Doctor’s orders: Don’t quit drugs without me

Doctors are taught from year 1 Medicine (if not before): First, do no harm. And yet, in treating addicted individuals, doctors often do more harm than good — by obstructing or totally derailing the recovery process. That should never happen! I want to show you what I mean by telling you part 2 of Sally’s story — the first part of which appeared a few posts ago.

That post was about the value of pharmaceutical opioids for supervised “maintenance” or tapered withdrawal, and about my failure to use a publishing opportunity to educate doctors. In contrast, this post is about quitting, “getting clean” as people still say, without any supervision. Because you can and you want to. A lot of people quit that way.

And yet, incredibly, doctors often advise against it!

Sally (a resident of the UK) wasn’t taken care of properly in her teenage years, became a heroin addict in her mid-teens, became a prostitute soon after, endured physical and sexual violence, including rape, and finally dragged herself off the street by sheer force of will. At that point her soul was flattened. She had little fight left in her. Just enough. She was cared for by a friend for several months; she slept on a spare sofa. She was afraid of noises, afraid of silence, afraid of the night…because the man who had raped her was still out there. Until he killed himself. Good riddance.

Sally struck out on her own, found a stable relationship with a man, had a couple of kids, found a better relationship, had another kid. Life started to settle down — a much as it can with three young kids at home. Now her days are spent soothing, caring, teaching…giving her kids a lot of what she didn’t get enough of. A couple of nights a week she works with elderly people who need help. And if there are hours to spare, house-cleaning and all the rest of it. She and her partner are making it work.

When Sally got in touch with me to start psychotherapy, she was taking eight 30-mg tabs of codeine a day, prescribed by her doc, plus 10-20 tablets of codeine (12.5-mg) mixed with paracetamol (acetaminophen) which she got over the counter. Having survived Hep-C (with successful treatment) it was a wonder her liver hadn’t given up the ghost. But no, she was very much alive: vivacious, generous, funny, smart and pretty. She had made it to 40 and had every intention of staying alive.

I don’t tell my clients they have to stop taking drugs, but if they want to quit, if they want to cut down, let’s see what we can do. Sally wanted to quit. Although the codeine relaxed her and gave her the energy she felt she needed to keep house, images of opiates could hardly be kept apart from images of life on the street. And she tended to obsess about her next dose for too much of her day. She wanted to have done with it. Yet, withdrawing from heroin had been so grueling — it still terrified her. So the solution was obviously to taper gradually.

We talked about tapering in our sessions. I wanted her to reduce her paracetamol intake first, since it put her at great risk. But the rest…we can go slow, I said. With that message from me, she took matters into her own hands. From one week to the next her daily dose went down and down. She was proud and excited about her “detox” (as she put it). She was down to nearly half the amount of codeine she’d been on for years. She was the one pressing me: let’s go down another two tablets this week. I don’t think I need my second morning dose. She started to skip doses…and that meant she had a reservoir of spares, just in case. She was tailoring it, shaping it, doing it. She was the boss.

Until she was assigned a new doctor. Much younger, armed with the latest policies and trends. He knew enough about addiction to help her, and she needed help, he insisted. No, he would not prescribe Valium to carry her through the very end of her taper and possible withdrawal symptoms — not even 15 or 20 tabs. Valium is very addictive, you know. But that was okay: they’d taper together. She’d come to the office every week — not an easy trek for a mother of three small kids, but it was important for him to see her, to monitor her. And she would reduce her intake by one tablet — 30 mg — at a time, he insisted. But she had to agree that every time she reduced her dose, she’d have to maintain the new level. She couldn’t go back up. Not even for a particularly bad day. He knew what was best for her. Did she agree? Did she have a choice? If she didn’t agree he’d stop her prescription, and then she’d be in danger of paracetamol poisoning again, unless she went back to heroin.

I saw Sally next a few days after that visit. Her energy was gone. Her smile was sad and cynical. She’d gone back up to her previous high dose, including the paracetamol torpedoes, because…because it wasn’t her recovery anymore. That’s how she put it. And it was none of his damn business and she didn’t like his rules and she didn’t like him. But the threat of a sudden withdrawal trumped all that. That was the power he wielded, and he knew it.

Sally got a script for Valium from a shady mail-order pharmacy. Valium wasn’t a risk for her. She was saving it for when and if she needed it.

