Barring Healthcare Professionals from Working while on Buprenorphine

While buprenorphine has been prescribed for many patients over the last 10 years, there’s still controversy about whether healthcare professionals should be allowed to work while on buprenorphine.

In an article in March 2012 Mayo Clinic Proceedings, Hamza and Bryson  cite studies that support their conclusion that medical professionals should not be allowed to work while taking buprenorphine as maintenance for opioid addiction. The authors say studies show that people taking buprenorphine have some impairment when performing safety-sensitive tasks that are required in practice as a physician. (1)

I read this article with great interest, since I have been prescribing buprenorphine and telling my patients they won’t be impaired while taking a maintenance dose. Wanting to know if I am misleading patients, I scrutinized the studies cited in this paper.

I’m not sure the authors’ conclusions are backed up by the studies they cite.

The most worrisome misinterpretation was the Schindler et al study. The Mayo study by Hamza and Bryson interpreted the Schindler study thusly: “significant differences were found between them [methadone and buprenorphine groups] and the controls.” But when I read the original study, the authors’ conclusion was really the opposite: “The synthetic opioid-maintained subjects investigated in the current study did not differ significantly in comparison to healthy controls…” (2)

Hmmm…I’m confused.

When I looked at other articles cited by Hamza and Bryson, I discovered that what I read didn’t match Hamza and Bryson’s conclusions of what I read.

Three of the studies cited in the Mayo article (Pickworth et.al., Jensen et. al., and Zacny et.al.) all looked at healthy volunteers who were given buprenorphine, then tested to see if they were impaired. In other words, these test subjects weren’t opioid dependent. All three studies showed impairment, and I don’t doubt it, because opioid-naïve subjects would be expected to feel a great deal of opioid effect with their first dose of buprenorphine. But studies of opioids-naïve subjects given buprenorphine don’t seem applicable to opioid-addicted patients on buprenorphine for maintenance.

The Rapeli et al study looked at methadone and buprenorphine patients in early recovery, so these groups would be expected to be different than those on established maintenance therapy.

Soyka et al compared opioid addicts on buprenorphine and methadone at 2 weeks, then at 8-10 weeks. This study also had a control group. The patients on methadone and buprenorphine had impaired cognition on testing compared to the controls, but they improved with length in treatment. This study was randomized but not blinded. This means patients and researchers knew who was on methadone, buprenorphine, and who was a control subject. Interestingly, in a later letter to the editor defending their conclusions, Hamza and Bryson mistakenly claimed the study was double-blinded, but clearly it was not.  Also the study was relatively small, since only 46 patients completed the study. The purpose of the study was to see if methadone was more impairing than buprenorphine. The authors of the Soyka study didn’t conclude the buprenorphine group was impaired to the point they were unable to work, only that they performed better than methadone patients.

One study, by Messinis et al, did compare abstinent heroin addicts on naltrexone with opioid addicts on maintenance buprenorphine, and showed the buprenorphine group had more cognitive impairment than the naltrexone group in cognitive functions. To me, this is the main study that speaks to the actual issue of impairment. It gives a basis to require more studies be done. However, the small size of the study, 18 patients, limits the impact of this study. (3)

The ideal study to resolve this issue would be a double blinded prospective study of opioid-addicted healthcare professionals who are randomized either to abstinence-base treatment or buprenorphine maintenance treatment. Then cognitive abilities can be compared at various times during recovery, like 3 months, 6 months, 1 years, and 2 years. Such a test is unlikely to be done, since most addicted professionals enter abstinence-based recovery, and have a high rate of success.

I do think medication-free recovery is the ideal. I acknowledge that’s my bias, even though I strongly believe medication-assisted treatment is a life-saving option. But then, medication-free treatment is the ideal for all diseases. If a patient can achieve good blood pressure control by changing her diet and exercise, I think most of us would agree that’s a superior outcome to taking blood pressure medication to achieve the same result.

