Saving a life—now that’s a thrill! Physicians are privileged in many ways, and one of the most special is that we sometimes have the opportunity to use our knowledge and skill to bring a fellow human being back from the brink of death.
Saving a life may not be a daily occurrence, but it’s a powerful experience that many doctors have enjoyed and that stays with you for a long time. In fact, given how stressful and demanding the practice of medicine is today, it’s one of the infrequent yet powerful rewards that help us maintain a connection to our purpose and remind us of why we chose our profession in the first place.
When you think about “saving a life,” what probably comes to mind is preforming some grand feat like emergency surgery or resuscitating a person having a cardiac arrest. But sometimes it’s the subtle and undramatic acts that lead to a life saved, a past rescued, and a future protected.
How do I know this? Because it’s something I have experienced first hand as a physician practicing addiction medicine at Kaiser Permanente.
Treating people with substance use disorders, to many doctors’ surprise, can be one of the most satisfying things a physician can do. The experience that my colleagues and I have had is that people get better when they are in treatment and that it can truly save a life.
For me, this lesson would hit home especially around the holidays, when patients dropped off candy or cookies along with Christmas cards expressing their appreciation. A typical note might simply say, “Thank you to all the staff for giving me my life back.” I remember in particular one year when a young patient with a severe heroin addiction started a letter, “You probably don’t remember me, but five years ago I walked into your clinic with my life in shambles. Even though I came in kicking and screaming, you and the team didn’t give up on me. You believed in me, even when I doubted myself. And now, five years later, I have a great life!” The letter went on to describe the many accomplishments the person experienced, including a great job, close and loving friends, and a happy, supportive family.
Knowing that opioid use disorder is a very lethal disease, it felt fantastic to know that my effort and that of our entire team had such a positive impact. It doesn’t take many experiences like this to recognize that treating addiction is a worthy, valuable, and life-saving endeavor.
Saving the life of a substance use disorder patient — or saving them from a life of addiction, homelessness or bringing pain to others — is a surprisingly simple two-step process.
The first step involves actually treating the patient; that is, offering them the education, support, guidance, and behavioral skills to live a life in recovery. While this process is not always easy, it works on a consistent and reliable basis. In fact, research shows that treating addiction works as well as treating other chronic disorders such as diabetes or hypertension. From the 2022 National Survey on Drug Use and Health, we know that when you ask large numbers of people who have ever suffered from a substance abuse disorder, over 70% will confirm that they are in recovery or have recovered. And while it’s true that people with addiction problems may relapse, most people who enter treatment for abusing alcohol improve significantly after five years, with the majority either abstinent or drinking at safer levels. We also know that medications like methadone and buprenorphine can reduce the accidental overdose rate by more than 50% in people with opioid use disorder.
Given the great success of addiction treatment, it’s no wonder that the motto of our national professional organization, The American Society of Addiction Medicine (ASAM) is, “treat addiction, save lives.”
If there was ever a time we needed to provide more treatments for substance use disorders, it’s now. It’s difficult these days to turn on the news or open a medical journal and not be confronted by the awful magnitude of the opioid crisis. Announcements about the ever-increasing death toll from heroin, prescription opioids, and fentanyl are everywhere. According to the latest data we have, in 2021 there were over 100,000 drug overdoses in the U.S., the vast majority involving fentanyl. The grim reality is that these powerful chemicals are prematurely taking away our neighbors, friends, and family members.
If the news about fentanyl isn’t bad enough, we know that the harms from addiction go way beyond opioids. Abuse rates of all drugs are increasing. Addiction to methamphetamines is on the rise, and people are dying because — unbeknownst to the user— meth is being spiked with fentanyl.
Still, the number-one killer amongst substances is alcohol. In 2021, 178,000 people died from complications of excessive alcohol use according to the CDC, far more than the number of people who overdosed on fentanyl. That works out to 488 people dying every day from alcohol-related causes, or about one human being lost every three minutes. In 2021, the combined death rate from drug overdoses and alcohol-related causes was greater than the number of deaths from Alzheimer’s and pulmonary disease combined, and would have qualified as the fourth-leading cause of death in the United States behind heart disease, cancer, and COVID.
If addiction treatment is so effective, then why are so many people still dying? The answer lies in the fact that most people with the disease are not motivated to enter treatment. According to the latest National Survey on Drug Use and Health, 97% of Americans with a substance use disorder who were not in treatment didn’t feel they needed any treatment.
One of the most common ways to explain this seeming lack of motivation is to blame it on the patient’s denial that there is a problem. Throughout my career, I heard many colleagues express doubt and skepticism about our patients’ willingness to stop using drugs and alcohol to improve their health. “But seriously, how likely is this person going to stop drinking?” I remember one colleague saying. I’ve also heard, “C’mon, you’re wasting your time with that guy… He’s just a heroin addict — it’s a lost cause!”
