Terry Gorski Interview – Part II

14 May Terry Gorski Interview – Part II

Part II of a Series of Candid Interviews with the Famed Relapse Prevention Guru – Terence T. Gorski

TOPIC: What type of opiate addict is appropriate for medication-assisted recovery using drugs like Suboxone or methadone?

Interviewer:                

In the first segment of this interview Mr. Gorski you shared your opinions and thoughts on medication-assisted treatment, and for those unfamiliar with this term, it means the long-term use of medications such as methadone or Suboxone to help opiate addicts stay sober. You said medication-assisted treatment may be appropriate in certain cases. Which cases are those?

Interviewee:               

Well, for most people—there’s the severity of disease issue that we talked about last time.  There is severity of diabetes.  If you know you have diabetes in your family (genetics), you can delay the onset and the severity by living as if you were a diabetic before you were ever diagnosed.  Keep your weight way down, stay away from sugary foods, eat complex carbohydrates, keep a lot of protein, eat four to six meals a day that’s heavy in protein and complex carbohydrates, keep sweets to a minimum—you can really push back the onset of your diabetes.

The same is true for addiction. You can push back the onset of any kind of drug addiction indefinitely simply by not using the drink or drug, but sometimes you have to, like some people get addicted as a result of surgery or a catastrophic medical problem.

At the detox level you have to do your job….especially during the detox period. You have to evaluate how severe is the addiction? This is measured by the level of physiological anguish and craving the person is experiencing.

Interviewer:                

Isn’t that kind of evaluation unrealistic at the detox level of care? Detox only gives you a 5 to 14 day window to do the evaluation you are suggesting.

Interviewee:                

It all depends.  That’s when you define it in terms of what insurance will pay for, but detox—if you call it stabilization, then you’re really looking at a period of time, and it all depends on the drug, and it all depends on the length of time you’ve been using the drug and so on, but you’re really looking at an acute and a post-acute withdrawal period that can take six to nine months. That’s where medication-assistance comes into play.

Interviewer:                

I’m sure you are aware that the government, several politicians and the current administration has issued healthcare briefs and have come forward with very a pro-medication-assisted treatment stance.

Interviewee:        

Which in and of itself is a very good reason to distrust it.

Interviewer:          

[Laughter]

Interviewee:                

They’re also very pro this treaty with Iran on nukes, they’re also pro on Obamacare, if you have your insurance you can keep your insurance, if you don’t you’re screwed…and I could go on and on and on to all of the things this government was “very pro” about that have blown up and been disastrous.

Interviewer:                

But look at the research on people that have been on medication-assisted treatment. Relapse rates are down, crime rates down, incarceration rates down, overdose death rates down, risky sexual behavior down, transmittable diseases down…don’t these statistics show that treating opiate addiction as a medical disease and providing a medication to treat it works?

Interviewee:                

Have you ever met someone who’s lived their whole life on methadone, 10 years or longer?

Interviewer:                

Maybe not that long, no, but several years on methadone or Suboxone.

Interviewee:                

How’s their quality of life?

Interviewer:

Maybe not the greatest. They are dependent on a drug but they’re not committing crimes, or any of the other factors I mentioned that research has shown.

Interviewee:                

Yes but, they’re not thinking clearly, and they’re not contributing to society.  Maybe they can pick up garbage in the park.  The longer they’re on it, the more of a decline in functioning they’re gonna show.

Interviewer:                

Another plus is they’re not using heroin.

Interviewee:                

So methadone is somehow superior to heroin— is that what you’re suggesting?

Interviewer:                

That’s a subject we’ll address in the next segment, but you did say in the previous segment that medication maintenance is appropriate for a certain type opiate addict. What type is that, can you explain?

Interviewer:                

Yes of course! Think about this now, if you’ve got a 60-year-old guy who’s been on heroin and he’s on heroin for 30, 40 years, and every time he tries to get off heroin he’s in horrible agony. He can’t maintain any sobriety and the withdrawal is so awful that he keeps picking up again. He has to rob and steal to do it, you know to support his habit— I have no problem with that person being on methadone for the rest of their life.  None whatsoever.