Most doctors and dentists have the resources to afford the prolonged inpatient treatment needed for medication-free recovery. The monitoring required for continued licensure is additional leverage and accountability that most opioid addicts don’t have after leaving inpatient treatment. These factors produce excellent recovery rates in these healthcare professionals, much better than that achieved by the average opioid addict.

But no recovery works for everyone. If a healthcare professional has failed traditional abstinence-based recovery, but is able to do well on medication-assisted recovery with buprenorphine, is the data strong enough to say such a recovering person on a stable dose of buprenorphine can’t work in healthcare?

We must be careful about this decision. If the decision is going to be based solely on patient safety, and not on a bias against medication-assisted recovery, then healthcare professionals on opioids for acute or chronic pain must also logically be removed from the workforce, unless we can prove they don’t have cognitive deficits from prescribed opioids. And what of other medications, like benzodiazepines, which are more likely than opioids to cause impairment?

If professional monitoring boards rely on the evidence cited by this study to refuse to allow healthcare professionals on buprenorphine to return to work, they leave themselves open to accusations inconsistent safety standards if they allow other healthcare professionals to work while being prescribed opioids or benzodiazepines.

It would be a mammoth task to monitor every healthcare professional who is prescribed a controlled substance. But if a professional on stable a dose of buprenorphine can’t work safely, how can we assume a surgeon who takes legitimately prescribed opioids for back pain is safe to work?

Frankly I suspect most of the posturing about the dangers of healthcare workers on buprenorphine is really an attempt to remove medication-assisted recovery as a treatment option for healthcare professionals. I don’t know if the mayo article authors, Hamza and Bryson, have any underlying bias against medication-assisted treatments, or perhaps biases favoring abstinence as the only worthy treatment goal. I don’t know these two people at all. But my impression is that they have taken a sweeping position supported by shaky evidence. The studies they cite are evidence enough to call for larger studies, but don’t seem adequate in themselves to deny a potentially life-saving treatment to a healthcare professional.

1. Hamza H, and Bryson E, “Buprenorphine Maintenance Therapy in Opioid-Addicted Health Care Professionals Returning to Clinical Practice: A Hidden Controversy, Mayo Clinic Proceedings., 2012, 87(3);260-267
2. Schindler SD, et al, “Maintenance therapy with synthetic opioids and driving aptitude, European Addiction Research, 2004; 10(2):80-87acol.
3. Messinis et al, “Neuropsychological functioning in buprenorphine maintained patients versus abstinent heroin abusers on naltrexone hydrochloride therapy”. Hum. Psycholpharm. 2009;24(7):524-531

Pregnant Women Using Drugs

Pregnant addicts are the most stigmatized group in U.S. society. Even other drug addicts regard pregnant addicts with scorn. But the nature of addiction is the loss of control – pregnant addicts usually do want to stop using drugs, but have lost the power to do so without help. And even if they do seek help, pregnant women face special barriers to proper care. The stigmatization alone is enough to keep many women from getting help. They face overwhelming shame and blame from society and from their own families. Pregnant women don’t tell their obstetricians about their addiction, for fear they will be treated harshly by the professionals on whom they must depend to deliver medical care. I’ve already blogged about the atrocious misinformation some obstetricians accept as true about opioids addiction and treatment during pregnancy.  Female addicts, scared and ashamed to ask for help, try to hide their addiction as well as they can, and hope for the best.

If a pregnant addict does seek help, many treatment programs won’t accept her into treatment, because she is too high risk. Addiction treatment programs sometimes don’t want the liability of a pregnant addict.

At one of the opioid treatment programs where I used to work, a woman came for admission in her fifth month of pregnancy. I tried to be gentle as I asked her why she’d waiting so long to get help. She laughed without humor and told me she’d been turned away from three other treatment facilities. The first was an inpatient residential treatment program that turned her away because she was addicted to opioids. They told her if they took her into their treatment program, she would have to undergo withdrawal, because they did not “believe” in methadone or buprenorphine (Subutex). And if she went into withdrawal, she could miscarry.

