The most common concern expressed about medication-assisted treatment (MAT) with either Suboxone® (aka buprenorphine) or methadone is, “Aren’t we just replacing one addiction with another?” Patients, families, other clinicians, and various stakeholders interested in reversing the opioid epidemic, all have this question. In Heroin, Coffee, and Suboxone®: On Not Replacing One Addiction With Another, I use a dramatized conversation to show my way of responding to such concerns.
The second most common concern regarding Suboxone® tends to be, “How long should somebody stay on Suboxone®?” This concern is related to the first concern. It stems from the belief that treatment with Suboxone® is the same as replacing one addiction with another. Therefore, we must first address the primary concern before tackling this one. If the other person in the conversation hasn’t explicitly raised the first objection, we must speak it and then address it. Only then move on to the second one.
Below is my approach to the second concern or objection. Once again, I present it as a dramatized conversation based on many discussions across various settings.
* * *
The Objection
The man in the blue blazer is patiently waiting for his turn to talk to me after my presentation on medication-assisted treatment (MAT). He introduces himself as an alcoholic in recovery for 22 years and the medical director of an addiction treatment center. After a few pleasantries, he says politely, “I agree with you that Suboxone® helps people engage in recovery. But I don’t believe anyone should be on it long-term. So our program allows patients to be on it for six months. After that, we work on getting them off.”
I ask, even though I know the likely answer, “How did you decide the limit had to be six months and not three months? Or 18 months?”
“We just figured that if you are actively working recovery, six months is enough time to need a crutch.”
“Were there any studies upon which you based your decision?”
He admitted there weren’t.
“I must admit,” I confess, “Before I specialized in addiction, I too used to think that there could be no good reason for someone to stay on methadone or Suboxone® for more than a few months to a year. But, if you are working the steps and doing all the things your addiction counselors tell you to, you should be over the worst in a few months.”
He gives me a knowing smile. I understand where he is coming from.
“Do you want to hear what changed my mind?” I ask. He nods a yes.
* * *
Setting The Stage with Diabetes
“What’s your specialty in medicine?” I ask.
“Family medicine by training, but for the last ten years or so have mostly been working with people in recovery,” he responds.
“So, you must have treated many patients with type 2 diabetes throughout your career.”
“Of course. More than I would have preferred.”
“Can patients with type 2 diabetes ever be cured? Can they ever have their diabetes managed without any medications?”
“Well, they can’t be cured. If they have the diagnosis, it will stay with them. Everyone knows obesity is a common feature of type 2 diabetes. I haven’t had many patients who lost weight and kept it off. But those who do lose weight, especially early in their diagnosis, we’re able to manage their diabetes without medications. Most of the time, I tell patients, losing weight will improve your sugars, but you will have the diabetes diagnosis forever.”
“So let me ask you this,” I follow up, “Those who do attempt to lose weight to manage their diabetes, at what point would you say to them, yes, you can manage your diabetes without medications?”
“When their weight loss and glucose control is sustained,” he responds honestly.
“When would you call it sustained weight loss?”
“Honestly, though patients might be able to discontinue their medications when they first lose weight, I wouldn’t consider their weight loss sustained until they have been at consistent goal weight for at least a couple of years. Unfortunately, I have seen far too many people regain lost weight in less time than that.”
“What about the ones who don’t attempt to lose weight? When do you stop their anti-diabetic medications?”
“I don’t.”
“If they tell you they want to stop their meds, what do you say?”
“I tell them they might be able to reduce their medication dosage or stop it completely if they do diet and exercise.”
* * *
The Heart of the Matter: Addiction and Diabetes are Chronic Conditions
I shift gears, “Sorry to change the topic, but you said you are in recovery, right?”
He nods and says with deserved pride, “Yes. 22 years.”
“Looking back,” I continue, “At what point in time would you consider yourself as having reached true sustained, stable recovery?”
“You know, at the time, I thought I was in stable recovery at about a year in. But looking back, I don’t think my recovery was stable and sustained until 3-4 years in.”
“What makes you say that?”
“Initially, I entered recovery because if I hadn’t, I would have lost everything – my family, my job, my house. Swords were hanging over my head. You know how that goes. At one year, I was convinced I was doing well. I hadn’t relapsed. I was attending treatment diligently. My family was happy. My practice was running smoother than ever. But most importantly, my family was happy.”
Casting a glance at others listening to our conversation, he continues, “Looking back, it wasn’t until three to five years later, after I had done a lot of tough emotional work, that I believe my recovery was stable. I fell in love all over again with my wife. We climbed out of the financial hole I had dug for us over the years. It just took time. Most importantly, I got back into running and other things I enjoy. Before all that, there were many moments when I could easily have relapsed.”
“So that was your personal experience. But what about your professional experience? How long does it take the typical patient in your addiction practice to reach what you would consider sustained, stable recovery?”
“I would say, for most, it is three to five years. Some may take longer — even ten years. Some never get there.”
“I assume you would say someone is in sustained, stable recovery when they have done what you eventually did — repair broken relationships, regain trust, and re-engage with life without substances.”
“Yes, I would.”
“I know this is going to sound like a gotcha moment. I am not trying to get you. And I am sure you know by now where I am going with this. I am merely trying to illustrate the analogy that helped me understand how long someone should be on Suboxone® or methadone maintenance treatment.”
After that truthful disclaimer, I added, “For our patients with type 2 diabetes, we won’t stop their medications until they bring their sugar under control by diet and exercise in a sustained manner. Likewise, we won’t consider their weight loss sustained until they maintain it for at least a couple of years. Yet for people with opioid addiction, we somehow think their recovery is sustained and stable in 6 months?”
“I don’t think their recovery is sustained and stable in six months.”
“But isn’t that the underlying assumption behind stopping Suboxone® after six months — that they don’t need any pharmacological help any longer?”
* * *
How Long on MAT: As Long As It Takes To Sustain Recovery
“But, that’s different,” he interjects.
“How’s that? Both type 2 diabetes and opioid addiction are chronic illnesses that can be managed with lifestyle changes. Both have medicines that can help control the illness and save lives. The only difference is that for only one of them do professionals think it is appropriate to have arbitrary time limits on the duration of medication treatment.”
“Are you saying they should be on it for three years? Ten years?”
“No. We should decide how long a person should be on Suboxone® on a case-by-case basis. There should be no arbitrary duration limit for all patients. It takes some people a couple of years to make the behavioral changes that will help address the underlying causes of addiction and boost their relapse prevention skills. For some, it takes longer. Some, who had horrid lives even before their addiction began, may never get there.”
As we near the end of our chat, I continue rapidly, “We should continue each person’s Suboxone® for as long it takes for their recovery to be truly stable and sustained. Being on the medication lifelong may be the only solution for the last group of patients that I spoke about — those who were broken in many places before they even came upon drugs. Just like anti-diabetic meds forever are the solution for those type 2 diabetes patients who are unable to make the necessary lifestyle changes.”
His face tells me the wheels are turning in his mind. Finally, he says, “I know you have to go. Thank you for discussing this with me. This will make me think.”
As we exchange business cards, I say, “One more thing. At the beginning of our chat, you referred to medication-assisted treatment as a crutch. If it is a crutch, then every medication we prescribe to every person with a chronic medical condition with modifiable lifestyle factors is a crutch. And if that is the case, I see no harm in using crutches until we can truly walk on our own without falling.”
I start walking towards the exit, hoping I have changed someone’s mind.
[Featured image by TeroVesalainen from Pixabay]
