As a physician, where do I fit in?
By Sylvester “Skip” Sviokla, MD, ABAM
Shortly before I graduated from medical school, a well-respected physician and world-renowned scientist in medical research summoned our senior class for a discussion of our approaching “doctor” status. He reminded us of the narcissism that could get in our way, especially before we understood exactly what was happening during our transition from student to intern. Then he made a startling request, or so it seemed at the time.
He urged that we listen carefully to all of the hospital staff members with whom we would be working, and not be afraid to take suggestions. The ward clerks, the people from social work and the nurses all would be good sources of information to help us deliver better care to our new patients, he suggested. The nursing and social work notes could indeed be more informative than those of our fellow physician consulting staff.
At first I was somewhat skeptical, but by the end of a talk that was rife with examples, I believed I would be foolish not to heed his advice. In truth, I can say that encouraging discussion by inviting questions from the clinical staff in all of my subsequent hospital and emergency room treatment settings was more than valuable. Not only did my listening cause me at times to improve patient outcome vastly, but in one startling case it saved a patient’s life.
I listened to an experienced nurse tell me “her gut” said we should keep a patient even though I had decided that her vague complaints justified sending her home. I reversed course and insisted that the patient stay in the hospital, and 15 minutes later she suffered a cardiac arrest. Certain death would have resulted had she been in her car on the way home. Responding quickly in the hospital allowed us to resuscitate her and she was discharged within two weeks, alive and well, to her young family. That is only the most striking example of how that sage advice has worked for me.
The progression of my addiction, subsequent loss of my medical license, and eventual recovery (which motivated me to write the newly released From Harvard to Hell and Back) found me beginning a new career in addiction medicine in my early 50s. I had, upon renewal of my medical license, joined the American Society of Addiction Medicine (ASAM), studied the field and passed the certification exam. I had been given an opportunity to learn how outpatient addiction treatment was being delivered at Meadow’s Edge Recovery Center in Rhode Island, an enormously helpful experience for which I am grateful. I subsequently grandfathered into the American Board of Addiction Medicine (ABAM) and started a clinic devoted to the treatment of substance abuse only. But how was this going to work? I wasn’t sure.
Although research into the medical aspects of addiction had been carried on at a high level in many institutions of higher learning for decades, I wasn’t sure how I was to apply the knowledge I had acquired. I had no counseling experience and my temperament was much more suited to the surgical/emergency room side of healthcare delivery (“see it, fix it, move on”). This was going to be completely different.
My own recovery had been spurred either by a long-overdue flash of insight or by the power of a spiritual moment. Since I am not one of those people who are more spiritually certain, I tend to avoid that discussion with patients. What I am certain of is that my surrender began my recovery and gave me the peace of mind to cease use and then fill up my life with good things.
I was certain that surrender did not merely denote a cessation of hostilities but was an active force in helping win the war, providing an opportunity to stay vigilant in the newly found daily quest. All the while I was experiencing ever-increasing joy. How was I going to reach those patients still actively using, or perhaps in a stage of early abstinence during which they saw only the struggle? I wasn’t sure.
But as I reflected on what had worked in the past, I changed my plan. I had asked two counselors, one with an LCDP (licensed chemical dependency professional) credential and master’s in counseling and the second with an LCDP and an RCS (recognized clinical supervisor), to come to work with me. I knew that they were both accomplished in individual and group counseling. I also was fortunate to enlist the help of a PhD-level neuropsychologist with years of experience in dealing with addiction. Initially I had engaged the three or four best people in the field with whom I had worked. I saw myself as the boss sitting atop the organizational chart.
But quickly I realized that I needed continuous input from my staff that placed me more in a wheel of treatment—one spoke among many. On reflection, I suppose that being the hub of the wheel is a more realistic characterization. After all, the buck does stop with me.
My staff taught me about what they did as much as I could provide them with medical advice. I read Yalom’s work on psychotherapy but had to sit through process groups, nursing groups and intensive outpatient groups before I truly understood the power of group dynamics.
I had obtained a contract with the Rhode Island Board of Nursing that allowed me to evaluate, recommend treatment for, and monitor nurses who would return to work under strict terms of compliance. I made my application for the contract with the board based on what the Rhode Island Medical Society had required of me prior to allowing me to treat patients post-addiction. In addition to offering counseling, this meant that I needed a well-trained psychologist to evaluate the nurses at least twice: first as part of our assessment and second before we recommended that a nurse be allowed to return to work. I knew substance abuse and dependence, but I didn’t know much psychology.
We now get referrals from many different professions: lawyers, paramedics, pharmacists and physicians. I know our number would not have continued to grow had I talked more than I listened. Our weekly multidisciplinary meetings continue to educate me today.
Discussion of the nurses’ groups leads me to another subject I want to discuss in broad strokes: the use of Suboxone (buprenorphine plus naloxone) as a treatment modality to promote recovery.
I have been a medical director of methadone clinics and have seen both sides of the harm reduction approach. I do not believe that Suboxone is just an office-based substitute for methadone. A comprehensive approach using Suboxone on the way to full recovery is indeed possible, albeit lengthy. The extraordinarily long half-life of buprenorphine, its very high affinity for the opioid receptor and its partial agonist (activation) activity are the qualities that differentiate it from methadone.
The Rhode Island Board of Nursing has seen fit to allow nurses who have had opioid diversion drive them to treatment return to work on Suboxone under very strict monitoring, and this has shown great success. Over the last 5 years I have seen no relapse to opioids in that population.
And the ever-increasing number of people addicted to prescription opioids and only to prescription opioids has provided a patient population with some interesting responses. I frequently hear that after their first month on a stable dose of Suboxone, these individuals report that they feel “clear” and “just like they did” before they began taking their pills. I have never heard that from methadone patients.
Here is what is starting to work in my efforts to get people off Suboxone safely and satisfactorily. I expect a patient to be on a stable dose of Suboxone (usually 16 or 24 mg qd) for a minimum of six months before attempting any reduction in dose. The patient will be asked on a regular basis after that if he/she is ready to try a slow taper. The patient is reassured that he/she will not be prescribed less medication until a new lower dose has been established to the patient’s satisfaction. The patient also can stop the taper at any time.
The patient must meet two conditions while attempting the taper. One, an absolute, is that there be no mind-altering drugs detected while it is in progress. This certainly includes no use of either alcohol or marijuana. It is a perfect time to reiterate teaching about cross-addiction.
Second, the taper is aimed at reducing the daily dose by no more than 4 mg over a four-month period (i.e., going from 20 mg qd to 16 mg qd takes 4 months). As the dose approaches zero, more leniency is given the patient adjusting to the dose within parameters.
So far, this slow approach has begun to reap rewards. A very small dose decrease over months, not days, seems to allow a resetting of the receptors so that as one approaches the opioid-naïve state, he/she maintains equanimity and is craving-free with good energy levels.
This approach will not suit all patients. But its early success (literally after years of tinkering) is encouraging. Broader, double-blind prospective studies are needed to see if my rather large but clearly anecdotal experience to date has merit.
In summary, I believe that Suboxone is clearly one of the best advances in addiction medicine in the last decade. But the medication alone is not the answer. Individual counseling, along with more intensive treatment when indicated, is clearly as important as it has ever been in helping people to heal.
As I have gratefully learned, all of us working together still remains the best approach for encouraging our patients to attain the true joy of recovery.