They directed her to an inpatient detoxification program that also declined to admit her because they didn’t want her to miscarry while in their facility. They (correctly) referred her to an opioid treatment program. The first opioid treatment program offered only methadone, and since she preferred buprenorphine, they referred her to the clinic where I worked. This patient had (correctly) heard new studies showed less severe withdrawal in babies born to moms on buprenorphine (Subutex) compared to moms on methadone.  That clinic then referred her to our clinic, since we do use buprenorphine. All of this took a few weeks, delaying her entry to treatment. The treatment programs made the right decisions, but addiction treatment is so patchwork that it took time for her to ping-pong from place to place until she found the treatment she needed.

Pregnant women fear they will lose custody of their children if they admit to being addicted and ask for help. Sadly, in some counties in my state, their fear is well-grounded. Some women are told they will lose their children because they have enrolled in medication-assisted treatment with methadone or buprenorphine, even though it’s the treatment of choice for opioid-addicted pregnant women. In most cases, treatment center staff can act as advocates, and talk to social service workers who may not be well-informed about addiction treatment. Punishing a mom for getting help doesn’t help anyone. Word spreads in addict social networks, making other women less likely to get help for addiction.

Often, the pregnant addict’s husband or partner is also addicted. He may try to keep her away from drug addiction treatment, fearing loss of control over her, or he may feel like he’ll be asked to stop using drugs too. Even if she’s able to go to treatment, having a drug-using partner makes it more difficult to stop using herself.

Women, pregnant or not, tend to have childcare issues. If they want to get help, who will watch the children while they attend treatment?

Despite the difficulties faced by pregnant addicts, most want desperately to deliver a healthy baby. We know from several studies that harsh confrontation predicts addiction treatment failure in pregnant women. That is, if treatment facility personnel, obstetricians, nurses or any other member of the treatment team tries to blame and scare a pregnant addict into stopping drug use, it backfires. Pregnant women tend leave treatment when they are treated harshly, and have worse outcomes than women who stay in treatment.

I’ve written blogs about the negative attitudes some medical professionals have toward pregnant opioid addicts who come for treatment with buprenorphine (Subutex) or methadone. Thankfully, that’s not a universal attitude. Recently an obstetrician referred her patient to us, calling ahead to speed things along. I called her back after I saw the patient, and we had a cordial conversation which I appreciate all the more in view of negativity I’ve experienced in the past.

I thought again about the topic of opioid-addicted pregnant addicts because of an article in my most recent issue of Journal of Addiction Medicine. This article described the outcome of a study of opioid-addicted pregnant patients in rural Vermont. Since methadone and buprenorphine (Subutex) are the treatments of choice for these patients, the study looked to see if better access to these treatments improved outcomes. The results showed, not surprisingly, improved access to medication-assisted treatment for opioid addiction in pregnant addicts improved the health outcomes for both mothers and babies. Earlier research showed the same result, but this was a rural group, underrepresented in past studies.

Meyer, M, et. al, “Development of a Substance Abuse Program for Opioid-Dependent Nonurban Pregnant Women Improves Outcome,” Journal of Addiction Medicine, Vol. 6 (2) pp.124-130.

Gray Areas

I have a dilemma. A handful of physicians and physician extenders in my area appear to be skirting the regulations around prescribing buprenorphine (Suboxone, Subutex).  They are helping opioid addicts, but not in a manner I consider to be completely appropriate.

Each Suboxone prescriber can have up to one hundred patients on the medication at any one time, as decreed by law. This regulation was put into effect because some lawmakers were haunted by the specter of Suboxone mills, run with the same lack of professional responsibility that we see in pill mills.

Only physicians can prescribe buprenorphine (Suboxone) to treat addiction. Nurse practitioners and physicians’ assistants, frequently termed physician extenders, can’t get the DEA “X” number that allows them to prescribe buprenorphine (Suboxone) for addiction. Many physician extenders say this isn’t fair, because they prescribe all manner of other opioids. Despite their objections, the law is what it is, and they can’t prescribe Suboxone to treat addiction.

