Who is Failing Whom? Moving Towards Person-Centered Addiction Treatment

Close up of holding hands in a caring fashion.

By Sarah E. Wakeman, MD, FASAM
August 11, 2017

It is not enough to simply say addiction is an illness. If we truly believe this, then we must ensure our language and approach mirror how we care for patients with other illnesses.

The need for treatment modification is a hallmark of disease management, particularly for complex, chronic illnesses like diabetes or HIV. We expect that for many patients a typical treatment course will include periods of remission and recurrence with associated adjustments in medication or other interventions. We even have a term for treatment for the most severe cases of refractory disease; we call it “salvage therapy.” For cancer, salvage therapy refers to “Treatment that is given after the cancer has not responded to other treatments.”1 Note that the lack of response is focused on the disease, appropriately, and not the patient.

This framing of the illness as the agent of harm is the norm for most disease states, with the notable exception of addiction. When the illness is breast cancer, we see imagery of smiling women wearing pink ribbons, and we call patients “survivors.” Despite the association between breast cancer and various environmental or lifestyle factors such as exercise, no one would ever blame the patient (i.e., the victim) for her illness and certainly not for a lack of treatment success.2 Substitute addiction for breast cancer and all of a sudden the approach and even the language changes. Patients with addiction are “abusers,” their test results are “dirty,” and they are frequently described as “failing treatment.”

For an example of how patients with addiction are commonly portrayed, take this Business Insider article.3 This well-intended piece told the story of a young woman who was only offered medications for addiction treatment to manage withdrawal symptoms instead of for ongoing maintenance treatment. As a result, she suffered repeating, and predictable, recurrences of active opioid use. The article ends with this description: “Peterson was finally able to get and stay clean while serving a year in prison for narcotics possession. But many are not as lucky— when users fail out of treatment, they can go into an endless relapse cycle.” Let’s pause for a minute and consider the words used in this description. How would we react if this were a patient with diabetes instead?: “She was finally able to get her blood clean of hemoglobin A1C after a year in prison for sugar possession. But many are not as lucky—when diabetics fail out of treatment, they can go into an endless relapse cycle.” Ludicrous, right?

It is popular now to talk about addiction as a public health issue. And yet of the more than two million people incarcerated in this country, the majority are there for substance-related crimes, meaning they either have a history of substance use disorder, were intoxicated at the time of their crime, or committed their offense to get money to buy drugs or alcohol.4 Worldwide, as many as 90% of people who inject drugs will be imprisoned during their lifetime.5 Our long history of punishing and imprisoning people who use drugs doesn’t only impact policy, it also influences the way we speak about and treat people with the disease of addiction.

Recently, I sat listening to a clinical case conference about a patient who called his doctor to ask about restarting buprenorphine treatment. As the discussion unfolded it became clear there was deep discomfort that this patient was asking specifically for medication to treat his addiction; this sort of “behavior” is called “drug-seeking” when it relates to buprenorphine. But how would we react if it were instead a patient with HIV calling to restart antiretrovirals? I imagine we would say the patient was advocating for himself and his health.

It is not enough to simply say addiction is an illness. If we truly believe this, then we must ensure our language and approach mirror how we care for patients with other illnesses. A starting place might be to remember that treatment can fail patients, but patients don’t fail treatment.


Learning to recognize and replace stigmatizing language in medical practice encourages treatment for opioid use disorder. Learn more best practices in Harvard Medical School’s free online Opioid Use Disorder Program.

CME credits provided for physicians, PAs, NPs, nurses, and social workers.


References:

  1.  https://www.cancer.gov/publications/dictionaries/cancer-terms?cdrid=44176
  2. Holmes MD, Willett WC. Does diet affect breast cancer risk? Breast Cancer Res. 2004; 6(4): 170–178.
  3. http://www.businessinsider.com/heroin-addiction-why-many-fail-out-of-rehab-medication-assisted-treatment-suboxone-2017-4
  4. https://www.centeronaddiction.org/download/file/fid/487
  5. http://www.unaids.org/sites/default/files/media/images/gap_report_popn_05_idus_2014july-sept.pdf

Dr. Sarah Wakeman headhsotDr. Sarah Wakeman is medical director of the Substance Use Disorder Initiative and the Addiction Consult Team at Massachusetts General Hospital (MGH), co-chair of the Mass General Opioid Task Force, and clinical lead for the Partners Healthcare Substance Use Disorder Initiative. Dr. Wakeman is also an assistant professor in medicine at Harvard Medical School and course director for Understanding Addiction, part of a free online CME program from Harvard Medical School to help train medical providers in best practices for working with OUD patients. Twitter

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