology. Instead, it was my direct experiences that showed this to be the case. I had known some of my patients before they became addicted to drugs, watched helplessly as they degenerated into the depths of addiction, then observed them respond beautifully to medical treatment. Sounds like a disease, doesn’t it?
The second thing my interactions with patients taught me was that nobody really wants to be an addict. I frequently encounter people saying things like, “Addicts have to want to get well.” Believe me, nobody wants to be an addict. They might want to use drugs, but they certainly do not want to be an addict, just as people might want to eat ice cream but not want to be obese. Most overweight and obese people desperately want to lose weight, torturing themselves with restrictive diets, signing up for intense exercise programs, and even being willing to undergo major invasive surgeries to lose weight. Still, weight loss is not guaranteed. Telling an overweight or obese person that they just need to really want to lose weight to succeed would be an insult. We choose behaviors; but we do not choose the consequences that come with the behaviors. People might choose to text while driving, but they do not choose to cause an accident that kills someone. Nobody chooses to be an addict.
People addicted to drugs might refuse treatment because there are unacceptable conditions attached, or because they do not trust the person offering help. They might be concerned about who will find out, whether there are law enforcement implications, whether they might lose their job, or lose custody of their children. Treatment might seem too invasive, just as an obese person might wish to lose weight but be unwilling to undergo bariatric surgery. People who decline treatment do not necessarily want to stay addicted to drugs or alcohol.
Addiction is a terrible master; nobody would willingly be its slave. Like slaves, addicts have miserable lives. Like slaves, addicts have great difficulty escaping their condition. To blame addiction on choice is like claiming that slavery is voluntary. The chains that bind addicts might not be as visible as the physical chains on slaves, but they are no less binding. Anyone who has ever tried unsuccessfully to quit smoking or to lose weight should empathize.
The third thing I learned from my experiences was that I still needed a better understanding of addiction. Not all patients responded well to treatment, but enough did to truly amaze me. I wanted to learn how to help the harder cases. That’s why I decided to become an addiction specialist. That’s also why I am passionate enough about this subject to write a book addressing the missteps we have taken, to improve addiction care.