And yet, it appears that some extenders are doing just that. In my area, two physician’s assistants, in separate practices, prescribe Suboxone to patients with addiction. These patients’ charts (I’ve requested records when patients transferred to me) show the provider knows the patients have addiction, but in each case the Suboxone is said to be prescribed for the treatment of “chronic pain.” I don’t doubt these patients have pain, since at least 30% of people with opioid addiction also have chronic pain. So technically, since they say they’re treating pain, they aren’t doing anything that’s prohibited…though the FDA would consider it to be off-label prescribing.

A few doctors who don’t have an “X” number have been doing the same thing – they treat patients with known addiction with Suboxone, but they say they use it for chronic pain. I’ve heard rumors that even doctors with an “X” number treat patients with pain with Suboxone, and don’t count these patients as part of their one hundred allowable patients. This allows them to prescribe Suboxone for more patients, and get around the one hundred patient limit.

I’m conflicted when I see these practices. One the one hand, I’m glad more patients are getting treatment, and this is much better than addicts buying Suboxone off the street. It’s the safest opioid, and in some patients it does treat pain. If it works for the patient, why should I care if some doctors and physician extenders are skirting the regulations, and why should I care if they are getting it for pain or addiction?

Because they appear to prove the lawmakers’ fears are legitimate. If we have providers who can’t or won’t follow the present regulations, how can we expect the government to lift the one hundred patient limit? Government officials and lawmakers start to wonder if medical professionals can be trusted to prescribe buprenorphine safely and appropriately if the one hundred patient limit is raised or lifted, if they see providers outwitting present regulations so that they can treat more patients.

In the interest of full disclosure, I have two patients I treat for pain with Suboxone. I didn’t start either patient, but inherited them from another doctor. In each case, I agree that they don’t have evidence of addiction, but Suboxone has been treating their pain very well. Since it’s working, I’m not going to demand they change medication, but I also count them as part of my one hundred patients, to be on the safe side. I do NOT want to get on the wrong side of the DEA.

In the past, I’ve called a few doctors who were prescribing buprenorphine without an “X” number. Both of them were shocked to discover the special regulations around this medication, so in some cases maybe it’s just lack of knowledge about regulations around treating addiction.

Two other colleagues and I did report a doctor to the medical board who prescribed a month’s worth of methadone for opioid addicts, but that’s different, given the dangers of methadone compared to buprenorphine.

I don’t want to report these doctors and extenders to regulatory bodies, because in the grand scheme of things, they are helping the patient, and technically they are following regulations, I think. Plus, I don’t want to have anyone report me to the medical board in retaliation. No one’s charts are perfect, and even though I feel I’m doing a good job treating patients, many decisions in Addiction Medicine are judgment calls. Good doctors can disagree on many of the issues.

For example, I have a few die-hard pot smokers among my one hundred patients. I see them a little more frequently than patients who don’t smoke, and I make the marijuana use an issue in counseling. I don’t (usually) kick them out of treatment for marijuana use. The data show that if you keep these patients in treatment, there’s a better chance they will, at some point, stop using. But I know many diligent physicians who would dismiss such a patient from treatment, because these doctors feel if they can only have one hundred patients, why not use those precious spots for patients willing to enter into full recovery, forsaking all illicit drugs.

Are they wrong? Am I wrong? No, because as I’ve said before, one person’s harm reduction is another person’s enabling. But if the person reviewing my charts for the medical board thinks I’m enabling, it could spell disaster for me. I don’t want to make that kind of trouble for another provider, or myself.

Also I worry if I confront these buprenorphine prescribers, they’d point out the very real financial incentive I have for wanting them to stop prescribing. If the patient is coming to them, they aren’t coming to the clinic where I work, and this reduces my clinic’s profitability. I’m employed as an independent contractor, so it wouldn’t benefit me directly, but the financial health of the clinic I work for would, indirectly, benefit me.

