I am treating opioid dependence with suboxone. Dependence and addiction are difficult to deal with because the biggest sign of a relapse is when the story told by the dependent patient (or addict) does not match the evidence. I have to remind myself that denial is not quite the same as lying. The hallmark of addiction is a person lying to themselves as well as me, that they are in control and don't have a problem.

I want to believe they are ok, and so do their loved ones and so do they. But sometimes they aren't. I have to pay attention. It is unhelpful for me to act like a cop lying in wait for a violation. It is more useful for me to think of it as internal and external controls or boundaries. The person became addicted to opioids because they abused them or because they had chronic pain and multiple risk factors for dependence and/or genetic factors. They are seeing me to help get it under control. They are working at internal control and boundaries about the drugs. I'm one external support and boundary, to note when the internal ones have failed. My job is to respond to evidence of relapse.

To help myself stay on track and not get caught up in stories or how young someone is or how much they have suffered, I use categories.

Four general categories of narcotic use/abuse

1. Patient in control, urine drug screen matches story, regular visits, no aberrant behavior. They are doing well. Hooray!

2. Patient in mild relapse/questionable: lost medicine, missed visit, cancelled visit, one questionable urine or patient states that is in relapse and urine drug screen matches the story. Patient not in denial and/or rare or mild aberrant behavior. Resists behavioral treatment requirements mildly.

3. Serious relapse or markers for addiction outweigh chronic pain complaints. Patient denies that there is a problem, urine drug screen does not match story, tampered urine, other substances, repeated lost meds/attempts at early refills/missed visits/does not do behavioral requirement despite repeated reminders/warnings/ cancelled visits/requests phone refills/ repeated boundary testing. (Markers more likely to be charm, professed confusion or distraction about requirements or attitude of wounded innocence.)

4. Severe relapse. Patient denies problem. Illegal substances in urine (cocaine, methamphetamine, heroin) or continued use of outside narcotics or benzodiazepines or alcohol with suboxone. Or prescribed medicine not showing up in urine, concern of selling medicine. Pharmacy records indicate multiple prescribers. (Markers include open defiance but also charm, professed confusion, or attitude of wounded innocence.)

Provider responses:

1. Patient in control: Urine drug screens can go to random, minimum related to opioid risk tool/history/clinicians level of concern/patient stress level/concomitant behavioral health diagnoses.
Over time behavioral treatment can be reduced. (Time in years, not weeks or months.)
Interval for visits may be increased.
?minimum length for visits:
Suboxone 3 months
Methadone monthly

2. Mild relapse: First offense: warning and documented.
Repeat if long interval/low concern: repeat warning.
Short interval/high concern: shortens visit interval
And/or requires contact with behavioral component/attendance proof
And/or send out urine

3. Moderate relapse: First offense: warning and documented.
Continue to document warning and number of drug contract violations.
By second or third, interval must be shortened
Repeat send out urine
Repeat proof of behavioral attendance/contact.
By fourth offense within 3-6 months, referral to pain clinic/referral to addiction specialist/transfer to inpatient rehab or methadone clinic/ or discharge patient.

4. Severe relapse: First offense: warning, documentation/immediate shortened interval of visits.
With sales of drugs or illegal drugs, stop prescribing immediately.
Benzos difficult because diazepam may stay in urine for 6-24 days, do multiple visits and keep discussing.
Discuss other options (referral to pain clinic/referral to addiction specialist/transfer to inpatient rehab or methadone clinic/ or discharge patient) at first serious offense.
Multiple prescribers of potentially lethal medicine combinations or narcotics or benzos from two providers, discharge patient immediately/no further prescriptions.

I use the categories to step back from what is happening and to ask: should I write this prescription? It's hard not to when someone says, "You are making me use heroin." But the realization is, "You already are." They have gone back in to the addiction and it's no longer safe for me to prescribe: if they are getting prescriptions from multiple people, they are selling something, or I am just adding to the chance of overdose and death. I want to reduce suffering. But it is more important to not kill my patient, by giving them an additional drug to use.

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