Guest Blog by Katy Ottaway
I want to talk about treating addiction. I am going to use opioids as my example.
I think of addiction as a loss of boundaries. The person has lost their boundaries against the drug – alcohol, methamphetamines, heroin, oxycontin, gambling, sex, gossip, cocaine, kratom, whatever. The boundary is no longer there and the addiction now controls the person. The addiction speaks in a soft, devilish voice. “Just once more…you can stop after once more. You need to feel good enough to go to your daughter’s performance. You can’t feel sick today, there is too much to do. You are not an addict, you have control, you are in control. Just. Once. More.”
I tell new patients that it is my job to be present while they develop new boundaries. This means that I may like them and I may be nice to them but I do not trust their addiction. Therefore my job is to pay attention and be the boundary until they develop boundaries of their own. This means that I check. I check urine drug screens. I do not allow people to offer “dog ate my homework” excuses. If someone stole your drug, I require a police report. You left it at home? You will need to get it. You are in Seattle and cannot make your appointment? Do not worry, you will not be in full withdrawal for 48-72 hours. Perhaps you would like to reschedule. You can’t give me a urine sample? Here is water. We will do the appointment and then you may sit in the waiting room until you can give me a sample.
My job is not to be nice. My job is to check.
I once asked the head of the UW Addiction Clinic how many “dog ate my homework” excuses he accepted. He laughed. “Oh, by the fourth one in a short time, I know the person has relapsed.” I was reassured, because four was the number I had arrived at independently. So I keep track and number them.
I categorize the progress of a person with addiction into four categories.
1. In control, no problems.
2. “I tried some percocet, my urine sample will not be clean.” They slipped and they tell me. No worries.
3. “Dog ate my homework.” Behavior gets squirrelly. I do not have to witness the urine sample. People on drugs make mistakes. They are messed up. It gets very very obvious. I start tightening boundaries: I will give you two weeks of medicine, not a month. Here is your appointment for two weeks.
4. Obviously relapsed. Sometimes this is both horrible and funny. I offer a patient inpatient treatment. “You are forcing me to use heroin,” the patient says because I refuse to give them the prescription after multiple warnings. “You ARE using heroin. You need inpatient treatment.” The patient may refuse. My prayer is that they will survive to try again. One patient has a urine sample with meth and opioids. “Can I try again?” “Um. Sure.” I say yes because clearly the first urine is not his. I am very curious to see what is in the second one. Nothing, including the prescribed drug. Clearly this is a boundary problem yet he is surprised and outraged when I say: no prescription, I am happy to help you go inpatient. It is no longer safe for me to prescribe.
There are other sorts of clinics. Some clinics give the medicine no matter what the person is doing. That may indeed be life-saving. But both types of clinics have their place. A patient tells me that she was with another provider who gave her a prescription when she called from Seattle. She was still using intermittently. “But you were way stricter. I was surprised. I had to straighten out. Then I found that I liked being clean. Thank you.”
Why do people relapse? Sometimes they are initially overconfident. They are off the drug. Everything is fine. Everyone should love them. But….everyone doesn’t love them. And some people are not ready to forgive right away. I have seen people slowly realize how much damage they have done to friendships and to family members. Being clean is not enough. Sometimes that is so painful that they relapse.
And that brings us to AA or some other drug treatment. Why do I require it? When people are clean for a while and behaving and going to the groups, they come in outraged. “People are court ordered to go to drug treatment and I can tell that they are still using! They are sitting there lying! I can tell!”
I reply, “And did you ever lie when you were on drugs?”
“Yes,” they say.
“Do you think your family and friends could tell?”
And then they are silent. It is bad enough seeing a stranger lie. But seeing a loved one lie, “I am not an addict, I am not using, I am clean.” This is the pain that they must face, that they have caused, that they must heal.
I spoke to a physician who transitioned patients from heroin to buprenorphine to the injection that blocks the receptors. “How long do you keep them on buprenorphine?” I ask. “How do you know when to transition?”
“Oh,” he says, “It depends how much of a mess they have made of their life. If they have destroyed their job and all their relationships with friends and families, it can take years.”
Years. It can take years to repair the damage. And while we hope for people to forgive us, no one is under obligation to let us back in their lives. Forgiveness is one thing and reparation is another. Reparation is not under the control of the former addict.
If you are addicted to something please seek help. If you have someone in your life who is addicted to something, there is help for you too. Blessings to you and yours.
Thank you for elaborating on how you handle addiction; that is the kind of attention that is needed to resolve all kinds of medical and other problems. It seems to me that it would be very difficult to do this kind of care in a virtual meeting, or am I wrong about that? I certainly will refer to you if I get any clients with an addiction problem.
I did virtual visits starting in March of 2021, when I had to. For the substance overuse folks, we continued in person with masks and cleaning, in part because urine drug screens were part of the visit and because people left with a prescription. I think a virtual urine drug screen is a bit difficult. Most of my clinic visits were not virtual aside from the first month, partly because my clinic was small and with a very elderly and often isolated population of patients, I think that they felt safer coming to clinic than to the grocery store and they needed to get out and have human contact. I did have a gentleman in the first month who I said I would not do a virtual visit with: this was a good decision because once I examined him, he had to go to the emergency room and had his appendix out the same day. Initially he said, “I can’t go to the emergency room because of covid!” but when I explained what a ruptured appendix can do, he decided that he would go after all.
Thank you for such an informative essay.
I have known many people addicted to alchohol
and it ruined their life.
Thank you Nan-Toby. I am always hopeful that people can improve their health. To work with people with substance use disorders, I have to accept that some will not and that there may be overdose deaths. At one point the UW telemedicine docs thanked me for reducing the overdose death risk in Jefferson County. I hope that they were right.
Katy, thank you for this very informative description of your practice and methodology. What steps, if any, do you take to discover and deal with factors that motivated the addiction in the first place? Thank you!
It very much depended on the person. With one person I brought up Adverse Childhood Experiences at the first visit. He stated, “Oh, I have a 10/10.” He worked with behavioral health as well as with me because he did have a 10/10. Sometimes I can ask questions right away and sometimes I can’t. It depends how complicated things are and if there are a lot of medical problems that have not been addressed. Some things take time.