The result of this kind of thinking is that it puts the burden of responsibility so completely on the patient that the person either hits bottom before finally getting into treatment or they ultimately die from their disease.
We don’t put the burden solely on a female patient to find their own breast lump before coming in for medical care. Instead, we go to extraordinary lengths to educate the public about breast cancer, offer effective screening methods like mammography, and motivate our patients to get cancer screening and treatment. Addiction kills far more people each year than breast cancer (285,000 vs 42,000), yet with addiction our society tends to take a “wait-and-see” approach, with fatal results.
If fewer than 10% of women with breast cancer were motivated to enter treatment, it would be a national health emergency and no one would blame the resulting deaths simply on patient denial. If there is just one fact that I wish my non-specialist colleagues would understand, it is that our patients act the way they do because their brains become “hijacked” by the substance itself. The abuse of substances over time makes people act impulsively, irrationally, and distorts normal human motivation. This contributes to patients not recognizing they would benefit from medical help. This simple biological fact needs to be taken into account when we engage with our patients.
If fewer than 10% of women with breast cancer were motivated to enter treatment, it would be a national health emergency and no one would blame the resulting deaths simply on patient denial.
One of the wonderful things about the field of addiction treatment is that we now have a detailed understanding about how the disease of addiction works to hijack the brain. In fact, we probably know more about addiction than we do about other common disorders of the mind, including anxiety and depression. Based on decades of research, we know that subjecting the brain to potent addictive drugs over time leads to changes in the nucleus acumbens that turns impulsive pleasure seeking into compulsive drug use that has nothing to do with pleasure; that substance abuse leads to an over-valuing of drug-related stimulus and desensitization to healthy human rewards; and, that the most damaging drugs can weaken the brain regions involved in decision making, inhibition of drug seeking, and emotional self-regulation. For these reasons, our field champions the idea that the seemingly self-destructive behavior associated with drug abuse is a biologically based brain disorder that should be considered like other biological disorders.
Once we understand that addiction is a “brain disease,” it puts the issue of patient motivation in a new light. Impaired motivation does not mean that the patient is crazy, lazy, selfish, or a bad person — it is a symptom of the disease itself. In other words, addiction alters normal human motivation. This insight can shift our own thinking as professionals so we can better treat our patients.
Professionals in the addiction treatment field have been working hard to find new ways of motivating patients to enter treatment. One key strategy is to focus on lowering the treatment threshold: this essentially means meeting the patient where they currently are, whether they are motivated to become abstinent immediately or not. The next steps involve techniques such as employing motivational interviewing and being willing to prescribe medications for alcohol and opioid use disorders in order to create a therapeutic relationship with the patient even before the patient enrolls in a formal treatment program.
One novel strategy is contingency management, which involves offering small cash payments to patients who provide urine specimens to demonstrate they are not using substances. This last approach has been proven to be the most effective treatment for one of the most challenging addictions, methamphetamine use. The state of California currently has a pilot project underway to test whether contingency management for methamphetamine addiction can be scaled up to match the needs of our society.
Harm reduction, which seeks to first reduce the harm from using drugs and alcohol without the demand for abstinence or formal treatment, is also being employed more actively. There is growing evidence that approaches such as distributing naloxone kits and fentanyl test strips, providing medication assisted treatment for opioid use disorder (i.e., methadone and buprenorphine), and setting up overdose prevention sites can reduce negative outcomes.
Treating the disease of addiction is just one step of what is required. The second step needed to save a life is to being willing to establish a caring, non-judgmental, and compassionate professional relationship with the patient.
The power of compassion to motivate someone to get help with an addiction cannot be overstated. There are several reasons why compassion makes such a difference when treating substance use disorders.
First, there is the biology of addiction itself. The motivation to get help is frequently dormant and only appears at times that the patient is most vulnerable. People with addiction problems are often strongly motivated to get help when the pain of using is greater than the pain of not using. This might mean when they have a crisis involving their health, their work, or their family. The most dramatic example of this that I have seen personally is the strong motivation to enter treatment that some mothers develop after Child Protective Services threatens to take away their children. Unfortunately, people with severe substance abuse problems spend so much time drowning in the pain of craving and withdrawal that this motivation can be fleeting or emerge only intermittently. For medical providers, the goal is to treat every patient at every encounter with kindness and care so that we can catch them in the moments that they might be open to getting help.
Second, the connection that we can offer addresses one of the main drivers of the disease of addiction and why people turn to substances in the first place: loneliness and isolation. There is now a widely accepted belief in our field that human connection is the treatment for addiction, and overcoming social disconnection is a key part of reaching the best outcome.
This need for connection is commonly expressed by patients themselves. In a New York Times opinion piece written by Patty Davis (daughter of President Ronald Reagan and Nancy Reagan), who is in recovery herself, Ms. Davis writes:
“I was 16 when I discovered amphetamines, and I felt as if I had met my best friend. Suddenly I felt I was livelier, more entertaining, not the shy, nearsighted girl who felt uncomfortable around people.To understand an addict, you need to appreciate that companionship, that need to reach for what won’t judge you but will instead seem to transform you into who you wish you were.”
