| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
LETTERS TO THE EDITOR |
Department of Internal Medicine; McLaren Regional Medical Center; Flint, Michigan
There is a growing body of literature that suggests that moderation is a potentially successful therapeutic goal for substance-dependent patients (1). Unfortunately, those who choose moderation as a treatment goal will typically be denied inpatient rehabilitation services. Contrary to scientific findings, many inpatient treatment programs continue to require that patients commit to abstinence. In a paper summarizing the American Psychiatric Association practice guideline for substance use disorders, McCrady confronts this discrepancy between science and practice. "Based on the scientific literature, the guideline also supports views that are not widely accepted in the addictions treatment community, such as the use of nonabstinent goals and the use of harm reduction strategies.... Such perspectives are controversial among policy makers and may appear contrary to an abstinence-only goal for those who attend 12 step meetings" (2).
The philosophical and programmatic dogma of abstinence has gone generally undisputed, and it should be disputed on the basis of equal access to care. Patients who choose moderation and who meet the criteria for inpatient treatment should not be denied therapeutic advantages unique to the inpatient setting (3). The ethical profundity of this is even more apparent when the patient cannot choose abstinence without negative medical consequences. Such is the case with patients with chronic pain who want treatment for illicit drugs but need to be maintained on chronic pain medications.
A patient brought this ethical dilemma to our attention. Joe was a patient with sickle cell disease with known cocaine dependence. The team was committed to treating Joe’s pain but frustrated by his cocaine abuse, which likely exacerbated his condition. A psychologist was consulted, and she recommended inpatient drug rehabilitation. Joe agreed. Several days later, we learned that no drug rehabilitation program would take him on his current medication regimen. They objected to the patient’s pain medication (Vicodin ES every 6 hours as needed) prescribed by his primary care doctor. We contacted Joe’s doctor to see if it was possible to discontinue the medication, but he said that he would not recommend it. He argued that narcotics were the appropriate and only effective treatment for the patient’s chronic pain. We contacted a local substance abuse expert and he called drug rehabilitation programs all over the state. The answer was the same. If the patient was on narcotics, prescribed or not, he could not be admitted to an inpatient drug rehabilitation program to treat his cocaine dependence.
In the past, physicians did not treat chronic pain with narcotics, but the standard of care has changed (4). Opioids are now considered acceptable in chronic pain management, and distinctions made between physical dependence and syndromic dependence (addiction) guide physicians in administration of these drugs (5). In addition, there is unequivocal support for the notion that pain medication should not be withheld from patients, even in the presence of addiction (6).
If Joe’s use of narcotic medication for pain is considered abuse of a drug, a very conservative perspective, there are still compelling reasons for providing him with inpatient treatment for cocaine. Proponents of harm reduction suggest that patients who refuse to abstain from substance abuse may still derive medical benefits from reducing the quantity of use (7). This certainly applies to Joe’s case. Abstaining from cocaine while remaining on prescribed narcotics has clear medical benefits. Cocaine is a potent vasoconstrictor, and sickle cell crisis is precipitated by any condition causing decreased oxygen concentration in the blood. In addition, there have been case reports of cocaine contributing to priapism in sickle cell disease (8), and concomitant cocaine abuse and sickle cell disease can result in hepatic failure (9).
Joe was caught between the cracks of two shifting and conflicting treatment paradigms, the currently accepted treatment for chronic pain and the currently accepted protocol for treatment of drug dependence.
Staunch believers in abstinence will offer other solutions for this patient. They might ask, why not wait until he is out of sickle cell crisis? Why not treat him in the outpatient setting, perhaps making use of a methadone program? We cannot delay treatment unless there is an evidence-based argument to do so, and we have inpatient rehabilitation programs because some patients need to be removed from enabling environments to succeed in rehabilitation. The final argument might be that programs geared toward abstinence cannot afford to let in people who are "using." Admittedly, it would be a massive adjustment, but most paradigm shifts require effort and risk. As modern medicine succeeds in extending the lifespan, we have more and more patients living with chronic pain. We believe there is a substantial moral imperative to consider the options.
Instead of looking for patient-based solutions that defer treatment or offer less-than-optimal treatment, we need to consider programmatic change. If moderation is a potential solution for drug-dependent patients, let us design programs flexible enough to accommodate patients who prefer, or, in the case of patients with chronic pain, need a different kind of treatment program. If a drug-dependent patient with chronic pain is willing to abstain from the targeted illicit drug and have his prescription medications dosed by providers in the inpatient setting, then that should be considered adequate commitment to therapy. Asking patients to suffer the pain of one chronic medical condition or go without optimal treatment for another condition is unethical and, in a society that values evidence-based treatment, it is simply bad medicine.
DOI:10.1097/01.psy.0000172147.68729.92
REFERENCES
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
