Always love reading your and your guests articles, Dr. Cifu. As a former pain and addictions specialist (I trained in chronic non cancer pain at the Cleveland Clinic’s Chronic Pain Rehabilitation Program), I can tell you over diagnosis is huge in the psych realm. I came in when opioids were newly liberated, and OxyContin was all the rage. I was extremely worried about addiction and was continually shut down as drug after drug was put on to mask every symptom; benzos on top of opioids on top of muscle relaxers on top of amphetamines...we all know what happened. At the CC I learned about opiate weaning for chronic non cancer pain and absolutely concurred with it. Along with proper head shrinking, exercise, and weaning - people’s lives improved in all areas. We learned over time that chronic opioids CAUSE pain, not to mention a myriad other problems associated with chronic use. Oh and addiction too. Surprise. 🙄
Fast forward to the current use of opioids for addiction, and one would think that we could see what happened historically - but no, apparently brains can tell between addiction and “proper use.” So history will repeat itself with harm reduction - a preference among many addiction psychiatrists. I suspect you all can tell I’m not a fan. I always followed the idea to get people off as much as possible; recovery in an abstinence based manner makes a lot of diagnosable psych issues which would be medicated vanish. And, interestingly, abstinence can also unleash psych issues hidden by drug use. But getting a baseline is so important as the author demonstrates - and requires observation.
I finally left the field entirely and have never been happier. I feel sad for new professional coming in, giving a person buprenorphine while in horrific withdrawal, and then calling it a “miracle drug” bc it’s allegedly not abusable (trust me - it certainly is!). Without helping a person with a lifestyle change we are not providing maximum benefit for them.
I am glad to have worked in the field where “enforced compliance” was the norm (participation with all aspects of recovery while weaning from opioids slowly). It was a carrot, yes, but it kept accountability square on the patient and program. I’m also glad that I was treated with that same model for my own myelomeningocele-induced chronic pain AND addiction (I was misdiagnosed bc of the outdated term “pseudo addiction”), and have 23 years opiate free living (yes, total abstinence) with chronic pain still present but managed as I was taught. And the 18 years on opioids cannot touch the joy and fulfillment I have today. I loved helping others, and here’s my thoughts on how to help others the best of sharing your own experience / a VERY powerful tool in your clinical arsenal.
If self disclosure is helping the PATIENT, by all means do so.
This was a very thought provoking and insightful post. You opened a door with squeaky hinges for not having been opened often. I thoroughly enjoyed it and will work on integrating it throughout my work days. Like Patrick Dziedzic, I would like to hear more on this platform and know if you have your own podcast/substack/blog/etc where I (we) can visit.
Great post. Thank you Dr Greenwald for sharing what is probably just a glimpse into the psychiatric realm. I think here (Sensible Medicine ) is a good place to showcase the ins and outs of psychiatric medicine. Much better then the mainstream media where care for mental health is usually just a backdrop to the unfortunate ends of death by suicides and drug overdose (and likely Churnalism). I hope to see more posts and if you have your own Substack or outlet site please provide it.
Today is my weekly day to visit a mixed population SNF (elderly rehab & LTC, homeless adults w substance use disorders, chronic mental illness) and I’m going to try your interview technique. Can’t wait! Thank you.
Thank you for publishing this. I learned a lot.
Always love reading your and your guests articles, Dr. Cifu. As a former pain and addictions specialist (I trained in chronic non cancer pain at the Cleveland Clinic’s Chronic Pain Rehabilitation Program), I can tell you over diagnosis is huge in the psych realm. I came in when opioids were newly liberated, and OxyContin was all the rage. I was extremely worried about addiction and was continually shut down as drug after drug was put on to mask every symptom; benzos on top of opioids on top of muscle relaxers on top of amphetamines...we all know what happened. At the CC I learned about opiate weaning for chronic non cancer pain and absolutely concurred with it. Along with proper head shrinking, exercise, and weaning - people’s lives improved in all areas. We learned over time that chronic opioids CAUSE pain, not to mention a myriad other problems associated with chronic use. Oh and addiction too. Surprise. 🙄
Fast forward to the current use of opioids for addiction, and one would think that we could see what happened historically - but no, apparently brains can tell between addiction and “proper use.” So history will repeat itself with harm reduction - a preference among many addiction psychiatrists. I suspect you all can tell I’m not a fan. I always followed the idea to get people off as much as possible; recovery in an abstinence based manner makes a lot of diagnosable psych issues which would be medicated vanish. And, interestingly, abstinence can also unleash psych issues hidden by drug use. But getting a baseline is so important as the author demonstrates - and requires observation.
I finally left the field entirely and have never been happier. I feel sad for new professional coming in, giving a person buprenorphine while in horrific withdrawal, and then calling it a “miracle drug” bc it’s allegedly not abusable (trust me - it certainly is!). Without helping a person with a lifestyle change we are not providing maximum benefit for them.
I am glad to have worked in the field where “enforced compliance” was the norm (participation with all aspects of recovery while weaning from opioids slowly). It was a carrot, yes, but it kept accountability square on the patient and program. I’m also glad that I was treated with that same model for my own myelomeningocele-induced chronic pain AND addiction (I was misdiagnosed bc of the outdated term “pseudo addiction”), and have 23 years opiate free living (yes, total abstinence) with chronic pain still present but managed as I was taught. And the 18 years on opioids cannot touch the joy and fulfillment I have today. I loved helping others, and here’s my thoughts on how to help others the best of sharing your own experience / a VERY powerful tool in your clinical arsenal.
If self disclosure is helping the PATIENT, by all means do so.
If it’s helping YOU, go see your therapist.
Interesting post for those of us who are fascinated by doctors and how they train and learn.
Clear, succinct, focused and some delicious tidbits to practice in the real world. Thank you
This was a very thought provoking and insightful post. You opened a door with squeaky hinges for not having been opened often. I thoroughly enjoyed it and will work on integrating it throughout my work days. Like Patrick Dziedzic, I would like to hear more on this platform and know if you have your own podcast/substack/blog/etc where I (we) can visit.
Thanks for the comment. We have more from Dr. Greenwald coming. He will also be posting at The Socratic Psychiatrist.
https://open.substack.com/pub/socraticpsychiatrist/p/coming-soon?r=n8zko&utm_campaign=post&utm_medium=web
Great post. Thank you Dr Greenwald for sharing what is probably just a glimpse into the psychiatric realm. I think here (Sensible Medicine ) is a good place to showcase the ins and outs of psychiatric medicine. Much better then the mainstream media where care for mental health is usually just a backdrop to the unfortunate ends of death by suicides and drug overdose (and likely Churnalism). I hope to see more posts and if you have your own Substack or outlet site please provide it.
Thanks for the comment. We have more from Dr. Greenwald coming!
Today is my weekly day to visit a mixed population SNF (elderly rehab & LTC, homeless adults w substance use disorders, chronic mental illness) and I’m going to try your interview technique. Can’t wait! Thank you.
An extremely good post. Thanks.