And yes, I’m petty enough to be miffed that I’m following the rules, and other doctors aren’t, yet they reap the same benefits. I’ve decided it’s human to be miffed about such things, but not healthy to get stuck in “miffness” and thus I’m writing this blog in an effort to release my feelings.

For now, I’ve decided I don’t have to do a thing. I’ll discuss the issue to the North Carolina chapter of the American Society of Addiction Medicine, and let those smart people decide the best course of action, if any.

It’s Déjà vu All Over Again

I’ve got another obstetrician on my mailing list for current articles on the management of opioid addiction in pregnancy.

I am amazed at the lack of knowledge on the part of doctors in this area about opioid addiction treatment in pregnant women. Management of this issue shouldn’t be left up to what each doctor “believes.” Opioid addiction in pregnancy is an all- too- common medical issue that has standard, accepted treatments, clearly outlined in both the obstetric and addiction medicine literature. It’s not like I’m making this stuff up. It comes out of the committee opinions made up of the most knowledgeable of obstetricians, neonatologists, and addiction medicine specialists.

Yesterday I talked to another OB, the doctor of another pregnant patient who started on the buprenorphine (Subutex) program.  I’d entered his patient into treatment with buprenorphine, a month or so ago, and she finally signed a release so that I could call him. She’s about five months pregnant.

I was more cautious this time, easing into the conversation, saying I’m calling because I wasn’t sure he was aware the patient is now in treatment for her opioid dependency, and that she is doing very well on buprenorphine, and has been able to stop all other opioids. There was a long pause and then he spoke.

“Yes, I know. I tried to get her set up with a pain clinic but she never showed. They were going to take her off pain pills,” this doctor said. “I can’t get anybody else to take them off pain pills during pregnancy.”

I gulped down my first response which would have run along the lines of “Of course not because that’s medically contraindicated you uninformed doc, what were you thinking thank god she didn’t follow you advice.”

Instead, I said, “Maybe that’s because all the literature now says the outcomes are better for mom and baby when you keep them on maintenance medications like methadone and buprenorphine. And with buprenorphine, studies are showing the babies have less severe withdrawal.”

“You aren’t going to raise her dose, are you? Because I don’t want you to raise her dose. It makes the withdrawal worse in the babies.”

“Actually, there has not been a clear relationship between dose and severity of withdrawal, and outcomes for mom and baby are better if you keep the mom on a blocking dose, so she won’t relapse.”

“Nope. I take women off opioids during pregnancy and their babies don’t have withdrawal.”

“That anecdotal experience isn’t a match for clinical trials…”

He was getting angry now. “I’ve been a doctor for years and they’re my patients and that’s all the proof I need. That’s my clinical trial.”

I did a mental forehead slap. Again, I’d managed to rile one of the local doctors.

I made nice, apologized, and said how grateful I was for taking care of our patients, and for returning my phone call. I asked his permission to send him the committee opinion paper I mentioned above, and he consented.

I’ve decided I’m going to use the same approach as medical teams traveling to third world countries.  In order to get along with the natives and be accepted, medical personnel first visit the local shaman, or medicine man, and make nice. They seek rapport with important people in the tribe, like the tribal chiefs. They try to involve the tribe’s elders in their work, so that they may be supportive instead of antagonistic. This makes sense to me.

Maybe if I’m friendlier, more sociable, these OBs will be more open to new information. Who knows, maybe I can convince them to give up leeches and bloodletting, too

Doctor Behaving Badly

Last week I admitted a pregnant patient to one of the opioid treatment centers where I work. She’d only been using for about three months, but had physical withdrawal symptoms, and had more than eight years of intermittent physical dependence. She had a successful pregnancy while on methadone four years earlier, and she knew she’d be at risk for miscarriage if she tried to stop using opioids on her own and went into withdrawal. She also knew herself and her addiction well enough to be afraid she’d relapse even if she was able to stop using opioids in early pregnancy.

