Column: Advice on medication-assisted treatment for substance issues

Thursday, May 30, 2019 By Dr. Jeff Fortgang
A "Tips on Law Practice and Lawyer Life" column

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Question: My son had to drop out of law school this year because of an addiction to painkillers, leading to heroin, that had begun during college when he needed orthopedic surgery. He went to a detox/rehab facility, and started going to NA meetings, but relapsed fairly soon after coming home. Now he’s begun a new program where they want to put him on Suboxone, which I understand is, itself, an opioid. To me, this sounds like more of the problem, not the solution. But on the other hand, the first approach didn’t work for him. I’m not sure how to think about this.

Answer: It’s true that we’re in new territory these days. Most of us who’ve been in the field for decades have had to adjust to changing paradigms to what is now called “medication-assisted treatment.” But now the majority of even the old-school rehabs are including medications like Suboxone among their offerings. The reason is that astounding numbers of people have died of opioid overdoses; that tragic fact overrides the inherently unappealing notion of “replacing one addiction with another.” One of the ironies is that in many cases it was prescribed medication (for pain control) that originally led to the development of the addiction.

Although many people, over the years, have eventually found ways to enter and sustain recovery from opioids in the more familiar way (drawing upon motivation borne of the scary consequences of use, sustaining sobriety through mechanisms, including high-intensity social support, lifestyle modifications, self-knowledge, and ongoing hard work, to make internal and “spiritual” changes), we have had to face growing evidence that using these drugs brings about long-lasting (perhaps permanent) brain alterations. These enduring effects seem to make it even more challenging for opioid users than for those on other substances (like alcohol) to draw upon rational/reasoning capacities to override more primitive urges to consume the drug. That consideration trumps our philosophical preference for what we might call traditional recovery.

In the case of medication-assisted treatment, we essentially redefine sobriety as the absence of substance use other than medication as prescribed.  

One encouraging recent finding is that Naltrexone alone (generally as an injectable known as Vivitrol or in the form of an implant) seems to be as effective in the long run as Suboxone. Unlike Suboxone, Naltrexone blocks opioid receptors but does not itself contain an opioid. However, commencing Naltrexone treatment presents certain dangers (beyond the purview of this column) and must be done carefully.

I said above that sobriety is redefined in a way that permits prescribed medication use. But that is not a sufficient definition. Medication use is not considered a solo treatment. It provides a kind of stabilization that permits lifestyle and internal changes, which, with the aid of self-help groups, psychotherapy, spiritual practices, etc., pave the way for lasting recovery.

Dr. Jeff Fortgang is a licensed psychologist and licensed alcohol and drug counselor on staff at Lawyers Concerned for Lawyers of Massachusetts, where he and his colleagues provide confidential consultation to lawyers and law students, and offer presentations on subjects related to the lives of lawyers. Q&A questions are either actual letters/emails or paraphrased and disguised concerns expressed by individuals seeking LCL’s assistance. Questions may be emailed to DrJeff@LCLMA.org.