I visited a treatment program recently and had a chance to talk to a current client, a 22 year old with a severe opioid addiction. “I’m getting on Suboxone now,” he explained. “The plan is to stay in therapy and finish college in a couple years and then taper off the Suboxone, with a goal of being drug free. What do you think?”
Stopped me for a minute. Suboxone’s fine for harm reduction, but as far as I can determine, going on maintenance isn’t usually a path to becoming drug-free. Far from it. There’s not as much data available on long term buprenorphine use as there is on methadone, but what there is seems to suggest relapse rates in the 80-90% range for those who leave the program– even with an extended taper, and even among the highly motivated.
Like I said, more data would help, but the client’s asking the question now.
A couple colleagues weighed in with opinions. “Tell him the truth,” one said, with a shrug. “There’s a good chance he’ll be on it permanently.”
“I wouldn’t,” argued another counselor. “Suboxone’s a lot less dangerous than going back out on the street. Even if he relapsed to other drugs, maybe he’d use less because of the bupe. You don’t want to say anything that would discourage him from taking advantage of it.”
“How’s he going to make an informed decision with only half of the information?” argued a third. “I’d talk to him honestly and let him know we’ll support him regardless of his choice.”
Reading up on the subject, I see that current best practice is to encourage the opioid addict to go on maintenance “indefinitely” but to also support a taper attempt if the patient so desired at some future point in recovery. Fair enough. Still, addicts tend to ask the awkward question, along the lines of “Yeah, sure, but– what are my chances? You seen people do it?” Right now I’d have to admit: Only rarely.
The notion of prognosis, or likely outcome, is integrated into healthcare. Patients are often afraid to ask, but when they do, they seem to want the truth. And there’s the important clinical principle of ‘informed client choice’ to consider.
What’s the clinician’s responsibility? You tell me.