She’d been getting prenatal care, but hadn’t told her obstetrician she was addicted to opioids. She’d been struggling on her own, too afraid to tell him about her problem. She was also afraid to tell him she came to our program to get help, but I insisted he needed to know.

Foolishly, I downplayed her fears.

“Oh, I think he’ll be happy you’re getting the treatment you need. As you know from your last pregnancy, forty-plus years of research show better outcomes for the mother and the baby if the opioid-addicted mother is on methadone. And now we have buprenorphine.” Due to recent studies that showed lower severity of neonatal abstinence syndrome in babies born to women on buprenorphine compared to methadone, we decided to start her on buprenorphine, sometimes better known under its brand names Subutex and Suboxone.

She looked at me warily. “You don’t know Dr. B. He hates methadone. He hates this place. He’ll hate Subutex too.”

I smiled reassuringly. “I’m pretty good at talking to other doctors who have concerns about treatment for pain pill addiction. I can give him some information that might help him change his view.” I keep my office stocked with SAMHSA (Substance Abuse Mental Health Services Administration) brochures for medical personnel, law enforcement personnel, and concerned citizens, describing medication-assisted treatment with methadone and buprenorphine and addressing many of the misconceptions people have about these medications.

She was hesitant, but said, “OooooK. I’ll sign a release. I can’t wait to hear what he says. I don’t want to be the one to tell him. He’ll yell at me.” Surely she was exaggerating, I thought.

Later that day, I called Dr. B.  Perky as a robin, I said I was calling to touch base with him, to inform him his patient had been fearful and ashamed to admit her addiction, but she did the right thing by seeking treatment, and had decided to start on buprenorphine. I asked if he had any questions or concerns we needed to discuss.

He was not pleasant. “Concerns? Concerns? You bet I have concerns! You people have put five of my patients on that crap. You don’t even call to tell me you started them on the medication! And one of them had been taking opioids for two weeks! Two weeks! I’m…”

I interrupted, “I didn’t start anyone who had been using for two weeks. And I can’t call you until the patient gives me permission to call….”

“You put patients on that crap and you don’t even care about those babies in withdrawal! It’s pitiful!”

As politely as possible, I interrupted. “Is it possible you don’t know that methadone, and now buprenorphine, are the treatments of choice for opioid addicted pregnant women? I can send you some review articles and…”

“You’re not gonna change my mind! All your articles were written by your kind anyway…” (I wondered to myself what kind did he mean? The educated kind?)

“Actually, the articles were written by neonatologists and are in the obstetric literature…”

As he was ranting, I scurried to get a pen and paper, because I wanted to write down his words verbatim. Even as I was being yelled at, I was thinking about how this was going to be good material for my blog.

“You’re not gonna change my mind! You just want their Medicaid! You just get them in there every day to punch their card and make money! You…”

“Um, we don’t bill Medicaid.”

“I don’t care! You just want the money!” (I didn’t ask him if he worked for free)

I trudged on, trying to give him information. I told him how withdrawal places the mother at higher risk for complications like miscarriage, placental abruption, low birth weight…things he should already know….and then he said an even more amazing thing: “I don’t care. That doesn’t matter. My patients aren’t gonna take that crap. Let me tell you now, if my patients become your patients, they won’t be my patients any more. I’ll fire them from my practice.”

He spouted on, completely ignorant of the gold-standard, state-of-the-art care for opioid-addicted pregnant women. As he was squawking, I periodically waxed eloquent, repeating, “Wow,” over and over again.

At some point I realized I wasn’t going to be able to educate this doctor. How sad. He didn’t have the facts, but it didn’t prevent him from having a strong, implacable opinion. This doctor’s lack of information and closed-minded refusal to consider facts instead of personal opinion show the extreme prejudice some patients face in my area of the country, even from their own doctors.

“You’re telling me that this patient can’t come to see you anymore?”

