U.S. physicians are in dire need of specialized training in withdrawing patients from physically and psychologically addictive drugs.
I crave dramatic scenery and charged weather - the craggy splendor of the Cascades; the roaring, troubled ocean on a blustery day in Florida, Hawaii, or Hong Kong. The rolling hills of Upstate New York don't exactly qualify, but the summers here have their charms. Lately, we've had these stippled, pastel sunsets in pinks and blues followed by bloodred-and-neon-fuchsia sunrises. It's contemplative scenery, beautiful and temperate.
I've mentioned elsewhere that my (very relaxed) editorial calendar now has over 120 items on it. Rather than continuing to add to this list, I've decided to tackle several limited but interconnected topics through a series of psycho-riffs like this one.
I've been thinking a lot about how - decades into the opioid epidemic and with hundreds of thousands of Americans dead from prescription drug overdoses since the turn of the millennium - most American physicians are still woefully ignorant about getting their patients off of addictive drugs.
Technically, the specialties of Addiction Medicine, Psychiatry, Anesthesiology, and Pain Management should include training on withdrawing patients from mind-altering drugs that are physically and psychologically addictive.
The sheer number of requests for information that I get each week from desperate people in benzo or opioid withdrawal speaks to the facts that A) most physicians in these specialties have next to no training in withdrawal medicine; B) that those who do are still using ineffective pharmacology and protocols that are decades old; and C) that, more broadly, many physicians who prescribe these highly addictive substances are not trained in any of the salient specialties and have no idea how to get their patients off of them.
Although my At-Home Opioid Detox guide is far from groundbreaking, I've had several readers contact me to express how helpful it was; more than one has mentioned bringing this post to their doctor to obtain prescriptions for comfort meds that their doctors either hadn't been aware of or hadn't understood the logic behind using to ease withdrawal.
Make no mistake: No matter how grateful and relieved your patients are when you first prescribe them these insidiously addictive drugs, the vast majority of them will want to get off of benzos and opioids eventually. Neither class of drug is intended for extended use because the effectiveness of benzos and opioids against anxiety / insomnia and pain, respectively, does not hold up in the long term.
In fact, a cruel twist of biochemistry and physiology means that taking opioids for pain will in the long term actually increase pain - a phenomenon known as opioid-induced hyperalgesia. In the case of benzodiazepines, similarly, there is a marked increase in insomnia and anxiety / panic caused by interdose withdrawal and other shifts that occur with regular use.
You can increase the dosage and move to stronger agents, of course, but eventually, the side effects will become unmanageable. Benzos cause intoxication similar to alcohol, meaning that driving and other daily tasks become dangerous, and they obliterate memory - plus, their long-term use even at therapeutic dosages is associated with marked increases in dementia risk. Similarly, opioids induce memory and mood disturbances as well as chronic constipation severe enough to cause gastrointestinal blockages. They also put the patient at risk of many other serious problems, including aspiration pneumonia.
Despite all of this, U.S. physicians with no particular training in using these substances routinely prescribe them for extended, non-PRN (as needed) use.
Many readers find it unbelievable that - in my 15 years of being prescribed benzos and opioids by a couple dozen medical practitioners - only two clinicians, one a buprenorphine (Suboxone) provider and one a Family Practitioner who refused to up my Xanax dose, advised me of the risk of physical / psychological dependence and addiction.
To this day, I have never had a physician provide a realistic, front-end walkthrough of what it would entail to detox from either of these substance classes despite the fact that they were providing me with quantities that would almost certainly lead to physical dependence if not addiction.*
*This lack of discussion of dependence / addiction risk and of what tapering off of a physically addictive substance will likely entail is so commonplace that I believe that it warrants a specific informed consent acknowledgment form to be signed by the patient before a prescription for an addictive controlled substance is issued (similar to the forms used for surgeries and other procedures).
I have, however, had multiple physicians who - after it became obvious that I was tolerant / dependent / addicted - advised me that I would probably never be able to get off of these drugs and recommended against trying to do so (this despite the fact that it is nigh on impossible to get a new, daily prescription for benzos in this country because the FDA has finally cracked down decades too late).
This is a staggering abdication of the Hippocratic Oath.
Hey, how's this for an idea: If you can't get a patient off of a drug, don't start them on it?
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I'm currently writing an article on rapid transition protocols for methadone to buprenorphine switches, and almost all of the salient research was conducted in European countries. As I discussed in Metha-Don't, methadone maintenance programs in the Netherlands, Denmark, and elsewhere in Europe are more advanced and effective in that they offer breakthrough, injectable opioids to patients who continue to use illicit opioids after starting methadone treatment. They also use benzos, gabapentin, and many other adjunctive medications that are almost all prohibited for use by methadone patients in the U.S. for reasons that are archaic, founded in stigma against addicts, counterproductive, and unscientific.
