Shirah Vollmer MD

The Musings of Dr. Vollmer

Opiates, Race, and Public Health

Posted by Dr. Vollmer on November 2, 2015

 

http://www.theatlantic.com/politics/archive/2015/08/crack-heroin-and-race/401015/

 

“Heroin use has changed from an inner-city, minority-centered problem to one that has a more widespread geographical distribution, involving primarily white men and women in their late 20s living outside of large urban areas.”

What role should psychiatrists play in this changing epidemic? Is Opiate Use Disorder, (the new ICD 10 language), a psychiatric diagnosis? The issue of psychiatry and addiction has always been murky. Substance abuse as a disease is the common conception, and yet, little is known about what is diseased. What is the difference between substance abuse and criminal behavior? Is every armed robber in need of psychiatric treatment? Is there a difference between bad behavior and “sick” behavior. This Atlantic article highlights the issue that when the problem is predominantly in minorities, we tend to criminalize the behavior, but when the problem hits the middle class white folks then we see the need for rehabilitation.

Certainly the field is exploding, both because of the epidemic of opiate use disorders and the expanding health care coverage for drug problems. Yet, our understanding is very primitive. How do we help these people? Is it “tough love” or should we put them in a cocoon, feed them three square meals and tell them how to spend their time? Should we pamper them so they learn to love themselves or should we turn off the spigot of support so that they can “hit bottom”? Or, do we start with the loving, warm approach to treatment and slowly, as they “get better” diminish the support? Do they need group therapy, individual therapy and/or family therapy? How long does therapy take to prevent a relapse? On the other hand, if relapsing is part of the problem, then how do we hold providers accountable for their treatment?

Accidental overdoses are an all too common happening in this world. Who is responsible? Heroin use has grown in popularity in large measure because of prescription opioids. When the patient cannot get their “pills,” in order to prevent withdrawal, they have to switch to heroin. So, do we hold the prescribing doctor responsible for the addiction, or is this physician just trying to provide relief to needed suffering? What about the drug companies? Are they to be praised for creating a pill which diminishes pain, or are they the evil corporations which knowingly gets massive amounts of people addicted to drugs which  could lead to death?

Psychiatrists usually do not treat chronic pain, and yet we do have medications which diminish the cravings associated with substance abuse. Again, are we part of the problem or are we part of the solution? Diminishing cravings is helpful, but does it make sense to substitute one drug for another? Certainly if we can prevent the rise in accidental overdoses we are helping the world, but on an individual basis, the answer is less clear. In a simplistic sense, psychiatrists can be most helpful by trying to help the patient understand the escape. What is the patient trying to numb out about? Is it trauma? Usually, in my experience, the answer is yes. Metabolizing this trauma, helping to put it in perspective with a caring listener is, by my way of thinking, the best way for psychiatrists to help these patients. When the patient faces the childhood trauma with an adult, mature mind, the patient has less of a need to escape themselves. Can I prove that what I propose is true? Nope, but neither can anyone else. Given the lack of evidence in this field, intuition has to play a role, until otherwise notified.

2 Responses to “Opiates, Race, and Public Health”

  1. Shelly said

    When you listen and understand the heroin (or drug or alcohol) abuser, how does that help? When they want to escape their painful world, how does listening make them less want to withdraw? The problems and issues that made them want to hide from their problems are still there. Who are we, as a society, to say, “Hey, you aren’t allowed to want to escape your problems!” and throw them in a psychiatric or substance-abuse center? Why do we blame them for getting hooked to these medications when they are so much like all of us, simply trying to numb the pain that each of us, day by day, have to face?

    • Let us, for example, imagine a patient who was emotionally and physically abused by his father, and his mother did not protect him from the obvious abuse. The first path might be towards heroin, but when they sober up, it is possible that through in-depth psychotherapy, they begin to see themselves as helpless as a child, one who suffered beyond a reasonable amount of childhood suffering, and as such, the adult patient learns to have compassion for his childhood self. In so doing, the patient learns to see himself as one who although mistreated has a lot of interesting and lovable qualities, which have not been nurtured due to his psychological pain. Learning that what was once a helpless child is now an autonomous adult is a very challenging lesson as most of us get stuck in the “helpless child” dilemma. We feel as if we have few choices, when in fact, we have choices but we do not allow ourselves to open up to novel ways of being in the world, and hence it feels like there are no choices. Change is indeed hard, but through this hard work, lasting internal change can take place. Also, I am not advocating involuntary treatment for substance abusers, although there is an argument for that. I am also not blaming them for getting hooked, but I am saying that there is a way out, although at the moment, that way is simply intuitive and not scientific. Thanks.

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