There are many elements to AA/NA, but the secret is in the meetings–for beginners, daily–which brings the addict out of seclusion and into the presence of many others who are suffering from the same disorder and share their experiences with the group. At least the naïve addict knows that he is not alone, and while shame and humiliation might initially stop him from “sharing,” he listens to the others and recognizes his own pain as he hears about the pain suffered by others.
Finding a sponsor is critical, and for some, the sooner the better. The psychiatrist or psychologist cannot do what the sponsor can do. Some psychiatrists try to be constantly available to the addicted patient but always fail, because such availability is not really part of their general modus operandi. Such expectations only serve to put a hostile distance between the doctor and the patient, and will clearly lead to failure, for which the doctor generally blames the patient.
There are several forms of iatrogenic precipitation of addiction. The first deals with actions that I feel are appropriate: the proper prescription of opiates to patients with severe and unremitting pain, most often in patients with advanced cancer. Unfortunately, some physicians still underprescribe opiates for their patients, because they do not want to cause them to be addicted (even though in many cases, the condition is incurable and the patient is going to die relatively soon). This absurd idea is sadistic on the part of any doctor who would deprive such a patient of adequate relief of pain for sanctimonious and righteous reasons.
The prescription of opiates for undefined and poorly described pain, e.g., back pain or headache, is an opposite situation. Often, psychiatrists are cajoled into prescribing such drugs for patients who may see a general practitioner or internist very rarely, and without a clear diagnosis of the problem and a determination of whether the problem is physical or mental.
Such determinations often require imaging procedures and/or blood tests that are not part of the psychiatrist's usual practice, and it is easier to prescribe the drug than to worry about the threat of addiction. These psychiatrists often find themselves with an iatrogenically produced addict on their hands and in a real dilemma about how to resolve the problem. We psychiatrists generally are not schooled in how to detox a patient, and it becomes apparent in both of these situations–the patients whose complaint sounds very severe and the patient with less severe pain.
Writing a prescription that says “go to a methadone clinic” is not only inadequate but cowardly, because the psychiatrist would rather not expose himself to criticism over his poor behavior. Once again, narcissism gets in the way of the best interests of the patient.
In the prescription of nonopiates, we are also often too cavalier. Xanax and Valium are highly addictive psychotropic drugs. While I believe that prescriptions for Valium are fewer these days, there is still a lot of Xanax being prescribed, because it is an extremely efficacious drug for people with panic disorder or severe anxiety. Psychiatrists have to be more careful in prescribing psychotropic drugs and try to avoid creating an avoidable problem.
The concept of the addictive personality is important. There are people whose propensity for developing an addiction, whether one that is socially acceptable or one that isn't, is very important because we generally have not considered the factors that contribute to this kind of diagnostic formulation.
The study mentioned in the question above demonstrated that patients with a psychiatric history are at risk for aberrant drug-related behavior if they have chronic pain (Clin. J. Pain 2007;23:307-15). The investigators found that patients who were classified in the high psychiatric group used more drugs and higher doses. The bottom line? A consistent association was seen between psychiatric morbidity and prescription opioid misuse in chronic pain patients.
We as psychiatrists must be acutely aware that factors such as a history of mood disorders, other psychiatric problems, and psychosocial stressors might place patients at risk for misuse of prescription opioids. We often contribute to patients 'addiction by continuously prescribing opiates at patients' request without carefully scrutinizing the problem or even thinking twice about the deleterious effects of what we are doing.
“Use caution” and “Have a high index of suspicion” are two expressions we heard often as medical students. This column raises many issues that call those expressions to mind. The addict is often wary and suspicious, certainly distrustful. Much of his energy is exerted in persuading us to write the prescription. As I indicated in the case examples, such patients are often not committed to therapy–which is why I tell residents and students to make sure that a dual-diagnosis patient gets rehab first and then psychotherapy.