Resolving Aberrant Drug-Taking Behavior Involves Choices and New Habits

LAS VEGAS—Clinicians and patients share responsibility for changing behaviors of aberrant drug-taking behavior (ADTB), and must make choices and take action to change those behaviors, Michael R. Clark, MD, MPH, MBA, Director of the Pain Management Program at Johns Hopkins University in Baltimore, Maryland.

Providers “struggle with this teeter-totter of risk versus benefit, and whether we're undermedicating or overmedicating our patients,” he said. But “we are having an effect on society when we prescribe these medications. Once you know ADTB exists, you have a responsibility to change it,” he said to attendees of PAINWeek 2014.

The story of opioids has followed a typical story meta-plot, Dr. Clark argued, from anticipation and dream phases, to frustration and nightmare phases: originally, pain was largely untreated, leading to a call for opioid prescribing. For many, the dream was fulfilled; opioids “really do help,” after all, he said.

Pain relief for all patients did not prove possible. And worse, “opioids are abused and people are dying,” he noted—a genuine societal nightmare.

But that story's resolution has yet to be found, Dr. Clark argued.

That may be partly because society has not yet agreed upon how to describe ADTB. Concepts of criminality and deviance, approaches to (and the goals of) punishment – these all represent contested terrain.

“So what's the story's resolution for opioids,” he asked. “Opioids are not a panacea or the only option. There are different ways to prescribe it, there are other treatments to utilize and to combine with them. There are ways to do this better.”

Helping patients see that they have choices and can develop new habits, is also key, Dr. Clark suggested. The focus of ADTB tends to be on the patient's wishes, not the consequences of his or her choices, he said. “The actual outcome is rejected as a temporary state,” he said.

But that narrative can be confronted. Referencing Crime and Punishment, Dr. Clark explored a redemptive model of intervention. “Dostoyevsky offers the use of punishment ideally as leading not to suffering, but to happiness and redemption,” he said.

“We want people to be part of society; we want to bring them back into the clinic and back into the fold,” he said. The idea “is one of conversion,” he explained. “When you run into aberrant drug-taking, you're trying to convert them into something else. It's not a disease to cure.”

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