“That’s right! I don’t believe in that crap. She shouldn’t be on it……”  and he was off again, now telling me how evil I was to be prescribing methadone. Apparently he didn’t hear or didn’t care that I had prescribed buprenorphine in this case.

“OK. Thanks. I’ll tell the patient.” And I got off the phone.

It’s not much of a victory, but I didn’t resort to obscenity, name calling, or even raise my voice. I remained relatively calm, while Dr. B spewed.

Once off the phone, I felt tired, sad, drained. How long will the medical profession remain in the dark about all the evidence supporting medications like methadone and buprenorphine? These medications are by no means the only treatment for opioid addiction, and they aren’t the best treatment for every opioid addict, but this medication saves lives and helps addicts live more normal lives.

I thought about the top doctors, the experts of addiction medicine who lecture at our national meetings. Do they ever have to deal with this kind of lack of knowledge and implacability? I doubt it. Many of them work in states where the medical profession is more educated about addiction and its treatments.

So now I had to find another doctor for this patient. Fortunately, I’d seen another pregnant women a few weeks back, who named Dr. H. as her doctor. So I called Dr. H, a balm to my weary soul. I asked him if he’d be willing to take another pregnant patient on replacement medication. These are high-risk patients, on or off maintenance medication, so I was asking a favor. He said sure, he’d take them, and that he often had to take patients who were turned away by another doctor in town. I laughed and said yes, I think I may have just talked to that doctor.

I thanked him profusely for helping our patients

For years I’ve told patients on methadone and buprenorphine that they need to develop thick skins. Especially in the rural South, prejudices abound, and friends and relatives with the best intentions can make hurtful and uninformed statements to patients who are doing well on methadone or buprenorphine. Then there are the more vicious members of society who blame and shame our patients, telling them they are just going to a legal drug dealer and that they need to “get off that stuff.” I tell patients that they need to do what is right for their health, and ignore the opinions of other people who don’t approve of the medical treatment you they’ve chosen.

Today I told myself that I need to grow thicker skin, and not to let the opinions of medical professionals like Dr. B discourage me. I know I’m helping people, and I know the medical literature supports what I’m doing. I can share information with other doctors, but only if they’re willing to listen. I also try to maintain a balanced view, and not to dismiss other treatments that have data to support their usefulness. I want to remain teachable if there’s new information about a better way to help opioid addicts. But Dr. B didn’t have information, only opinions. I’m idealistic enough to believe we should base medical care on data, not opinions.

I don’t need to hide or apologize for prescribing methadone and buprenorphine.

Pain Management on Buprenorphine

I had a bit of writer’s block this week. I was pondering what topic I should tackle next on my blog. Then I got a phone call from a dentist’s nurse, and voila, problem solved.

I’m going to change the name and description of my patient to protect her identity.   “Sally” has been doing great the entire six months she’s been my patient. Sally was ready for recovery. Over the last ten years, she’s been to multiple inpatient programs, for up to three months at a time, for treatment of her opioid addiction. She had achieved some time in abstinent recovery, ranging from a few weeks up to nine months, but relapsed because she never felt normal off all opioids. She continued to have low-grade nausea, fatigue, and felt achy most days. When she saw me last summer, she’d been in a terrible relapse for around eight months, and had been injecting the opioid pills prescribed by a local pain clinic. Her husband was supportive, and appropriately worried Sally was going to die of an overdose.

Sally wanted to start Suboxone, but wasn’t expecting much from it. She’d investigated Suboxone on the internet, and thought her opioid tolerance was too high for this medication to work. However, but she wanted to try every option before entering a methadone treatment center. I also suspected Suboxone wouldn’t be strong enough, but agreed with her that it would be worth a try.

She felt normal within the first week. We started with 4mg on the first day, and then went to 8mg on day two. When we went to 16mg on day three, Sally was amazed and relieved that she felt back to normal. She didn’t feel high and she didn’t feel in withdrawal.