This malignant malpractice affects the back end of the process, too. I've mentioned that I'm currently tapering off of methadone, and - despite the fact that the withdrawal syndrome from methadone lasts the longest and is reputedly the most intense of any drug - I have not been offered a single medication to ameliorate any of the host of severe withdrawal symptoms that I'm suffering from.
I can't even take over-the-counter Non-Steroidal Inflammatory Drugs (NSAIDS) like ibuprofen or acetaminophen without prior approval from the clinic on account of the fact that they could throw off drug test results.
Were I to bring myself to the Emergency Room and ask them to treat my withdrawal on a particularly bad day, and were a physician there to decide that a rescue dose of a short-acting opioid or a single dose of a benzodiazepine was appropriate, I would be subject to disciplinary action by the methadone program (which does not offer either type of medication, or any of several non-benzo, non-opioid alternatives like gabapentin, to detoxing patients).
Per capita, the U.S. consumes more of these addictive chemicals than any other population on Earth. Why aren't we devoting research dollars to getting people off of them? Why are despondent patients turning to YouTube videos and people like me for answers?
Unfortunately, while I'm not usually one for a grand conspiracy theory, I believe that in this case the answer is rooted in our for-profit healthcare system and the enormous lobbying power that Big Pharma wields in this country. It is not in their financial interest to get people off of these drugs. As every pharma rep knows, the best patients are lifelong patients.
As I alluded to above, even those American doctors who clinically supervise withdrawal from benzos and opioids are often using decades-old protocols.
The blood-pressure agent clonidine, which is an alpha-adrenergic agonist, is often utilized, and I have found it to be very helpful.
However, as I have written about in RIP, Gabapentin, the drug gabapentin, which was once an unscheduled medication in the U.S. and is in my opinion the most helpful non-benzo, non-opioid agent for benzo and opioid withdrawal, is being removed from clinical use following its scheduling in many states.
We have had hundreds of thousands of fatal overdoses on these substances since 2000, and we're moving backward in terms of the treatment options on the table for avoiding benzos and opioids in the first place as well as getting people who are addicted to these drugs off of them.
Words fail. Truly.
I've had at least a dozen doctors prescribe me benzos such as alprazolam and clonazepam. Of the three who I eventually asked for help in tapering off of them, not a single one had heard of British physician Heather Ashton's method for gradual withdrawal from benzos, which involves conversion from whatever benzo the patient is on to an equivalent dose of diazepam, then scheduled, incremental decreases from there.
What's particularly pathetic about this is that there is really nothing pharmacologically surprising or revolutionary about her method. The low-and-slow taper using a moderate-potency agent with a longer half-life is the rule in successfully withdrawing a patient from almost any medicine, from a blood pressure regulator to an antipsychotic.
As recently as 2015, I had a doctor who was certified in Addiction Medicine tell me that jumping off of buprenorphine (Suboxone) at a dose of 2 mg per day should entail almost no withdrawal symptoms.
We now know that this is emphatically not the case, a fact that would have been obvious to any physician who listened to his or her patients in the first place.
In reality, the majority of patients who successfully taper off of buprenorphine find it necessary to get down to a dose of 0.2 mg or lower, at which level there are still marked discontinuation symptoms.
Why aren't we researching agents such as ibogaine, a powerful hallucinogen that acts at the mu opioid receptor and has been successful in treating opioid addiction, leading to the establishment of a series of ibogaine-based underground treatment centers in Mexico*?
*I've had two acquaintances go through ibogaine treatment. It saved one friend's life, miraculously ending a decade-old heroin addiction (he's been clean for over 8 years at this point). The other person came back and relapsed almost immediately. I will either write about ibogaine, or, better yet, solicit a submission from someone who has been treated with it.
Even if we don't have brand-new medications ready for clinical trials at the moment, why aren't we at least mixing up our current pharmacological tools - for example, by investigating the use of "rescue" doses during withdrawal from short-acting and long-acting benzos and opioids or by incorporating variable-ratio reinforcement into dosing schedules? By experimenting with novel combinations of full agonists, partial agonists, and antagonists?
We're not even trying to innovate.
Can you imagine the outrage and outcry if this many people were dying of a new type of cancer?
I have said it before, and I stand by it: The prognosis of severe opioid addiction is worse than that for pancreatic cancer. At that level of risk, almost any treatment option is better than the status quo.
So long as we obtain informed consent from patients, we should be embracing any potentially effective treatment. The current treatments' "success rates," which are in reality failure rates of 95-99% for severe opioid addiction, are so abysmal that any other plausible treatment is worth a shot.