But I don’t think she will need it. She got her old doctor back again, and even though he isn’t knowledgeable about addiction, he’s willing to continue the monthly prescription he’s provided for years. Now it’s Sally’s turn again. She’s tapering. At her own rate. The drawer of unused tablets is filling up again. And she’s smiling again. She figures she’ll be down to zero in another month or two. I occasionally remind her that she can take a few extra if things get particularly rough. People need to know that recovery isn’t a straight line.

Why on earth coerce or scare someone out of their addiction when they want to quit and it’s within their power to do so? Why would you take that away from someone, when it means so much to them?

My brother’s a great doctor — a GP. He’s helped a lot of people. He’s kind and generous and smart. But he doesn’t pretend to be God. And he doesn’t pretend to know his patients better than they know themselves.

 

 

 

 

26 thoughts on “Doctor’s orders: Don’t quit drugs without me

  1. Rat Race Rebel September 20, 2019 at 5:07 am #

    Wow, I hope this initiates some interesting discussion, Marc. Great post. I see this happening over and over, “doctors know best” and it’s frustrating and excruciatingly stymying. Here’s my rant; I went to my gp when I was about 2 years into recovery from alcoholism and she mentioned the fact that I was on about 5 different psychiatric meds several of which had been prescribed “in recovery”. She was no longer comfortable prescribing and suggested I get a psychiatrist. In an addiction treatment program, I’d seen a program psychiatrist who initially added and/or increased dosages of several medications but there was no process for tapering said meds. I was advised to go back to my own psychiatrist or find another . I was already managing the care for several children with major medical and mental health issues and one more appointment and intake process to start with a psychiatrist was just more than I could handle and keep up with other facets of my life. So I decided to do my research and taper off my psych meds myself. I developed my own harm reduction plan using cannabinoid medicine and kratom as well as long-distance running and was able to taper off all of these medications at my own pace. This combo(MJ, kratom, running) also had a psychedelic effect leading to deep processing from years of trauma. I was literally able to get above it to the point where I could look back and integrate the various experiences into my understanding and get to some level of acceptance and appreciation for what I’d learned and experienced. I cannot tell you how valuable this process was for my own consciousness and withdrawal regimen. My mental and physical health improved immensely and while I still use these alternative substances, I have greatly reduced use and feel at long last as if I am navigating towards relative stability and improved quality of life. I do not trust docs overall. Until there is more integration and continuity of care between all medical and mental health professionals “treating” individuals, combined with a “trauma-informed approach”-a partnership between doc and patient-the issue you raised with docs highjacking treatment will only getting worse. Thanks, Marc, for bringing this issue and discussion to your readers and I’ll look forward to reading the comments.

    • Janet September 20, 2019 at 4:57 pm #

      Wonderful and empowering. Thank you so much for sharing. You put a lot of “skin in the game.”

    • Larissa Goruk September 21, 2019 at 7:34 pm #

      Yes it’s empowering – so glad that you are managing your health and recovery the way you know best. Doctors still have this attitude that they know better about everything, it’s disappointing that things haven’t changed.

      thank you for sharing

    • Marc September 30, 2019 at 6:48 am #

      As other readers have commented, this really is an inspiring story. Like Sally (in my post) you let the frustrations of accepted medical practice push you back more deeply into your own life, where you found your own resources, and accomplished something that would have been very unlikely while chained to the pillars of medical/psychiatric *authority*.

      It’s not that I don’t trust doctors. As mentioned, my brother is a doc and he’s the most trustworthy person I know. It’s just that their knowledge is limited (of course!) yet they’re led to believe that their role is that of an authority in domains that fall far outside their knowledge. And it’s partly our fault, really. We want our doctors to personify parents and gods, we WANT to trust them in domains where we should know they’re not expert. That’s our problem too.

  2. Mark September 20, 2019 at 7:14 am #

    I’m reminded of psychophysiologist Steve Porges’s (originator of Polyvagal Theory) profound observation that … “Safety is the prescription.” Time and time again I see safety compromised in all manner of human suffering. Often it’s unwitting and unintentional.

  3. Ryan September 20, 2019 at 11:13 am #

    I’m a substance use counsellor working with adolescents. I attempt to have my clients communicate efficiently with their doctors to establish this partnership, but I am told a lot of the time that the client does not feel comfortable speaking up to the doctor (because they know everything), and this typically leads to non-compliance or some other undesirable effect. Is there any suggestion to encourage the client to foster this relationship and engage in communication about tracking the efficiency of medications? Please advise.