Interviewer:                

So we are back to making the case based on severity of the addiction and withdrawal and number of relapses?

Interviewee:                

Yes those are factors that help you decide who is appropriate for medication maintenance. I also have no problem taking somebody who’s indigent and on the street and trapped in a high cost daily habit. Imagine this:  You’re on the street, you’ve been reduced to prostitution, you’ve been reduced to selling, and you’ve been reduced to sleeping in dangerous places.  You’ve been assaulted and mugged and raped many, many times.  You have to come up with $500.00 a day for a heroin habit, you have no known skills. You’re gonna use the only thing you’ve got, which is your body, which is prostitution, or your ability to steal, so crime goes up, prostitution goes up.  Your risk to your health goes up, but you’re in a trap, you can’t get out of it, because you’ve got to turn $500.00 a day to support a dope habit.

Interviewee:                

Just so we’re clear, that’s another situation where maintenance is appropriate?

Interviewee:                

Yes absolutely. Now, I have no problem at all with you going into a doctor and into a clinic, saying, “I want to break out of this,” and the doctor starts you on methadone, gives you a script for methadone, but not a forever, not telling you you’re gonna be on this forever.  The minute you start taking legal methadone, you don’t have to come up with $500.00 a day any more. You can break out of that trap.

Interviewer:                

That’s an interesting argument; sociocultural factors can make it acceptable for methadone management? If you are poor, have few prospects and stuck with an expensive drug habit methadone or Suboxone is acceptable. That’s a similar argument the government and the administration is making –

Interviewer:                

Now, let’s get away from the general thing about medication-assisted recovery for everybody, and why don’t we reframe the question on evaluating who are appropriate candidates for long term medication-assisted recovery?

Interviewer:                

We’ve come full circle with the appropriateness argument.

Interviewee:                

Well that is key. These drugs are powerful and have lasting effects. They simply aren’t suitable for every opiate addict because there are different severities of narcotic addiction, different durations of narcotic addiction, different individual biology and genetically inherited factors.  We should have a profile from somebody, a professional who comes up with guidelines that help determine who is appropriate for medication-assisted recovery—a kid’s messing around with Oxys for two or three weeks, you don’t put them on Suboxone for the rest of their life, in a detox program to help with withdrawal symptoms – that’s appropriate. A doctor that prescribes Suboxone to a kid like this for long-term use, that person should be shot.

Interviewer:                

So what you are saying is that somebody who has relapsed a whole bunch of times is a good candidate?

Interviewee:                

Yeah, or at least once and you see that the relapse, they are doing the normal behavioral and psychological things that should be helping them, they were adequately withdrawn, they’re now working a program, but they’re just so uncomfortable they can’t live in their skin, and it’s not going away.

Interviewer:                

So it’s an interesting idea, “allowing” people, a relapse once, maybe more than once, in order to be an appropriate candidate for medication-assisted treatment—as opposed to a first line of defense? Or as a prevention drug?

Interviewee:                

Listen don’t you know people on Suboxone who relapse all the time?

Interviewer:                

Oh, sure.  The opiate addict who cycles back and forth is very common.  They don’t take Suboxone for a day or so, so that they can GET high, they go back to using, and—

Interviewee:                

Or they take it, and they wonder, “What would I feel like if I put some heroin on top of this medication?”  Because you’re dealing with the addictive thinking, non-rational thinking [Laughter] you know such opiate addicts?

Interviewee:                

I do and you make a good point. Many addicts are not simply opiate addicts- they abuse other drugs too as well as alcohol. Also many addicts abuse methadone and Suboxone…

Interviewee:                

That alone complicates the whole idea of medication-assisted recovery and makes it very dangerous.

Interviewee:                

Thank you once again for your time and I look forward to the next segment on inpatient rehab and the role of medication-assisted recovery. I am curious to hear your opinions and whether multiple times in treatment is even necessary with medication-assisted recovery.

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