Competences versus fears and attitudes
- Goda Tikniūtė
- Dec 4, 2020
- 7 min read
Updated: 4 days ago
Interview with addiction psychiatrist Darius Jokūbonis
When talking about polarization in the field of addiction treatment, several fronts immediately come to mind: the opposition of complete abstinence to harm-reduction strategies and addiction treatment with addictive medications, as well as a certain opposition to medication-assisted treatment in general, with the aim of achieving complete sobriety in mutual aid groups. In the context of legal alcohol and other psychoactive substance (PAS) regulation policy, there is a conflict between liberal and conservative advocates of restrictive positions, as well as between those who support stricter measures to restrict the prescription of benzodiazepines (BZDs) and those who support the freedom of individual doctors to make decisions. We identified these polarizations and discussed them with Darius Jokūbonis, an expert, enthusiast, and educator in the field of addiction.
Darius Jokūbonis is a psychiatrist, head of the addiction psychiatry round of Psychiatry Residency Program at Kaunas branch of Republican Addiction Treatment Center and lecturer at the Lithuanian University of Health Sciences (LSMU) Psychiatry Clinic.
The doctor has encountered patients suffering from psychoactive substance use disorders and their relatives in various settings – psychiatry residency, inpatient psychiatry, psychotherapy studies, military medical service, private clinical practice, primary health service and specialized addiction care.
While interacting with colleagues at various medical settings, he quickly realized that doctors, often despite their wealth of knowledge, experience controversy and the resulting difficulties in communicating with and providing assistance to patients who use substances in problematic way. The doctor's areas of interest are clinical practice in addiction psychiatry and medical education.
As the head of the Lithuanian Association of Addiction Psychiatry, he focuses on international cooperation and is a member of the Training and Education Committee of the International Society of Addiction Medicine (ISAM).
Goda Tikniūtė: First, I would like to invite you to look at it from the patient’s perspective. When I started working in the field of addiction and looking for possible points of contact with mutual aid groups, I began reading AA literature and got the impression that it spoke rather negatively about the role of medicine, and especially psychopharmacotherapy, in the treatment of addiction. What is the reason for this polarization (or what are the reasons) from your perspective?
Darius Jokūbonis: Around 1970, as benzodiazepines began to be used more widely in psychiatry around the world, these drugs were also used to treat addiction. Prescribing benzodiazepines for longer periods than the duration of alcohol withdrawal, as we now know, did not cure BZD addiction, but often complicated the condition as a second addiction and as a dangerous interaction, which caused a reaction from the medical community and society, as the consequences were very clear, and many stories were told at AA meetings.
Of course, nowadays, the treatment of addiction with benzodiazepines has been abandoned, but there are comorbid conditions that need to be treated with safe drugs that do not cause use disorders. However, based on previous experience, the AA position remained that all drugs alter the state of consciousness and are dangerous. Traditionally, AA and 12-step programs have had a friendly and cooperative relationship with medicine and the treatment of addiction with medication, and they have been happy to go to hospitals, which continues to this day. AA remains an important resource for shaping attitudes toward addiction, relationships with addiction, and treatment.
Perhaps this trend is even more pronounced when it comes to opioid treatment?
Opioid users leaving treatment programs, we give them a naloxone kit. A person who has completed treatment in Minnesota rehabilitation programs may feel strongly motivated to stay sober, and such a gift may disturb both the patient and the specialists themselves. We are sending the patient a message that their life is our top priority, and that if they relapse, it is important to us that they stay alive and that we are waiting for them to come back and pick up where they left off. The patient’s commitment to “stay sober” does not help anyone’s health; it can only create an additional barrier to seeking help.