    • Marc September 20, 2019 at 11:34 am #

      Let’s see what others have to say, but you see the problem. Many people with addictions feel (often correctly) that anyone who hasn’t been there really can’t understand. With teens this is amplified. And the power differential with doctors, not to mention adults, can be overwhelming.

      Your clients might need you as a go-between, to translate from the “know-it-all expert” to kids living their lives. Perhaps help them to see that doctors undergo rigid training and speak a certain language / endorse certain attitudes as a result. You might also try teaching them that doctors are brainwashed into classifying addiction (and much else) as a disease, hence their rigid pronouncements about treatment.

  4. Ryan September 20, 2019 at 12:58 pm #

    I work for the DMH and use a lot of what I’ve learned from your books/lectures/talks to inform my coworkers about different approaches to understanding addiction. Do you suggest it would be more helpful to speak with the clinicians or continue to engage the client in dialogue with the explanation of the doctor’s stance.

  5. Janet September 20, 2019 at 4:49 pm #

    “Help” is a four letter word especially in the world of addiction treatment. For those who ask for help and those who “provide” it…HELP is a loaded word.

    If the addict asks for help… they usually want to do it their way which is, of course, the addict way… because the addict is stronger than the sincerest desire to quit in the best person. No matter how much our loved ones want to quit, the addict is almost always running the asylum; overriding the honest and brave need to stop.

    Physicians set up parameters to do no harm to themselves, and to hopefully assist the patient in reducing the amount of harmful medicine the patient is consuming. If the patient is able to follow the protocol… it’s a win win.

    But that’s not recovery.

    Marc is correct in that patients need a partnership with health care providers that includes someone who speaks the language of experience. It’s not empirical. It’s experiential on every level and requires an insider’s perspective.

  6. Joanne September 21, 2019 at 8:43 am #

    Thank you for bringing this to light! You certainly have captured a big problem with many doctors and their rigidity of treatment. My son, who was addicted to benzos following an addiction to heroin, was lucky enough to find a doctor at the VA who worked with him on the timeline for tapering off the xanax.. The VA’s written protocol of their suggested taper schedule felt ridiculous for him and he expressed this to his doc. The doc was willing to work with him on his own timeline, in spite of having to answer to his superiors, I’m certain. Sometimes it has to fit the patient….a good doctor will know but I suspect they are hard to find.

    • Janet September 21, 2019 at 11:26 pm #

      So good to hear this, Joanne. The V.A. is really making an effort in many many ways. My adult son is receiving treatment from them as well. As with everything,
      you can’t teach AT the student. It’s a willing partnership that works best.

  7. Eric Nada September 21, 2019 at 11:39 am #

    Great points here, Marc. Addictions are such a representation of underlying dependency needs and the personal feelings of agency that you were helping your patient create around her decreasing her drug use must have felt amazing to her after a life with so little of it. I wonder, too, how triggered she may have been by possibly feeling “dominated” by her new doctor, given her history. I would assume this may have brought up some trauma for her in addition to his interfering with her tapering regiment, further complicating the positive self-esteem she was building. Lastly, it also sounds as though her new doctor was fixated on the substances and didn’t even consider the underlying emotional patterns that he was inadvertently usurping with his authoritarian approach with her.

    • Marc September 30, 2019 at 6:57 am #

      Hi Eric. I agree with all three of your points: addiction is *about* dependency…so docs and other treatment professionals need to tread very cautiously so they don’t just fill in the vacuum left by the addiction. And yes, the “domination” aspect. We generally know that every aspect of the physician mythology is linked to patriarchal assumptions, “Father knows Best” — at least in the West. That’s gradually changing, thank goodness. But it’s still very much there, it’s insidious, and women who have been dominated by men in the past must be particularly vulnerable. And the fixation on substances: well that’s the elephant. We who understand addiction more deeply recognize that it is not caused by substances and so there’s no clear correlation between “detox” and recovery. But try explaining that to a GP.

  8. Terry John McGrath September 22, 2019 at 7:07 pm #

    its not only doctors – those of us who work in the drug and alcohol sector are doing harm as well by maintaining the negative and controlling attitudes towards substance users and by maintaining archaic morally based treatment methods – give them a break – if we treated others as we treat substance users there would be much hue and cry

    • Janet September 25, 2019 at 1:11 pm #

      Agreed. Imagine treating obese patients this way.

