People mostly come to see me as a last resort. They have tried everything else - cutting down, home detoxes, using other drugs to get off opioids, rehab, inpatient detoxes. They are usually in some kind of destructive cycle and there is financial or legal chaos and they just can't stop. This isn't a personal failing or weakness, it is the nature of opioid dependency and it's common to all people who become truly addicted to opioids --- acquiring and using the drug takes a prime place in a persons life to the exclusion of all other activities: family, friends, work, sport, personal interests, travel, and the person is willing to sacrifice anything to stay out of withdrawal.
By now you probably know more about opioids and illicit drugs than most doctors. Your experience and knowledge need to be respected. I have spoken to thousands of opioid addicted people - each one has told me about their lives, the nature of their addiction, what it is like to be in withdrawal and what they will do to stay out of it. And each person's story is different. Whether it's the dark web, over the counter codeine, the local neighbourhood dealer or prescription opioids, the basics are the same - comfort from using, then withdrawal, then acquisition, then using again in a cycle that repeats every single day. Guilt, shame, sickness and remorse are a common thread throughout most people's experience. Then there is the anger at prohibition that has led to this situation, the downward social spiral caused by the criminalisation, stigmatisation and marginalisation of people who may have found opioids helpful at treating their depression or PTSD. People who use opioids are clever, you have thought about these things and the legal and social consequences to drug policy are things you might want to talk about. You shouldn't have to dumb yourself down to access treatment.
My knowledge comes from your experience. Any expertise I have in this area comes from fact that I have learned from the experts - the people who come to see me. I cannot tailor treatment to suit you unless I understand where you are coming from.
While OTP may be a treatment of last choice for people, it is far from being a poor quality, band-aid salvage therapy. In fact it is the gold-standard proven way in which people get off that destructive cycle. They are instantly safer than before and when the addictive drive to acquire drugs has receded, then family, work and travel can re-enter the space that drugs occupied. I see far more improvements in peoples lives than the vast majority of GP's - genuine transformations that seem miraculous. This is FAR from being dead-end medicine. People come to see me from living in the bush, in squats their cars or under bridges, malnourished and living in filthy degrading poverty, doing whatever they need to to pay for the drug they cannot live without. But six weeks later I may literally not recognise them in the waiting room. They have put on weight, their skin has cleared of sores and abscesses, their clothes are clean and they have a positive hope that wasn't there before. That is common, it is not an isolated incident.
The majority of people I see describe the program as life saving. Their words, not mine.
I find the thing that most people want when they come is STABILITY. They want to feel content, not high. They want to function properly. They want to feel like how they remember they did before they took drugs. The vast majority of people coming on the program want stability, free from complications, poverty, ill health and crime, and for the majority of people that's what they get. All I do is add in a clean legal opioid, offer a few pointers and do a hell of a lot of listening. The rest we figure out on the trot, maybe not getting it right on the first go, but getting it right in the end.
This then frees the person to choose stability on the program or gradual withdrawal and rehab. The choice is theirs. They are no longer hostages of their opioid dependency or the dangers of dealer-supplied opioids.
You don't burn any bridges coming onto a treatment program. Your opioid of choice is still out their waiting for you and the dealer who supplied it is ready and willing to have you back on their treatment program. My role is to make sure the opioids I prescribe are easier to access than black market opioids. No hoops to jump through, as few barriers to treatment as I can manage. Straight into treatment from the get go. Only the things required for your actual safety done first.... Blood tests, mental health reviews, complicated and protracted histories can all wait. It isn't rocket science. A GP model allows all that to happen gradually over time after you get the benefit of suboxone or methadone dosing.
It's not quite "dose first, ask questions later" but it is about removing unnecessary barriers to treatment. When it is easier to buy black market drugs than it is to stay on or come on the program then that is a treatment failure in my opinion.