All patients who come to us have something in common—the desire to be listened to, to be understood, and cared for. People with addictive disorders are no different.
Lastly, compassionate care by clinicians and health care providers helps patients overcome one of the biggest barriers to getting help: self-stigmatization.
Stigma against people with addictions has been identified as being common and widespread in our society. In 2023, a survey of 35,000 US households found that the majority of Americans held “high stigma” beliefs about people with opioid use disorder — and we know that health care professionals are not immune from exhibiting stigma. I have personally talked to many doctors who feel very justified in being harsh with patients; our patients also commonly talk about their negative experiences when being treated in the hospital, clinic, or emergency department.
We know from studies a sense of stigma among health care providers can be a significant factor contributing to people not seeking treatment.
We know from studies a sense of stigma among health care providers can be a significant factor contributing to people not seeking treatment. It is especially toxic because it fuels one of the greatest sources of stigma, the patient themselves. Universally, severe substance abuse is accompanied by shame and guilt. Social messages that the patient is unworthy or not deserving of respect can unconsciously compound the toxic self-stigmatization that is so common among people who abuse drugs and alcohol. If a person locked in the vice-grip of addiction feels worthless and undeserving, then why bother to get help?
There is a deeply seated attitude in some of us that patients need to experience brutal honesty in order to get better. This was highlighted in a recent Medscape opinion written by James Baker, MD, who learned about the power of compassion from his son, Mack, who had an opioid addiction and who died of an accidental drug overdose. Dr Baker wrote:
“I eventually came to understand that addiction is a disease, not a choice or moral failing. Before I learned that I thought that punishment was the solution, and I believed the myths that people with addiction needed to ‘hit rock bottom’ or only deserved ‘tough love.’ Late in Macky’s journey, I realized that he responded to understanding, compassion, and love, but it was difficult for me to maintain that self-control in the face of his SUD and the behaviors that accompany continued use.”
No one likes being lied to or taken advantage of. It’s understandable to have strong feelings of confusion, anger, or even disgust when treating patients who we see at their worst moments. I have experienced these feelings myself, especially early in my career before I received specialty training. Dr. Baker said that he experienced them before he became educated by his son’s illness.
At the same time, we can remember that most of the dysfunctional and distressing behaviors associated with addiction are merely signs of the underlying disease. Lying and manipulating are products of a hijacked brain. We know this because people’s behaviors typically normalize as the disease of addiction is brought under control. The majority of people in recovery regain their sense of integrity and commitment to their values, and return to a code of behavior that’s normal for our society. Seen in this light, getting upset with a patient who lies or manipulates makes as much sense as getting upset with a patient who is experiencing tachycardia from a pulmonary embolism.
The key to helping stem the tide of addiction is not to focus on the patient’s behavior, but rather to focus on how we respond to that behavior. When we get defensive and come from a place of judgment, we cut off any opportunity to be truly helpful. Alternatively, If we can recognize that our relationship with the patient makes a difference and is a valuable part of treatment, and that compassion can help overcome the stigma of addiction, then there is hope.
True compassion comes from a heartfelt desire to relieve the patient’s suffering and is not simply a feeling of pity or empathic distress. Empathy is a good starting place for compassion, but it’s not the endpoint.
When working with a patient suffering from the disease of addiction, even if all we are aware of is our own suffering, we can use that as a cue to trigger a compassionate response. This might mean just taking a few deep breaths and slowing down. It could involve suspending our judgement for just a few minutes while we make eye contact and listen with an intention to understand. If we can then generate a small space of calm within ourselves, we can ask ourselves how we can support this person and get them into treatment. These are skillful practices that any medical professional should be capable of.
Will this be easy to pull off? Sometimes not. Can we act with compassion and still feel frustrated, that our efforts are futile because the patient doesn’t respond as we hope? Absolutely! But this is really no different from treating patients with other life-threatening conditions. There’s no guarantee that the patient’s failing heart will respond to cardioversion or that a surgeon can make the bleeding stop. A good outcome is never guaranteed. But we are physicians, and this is what we do. We care and we try. You don’t have to be an addiction specialist to see the signs of substance abuse disorder in patients and provide the compassion and support they need to pursue the treatment they need.
Two simple steps is all it takes — being compassionate and working to help the patient get treatment. Medical professionals treat patients with substance abuse disorders every day, and if we keep these steps in mind we will have many more positive experiences treating people with the lethal disease of addiction. It all starts with a willingness to see the patient as something more than their disease. If we can acknowledge and let go of our own judgment and frustration, and instead focus on our compassionate desire to help, we can then creatively work to facilitate treatment. If we can do that, then we can save a life.
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