  9. Alison September 27, 2019 at 10:49 pm #

    I find many detox doctors have NO understanding or compassion for someone detoxing.
    Detox Doses are rigid and detox’s often won’t take someone on a benzo script. So detox doctors ignore not only what the patient says but other doctors prescriptions!
    If a person has been prescribed benzos for panic attacks how can a detox doctor refuse to take a patient detoxing from alcohol or opiates unless they detox from the benzos too?Does anyone want to look at the suffering here? What it’s like to detox off 3 substances? There is no belief in the “patient” anymore, and “addicts” they are suffering in detox, and it’s this attitude of “too bad that’s what you get” .
    And when they leave “AMA” aka against medical advice …because they are so uncomfortable…you think they committed a crime!

    It’s heart breaking. And doctors refuse to taper someone slowly off of benzos people using benzos for years… at least give Librium for a couple weeks??? If a person suffers through detox and makes it to rehab why can’t a low dose taper be given ?
    People can be more successful if they are more comfortable.
    Why can’t people be made as comfortable as possible in detox?
    I’ve had some sloppy painful detox stories of people being thrown into w/d cause they were given suboxone too soon.
    Why can’t treatment be individual? we are all different.

    We make people entering detox suffer and follow rigid regulations of “medically necessary”…. and the doctor ONLY knows “what’s medically necessary”?
    But “medically necessary” is the same for everyone?
    It’s disheartening.
    Thanks Marc for this post.

    • Marc September 30, 2019 at 7:08 am #

      Alison, you hit every nail on the head. But what comes out most powerfully for me is the lack of consideration, complete disregard of individual needs, and allowing suffering because “that’s what you get.” It’s not only stupid, as if suffering actually weakens the bonds of an addiction, but it borders on the sadistic. It IS disheartening.

      I gave a talk in Norway a couple of weeks ago. Actually two hours of lecturing to advanced students in the social sciences. I’m sure you know my spiel. At the end, just because I was feeling slightly belligerent plus whimsical, I asked my audience a question: After two hours of hearing me explain how addiction works, its links with earlier adversity and trauma, and even told you about my own addiction with some of the gory details, how many of you still FEEL that addicts are essentially aliens, something like a different species. Come on, if you feel that, raise your hands, let’s be honest.

      Roughly 80% of my listeners raised their hands.

      Yes, disheartening!

      • Alison October 5, 2019 at 11:24 pm #

        Sad indeed. That students minds are so closed….

      • Carlton October 8, 2019 at 9:39 am #

        A similar irrational behavior that may help students relate to addiction is Fanaticism, such as Beatle-mania.

        Fanatical people going to extraordinary lengths to be engaged in something over-and-over again with no end in sight, is much like Addiction, and also like Love.

        In fact, I think a major paradigm shift in the understanding of addiction may occur when a common denominator between Addiction, Fanaticism and Love is determined in some way.

  10. Amanda October 5, 2019 at 2:52 am #

    I’m a physician who went through detox and rehab last year and as someone who’s been on both sides of addiction treatment, I appreciate the stigma still encountered by addicts within the medical establishment. There is a power imbalance that persists between patients and their care providers that can make them feel they don’t know their own story and can’t be trusted to rewrite its ending. I would wager to guess that most doctors mean well; almost all of us can do much better. I’ve struggled to find my way as a medical professional in ‘recovery’ who doesn’t buy into the disease model of addiction, and it’s the work of individuals like Marc that allows me to feel less alone in that belief. My peers and I should be so lucky to pick up a “Prescriber’s Guide” with a chapter authored by yourself.

    • carl October 17, 2019 at 1:34 pm #

      Amanda you said “There is a power imbalance that persists between patients and their care providers that can make them feel they don’t know their own story and can’t be trusted to rewrite its ending.” Love this-as I have felt the same way from both my PCP and from a drug and alcohol counselor in the past. And now that I’m a D and A counselor I understand the contradictory information that people run into. Its a field that folks really have to navigate through very carefully still.

      • Carlton October 20, 2019 at 10:27 am #

        Hi Carl and Amanda, the two terms; “patients and “care providers” seem to be disease-based categories.

        A”patient” naturally has expectations that an authority will “fix” the problem for them, but addiction is really not like that.

        “Humans helping other humans”, is more the relationship in a recovery program.

        Each person is ultimately their own authority.

        If viewed that way, the “patient” and “care provider” is one and the same.. to use those terms.