Not only patients but also specialists are confused by the use of opioids, substances that cause addiction, in the treatment of addiction. I understand the AA approach, and I think this confrontation can be healthy. It exists in society, in the medical community, and even among opioid users themselves. For example, some patients commonly believe that heroin is better than methadone because methadone causes more severe addiction. Perhaps physically, yes, but currently, treatment with opioids or opioid antagonists is no longer considered merely harm reduction; it is a treatment method approved by professional organizations around the world, including the World Health Organization itself, and some of them have even included it in the list of essential medicines for the treatment of opioid addiction in all countries. If we work according to guidelines and standardized methodologies, constantly cooperating and applying best practices, we should not abandon this method because of preconceived notions, lack of competence, or unfounded fears. Substitution treatment with methadone primarily saves lives. When comparing patients on the waiting list with those being treated with opioid drugs, the survival rates are twice as high in the latter group. For us as doctors, this should be a desirable goal and outcome.
In your opinion, what treatment methods can be identified as being used by us, doctors, disproportionately to the available scientific evidence?
Excessive treatment of chronic pain with opioids due to pressure from pharmaceutical companies was widespread 20 years ago in North American countries and some European countries, and at that time, illegal fentanyls appeared, and this led to an epidemic of use and overdose, the consequences of which remain truly tragic to this day. While researching the situation in Lithuania, I found a master’s thesis from LSMU on opioid use for pain treatment in Lithuania from 2013 to 2021 and a comparison of data from 2021 between Lithuania and other countries around the world. According to the data from this study, opioid analgesics were prescribed five times less frequently in Lithuania in 2021 than in Finland and Sweden, and almost seven times less frequently than in Denmark. In her conclusions, the author is not happy with this indicator, as it would be difficult to believe that we experience so much less pain, which could indicate insufficient pain management in our country. The study concludes that although the law does not prohibit the treatment of patients with opioids, it is regulated, but perhaps the attitudes of our medical community are opioidophobic on the one hand and benzodiazepinophilic on the other. At least, I finished my medical studies with the feeling that prescribing opioids is highly undesirable due to the risk of possible abuse. “First, do no harm.” However, our work in medicine involves risk. In this case, in order to “do no harm” to one patient, nine others may not even receive the indicated treatment, even though this problem is well known in Lithuania and around the world, and there are protocols and procedures for managing side effects or complications.
The probability of developing an addiction in this case is approximately 1 in 10. As we know, alternatives can also have side effects. Ultimately, the pain itself sometimes disrupts the quality of life to no lesser extent than the disorder that caused the pain. This is an example of how fears and attitudes often outweigh indications or patient needs.
What about the polarisation caused by attempts to legally restrict the availability of PAS, as well as the restriction of BZD treatment? There are many interested parties here-consumers, doctors, entrepreneurs, and society as a whole.
I am in favor of state regulation; it is necessary, but it must be measured. We have a very good precedent for alcohol control policy in Lithuania, and it is very good that the impact of these measures on society and people’s health has been very precisely assessed from a scientific point of view. I am referring to the 2017 international research team’s study on the impact of alcohol control and excise duty increases on health and suicide rates in Lithuania. I think this perspective is very good because we in Lithuania are heavy alcohol consumers, and it would be wrong to leave the problem to psychiatrists alone when alcohol is found in the blood of over 60 percent of people who commit suicide. It is very important that we all act within our areas of competence and within the framework of legal regulation.
Six years ago, there was a stir in Lithuania over the excessive use of benzodiazepines, which had been going on for decades. It is interesting to note that, according to data from the State Medicines Control Agency (VVKT), benzodiazepines were prescribed two to three times more often in Lithuania in 2017 than in other countries in Northern Europe.
In post-Soviet countries, BZDs were widely prescribed as safe drugs for many disorders and ailments. They were considered suitable for older people to treat a wide range of emotional, insomnia, and anxiety conditions. It was even considered that there was no need to stop taking them in old age. The movement to change these trends, including through legal regulation, was progressive and effective. Although there was significant resistance not only from patients but also from the medical community itself, this initiative proved to be effective over time.
How would you summarize your message to go?
“Opioids are ‘bad’ drugs, but benzodiazepines are not at all.” These are assumptions that are completely unsupported by science. If a person seeks help, we should provide it based on scientific knowledge and our expertise, not on unfounded assumptions and fears. Fear will not protect us; expertise will save us. I believe that.
Thank you for the conversation. □