The arrival of fentanyl and xylazine on the scene* has removed any modicum of breathing room that we might have had in dealing with the epidemic.
*I've discussed this shift in the illicit opioid supply here.
I have heard of more opioid overdoses these days than at any other time in my life. In this regard, things are not getting better. They are worsening, accelerating.
Addiction medicine is the most heavily regulated of all the medical specialties in the U.S. On the other hand, Pain Management physicians - and the many mostly well-meaning but ignorant Family Physicians who prescribe benzos and opioids for extended use despite the lack of long-term efficacy and the fact that they know virtually nothing about the risks thereof - face a deplorable lack of regulation.
It's a system with clear priorities. Let's make it as easy as possible for people to get addicted. Then, let's cut off their supply and force them into the chemical torture of withdrawal, which eventually drives many of them into criminal activity tied to obtaining benzos, opioids, and other drugs that they are mentally and physically dependent upon from the black market. That way, our prisons - which cage a greater percentage of our population than any other prison system on Earth save for North Korea's, almost half of whom are there for offenses related to drugs - won't ever be empty.
That's a fantastic recipe for a successful society, no?
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Again, by the time that the patient is addicted, the damage is done. At that point, every emphasis should be placed on exploring all available options for harm reduction, medical maintenance, and withdrawal. This is no more and no less than what we would insist upon as a matter of course for any other disease with comparable mortality rates.
We need research and training in withdrawal / detox medicine. A fellowship for Psychiatrists, Addiction Medicine practitioners, Pain Management doctors, and Anesthesiologists would be a starting point.
Addicts shouldn't have to bring their physicians notes on YouTube videos and blog entries to come up with a plan for getting off of these deadly, stupefying drugs.
As I've asserted above, issues of tolerance, dependence, and weaning off of medications should be discussed on the front end, before the patient enters into dependence and addiction. If you're not advising your patients of these risks, then you're not obtaining properly informed consent. Period.
Let's bring back paternalistic medicine in the best sense - the sense in which physicians are informed, trusted gatekeepers rather than just legal drug dealers who scribble a prescription for any addictive drug whose print or TV advertisements catch the eye of a desperate patient.
For the third time, if you can't get your patient off of it, then don't put them on it in the first place - or, at the very least, advise them emphatically and comprehensively about the risk of tolerance / dependence / addiction before they start any new medication.
It's hard for me to write about this. I am exhausted, I am heartbroken, and I am livid.
I have a litany of names and a memory-montage of faces - not just of acquaintances, but of real friends who I have loved and lost to opioid addiction. Several of them died from accidental overdose; two by intentional overdose (suicide); and two from septic infections tied to injection drug use. Many of them had benzos as a part of their stories, too.
Their names are Dylan, Rachel, Tom, Jodie, Nyk, Micah, Sandy, Dave, John, Kris, Mike, Luke, Zach.
I am sure that I am forgetting a name or two, and I am so sorry for that.
No one who is my age should have lost so many of their friends that they can't remember them all when they sit down to write about them.
No society can afford to write off the loss of so many bright, young, beautiful souls.
And, as I wrote about in my Fourth of July post, I have a fear in my very marrow that the United States' descent into nihilistic decadence and widespread addiction presages its collapse - just as empires from Ancient Rome to the Third Reich and the USSR experienced greatly elevated use of and addiction to mind-altering substances as they collapsed.
I am brokenhearted.
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Quick note: I am touched by those of you who have sent your condolences regarding Lou's passing. I recognize that today's post - as well as the follow-up that will be published tomorrow or on Thursday, which contains my meditations on the spiritual, moral, and medical models of addiction - are more desultory / meandering and less polished than most of my writing, and this is a direct result of the sorrow, busyness, and insomnia of the past week (Lou's wake and funeral services, which were attended by hundreds of people, were held this past Saturday; I saw so many friends and relatives who I haven't been in the same room with since before I left for China, which was wonderful but utterly exhausting).
We're not even four months into this blog being online, and already I'm starting to feel a real sense of connection and community.
Probably because of the nature of the topics that I write about, most people aren't comfortable sharing their thoughts / questions openly, as comments, which I understand.
However, I so badly want for you guys to meet each other!
To facilitate this, I'm exploring the option to add a forum section, create a Discord server, or find some other way for us all to interface in a more conversational format.
As always, I'm open to suggestions!
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Playlist for the Week*
*The easiest way for me to express how I'm doing
(1) Paper Wings by Rise Against
(2) Danny Boy by the Irish Tenors
(3) Anytime by Eve 6
(4) No Surprises by Radiohead
(5) Miss Atomic Bomb by the Killers
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