  11. carl October 21, 2019 at 8:45 am #

    You had me until the end Carlton-your last sentence??? But I think the rest was spot-on! Another reason I love Marc’s blog! I guess I love the gray areas people on here expose that I think the field just fails to usually see(i.e. a physician that doesn’t agree with the disease concept).
    So many wonderful nuggets (A”patient” naturally has expectations that an authority will “fix” the problem for them, but addiction is really not like that) of information and testimony that really need to be part of a good recovery-“empowered freedom” program!!! I find so much of this to be such fascinating stuff! Learning can be so intoxicating.

  12. Elizabeth October 23, 2019 at 2:54 pm #

    Numerous medicine addicts acknowledge they can stop using at whatever point they have to. They have a tendency that they are in completed order over their drug use and their lives. Genuinely once you become subject to a prescription, it changes your cerebrum. This change in the mind makes you think and act particularly as opposed to you did before transforming into a somebody who is dependent, and the result is that halting drugs ends up being dynamically problematic

  13. Carlton October 24, 2019 at 12:36 pm #

    Hi Marc, I am curious if Daniel Jacobson’s talk on prediction via the interplay between gene networks and environmental challenges, could also predict genius, such in music, engineering, etc.

    My point is that I doubt genius will ever be predictable, nor addiction.

    The people I saw in the various recovery programs I attended, came from the full spectrum of humanity, and from all levels, types, etc.

    This new method sounds like a computer-assisted-gene-version of Phrenology, but it could be just the times we are living in 🙁

  14. Jed Olson December 3, 2019 at 2:31 am #

    Sorry to sound contrary Marc, especially as one who has read your books and gives them to my medical colleagues regularly…but your post seems to imply that your patient was better off with a liberally-prescribing physician who knew nothing about addiction treatment, than with a doctor who has taken time to read the research on safe prescribing and was trying to facilitate his client in successfully and safely freeing herself from an opiate addiction. Also, it’s regrettable that you and others who have posted here give in so easily to doctor-bashing; or rather, to bashing the simplistic strawman doctor stereotypes portrayed here.
    As a doctor, I pay out of my own pocket for my DEA license, which allows me to prescribe controlled substances. I took weekend courses and additional seminars, at my own expense, so that I could get an X-waiver to prescribe buprenorphine to clients who wanted to try it. My prescribing patterns are monitored by my state’s prescription drug monitoring program, and like many primary care providers, I get constant warnings if I happen to prescribe a lot of controlled pills, or if I prescribe potentially lethal combinations to the same patient (such as giving Valium to someone addicted to codeine, something you seem to feel is very reasonable). In other words, doctors like myself put in a lot of training and a lot of money so that we can be engaged in helping our patients treat their pain and treat their addiction, when they are ready. And we want them to succeed, whether that means being on buprenorphine for life or moving toward being completely off opiates and benzos.
    What do we get in return? In many cases, we get our DEA licenses suspended or revoked. We get sued if our patients overdose, which in turn leads to disciplinary action by our state medical boards. We get bombarded by institutional flags because we’re not ordering enough urine toxicology screens, checking our prescription drug monitoring programs often enough, or getting enough of our patients to sign “opiate consents,” the current politically correct term for what used to be called “drug contracts,” despite the fact that patients and providers alike find them demeaning and there is no scientific evidence to support them. Meanwhile, many of our health care organizations and multi-specialty physician groups have few (or zero) experts in the treatment of complex pain or addiction. Who treats those things, at least in the United States? Your GP. Your internist. Your family practice provider. That’s us- the ones with some of the lowest salaries, the highest rates of burnout, and by far the largest numbers of patients treated per calendar year (aside from pediatricians). Of course, I’m speaking from the U.S. medical system; hopefully some of your readers and contributors are fortunate enough to get their health care somewhere else.
    All I’m suggesting is that instead of bashing us for not letting a patient horde extra codeine for rainy days (a practice that has facilitated non-medical use of opiates by kids, who readily steal from these stockpiles), or for not co-prescribing opiates and benzos (a leading cause of unintentional overdose deaths), it would be nice to see some recognition for that fact that some doctors are trying to do good work in this area. We’re not control freaks in most cases. But if you (the patient) are asking us to prescribe potentially hazardous, heavily-regulated drugs under a license we have to pay for, surely we should be able to have some input on how your tapering or maintenance treatment should be structured. A doctor who always prescribes what you want and has a hands-off approach to how you manage your drug taper and your addiction is NOT a good doctor; he (or she) is more likely a doctor who doesn’t give a rat’s ass about what happens to you. Quite a few of us, by contrast, do care.

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