Today’s lunchtime conference at the Brigham was given by Dr. Mark Eisenberg, a physician at MGH-Charlestown since 1985. I was only able to stay for part of the discussion because I had a conflicting meeting but even a few minutes of listening to him was worthwhile. He has taken care of many people who use drugs over his career and told us some lessons learned from years of prescribing buprenorphine. Unlike most teaching conferences, he sat at the table (no powerpoint slides!) and had a conversation about his experiences.
Dr. Eisenberg reminded us of the history of HIV primary care, which began in the 1980s. HIV/AIDS in 1985 was an epidemic among people who were highly stigmatized, primarily gay men, Haitians, and intravenous drug users. Almost all were dying and doctors had no effective treatments to offer. Dr. Eisenberg told us he went to many wakes and funerals and had to comfort family members who asked him, “why did my son die of this illness?” Blame and fear were everywhere, with people saying that gay men choose their behaviors and were knowlingly putting themselves at risk. But everything changed in 1996 with the advent of ART. “It really was the ‘Lazarus effect,'” he said, as AIDS patients were rising from dead and getting their lives back.
Similarly, heroin addiction has always been a highly stigmatized illness. Methadone maintenance had been an option but when buprenorphine became available in 2003 that changed the landscape for people who used drugs because they would no longer have to go to a methadone clinic every day to pick up their medications. Dr. Eisenberg took an 8 hour training course on how to prescribe buprenorphine and soon had a number of patients receiving the medication. From time to time, he has seen the ‘Lazarus effect’ with this medication as well. For many patients who are able to get their opiate addiction under control, the drug is “truly miraculous.”
A few other points I found powerful:
- Stigma is widespread against people who use drugs. He suggests we write “opiate use disorder,” not “substance abuse/abuser” in the medical chart. The word “abuse” has strong negative connotations.
- When a patient with leukemia relapses, we don’t say that the patient “Failed her treatment.” So don’t blame a person who uses drugs for “failing treatment,” either.
- It’s not easy to prescribe buprenorphine. Many patients aren’t committed to sobriety. Their family members may make them attend the clinic, for example. There is certainly some scamming going on and clinicians deal with this different ways. A committed, multidisciplinary clinical team is needed to help these patients.
Drug use is widespread, throughout Boston, the United States, and the world. We really do need to recognize the importance of helping our patients control their addictions.