She hasn’t looked back since. Every urine drug screen, done nearly every visit, has been positive only for Suboxone. She goes to 12-step meetings, has a sponsor, and does service work at her home group. She’s relatively happy, though she still takes an anti-depressant to prevent a relapse of her depression, which has been severe in the past.

Anyway, I say all of this to point out how well she’s doing. She’s also getting her physical health concerns addressed, and started seeing a dentist to get her teeth fixed. She had neglected them during active addiction, and needed a great deal of work done. She opted for dental implants.

At her last visit, we discussed pain management after her procedure. The pain from many dental procedures can sometimes be managed with anti-inflammatories, but I knew dental implants were more complicated.  I told Sally I’d like to talk with the doctor who will be managing her post-operative pain. I wrote down my cell number for Sally to give to her doctor, rather than my office number, to allow her dentist to get in contact with me more easily. I told Sally to stop her Suboxone 36 hours pre-procedure, so that her opioid receptors wouldn’t be so blocked that short-acting opioids would be ineffective. We planned for her husband to hold the bottle of pain pills, and dispense as directed by her oral surgeon. I instructed her how to make the change back to Suboxone once she no longer needed pain medication. I planned to see Sally one week after the procedure, so I could make sure she was OK, and back on Suboxone.

I heard nothing until this morning. I got a call on my cell phone from Dr. “X’s” nurse. She said Dr. X had just finished the procedure, but didn’t feel comfortable prescribing opioids for an addict. Dr. X preferred for me to handle her post-operative pain.

I felt my temper flare immediately. “Gee, I wish your doctor had called me before the procedure so we could talk about this. Since I don’t do oral surgery, I don’t know how much pain patients usually experience. Surgeons usually manage their own patients after surgery. What does Dr. X usually prescribe for patients after this procedure?”

“Thirty pills of oxycodone 10mg. But the doctor wasn’t comfortable giving that many. He’s willing to give her only 15 pills.”

“You know, I gave her my cell number so your doctor could call me before the procedure. It’s better to decide all of this prior to the surgery, don’t you agree?”

“We don’t have time to call everyone.”

“But you called me today.” I felt a familiar twitch in my right eyelid. “Look, it’s OK for him to prescribe what he usually prescribes. After all, she will have as much pain as any other patient. In fact, because of her opioid tolerance, she may need a bit more than an average patient. We’ve talked to her husband and he’s going to hold the pill bott…”

She interrupted me, saying, “The doctor doesn’t want to get into some big deal, writing for a bunch of pain pills for an addict. The doctor wants you to take over prescribing for pain.”

“I know he does…” it came out as an evil splutter because I was thinking about how much Sally was probably paying this guy, who should have told her in advance that he wasn’t going to prescribe post-op pain medication. I know dental implants are not cheap and probably not covered by insurance. And I suspected this dentist, to whom she was likely paying a big pile of money, looked down on Sally because of her history of addiction. I felt anger.

“You know,” I said, spittle gathering at a corner of my mouth, “You know, it isn’t ethical to withhold pain medication if you do a procedure that causes pain.  I can understand he doesn’t want to write large amounts for an extended time, but we’re talking about an acute pain situation that will last what, about a week? He knows that better than me. He needs to prescribe what he usually does to any other patient. We’ve already talked to Sally about precautions to prevent a relapse.”

The dilemma was solved because apparently, a doctor was listening to our conversation at the nurse’s elbow. He indicated to the nurse that he would be willing to prescribe the usual amount. I was miffed that the doctor didn’t talk to me himself, but he may not have been the one who did Sally’s procedure. At any rate, that was what I wanted anyway, so I tried to be helpful and give them information for future use.

“You can call me any time about patients with both pain and addiction. It’s more complicated to treat them, but with proper safeguards it can be done without too much trouble…”

“Ok thanks. Thanks for talking to us.”

At that point it sounded like the nurse would rather get on with her work day than listen to me try to explain how addiction is a medical problem that can be managed just like any other chronic disease.

I was angry because the dentist didn’t call me before the procedure, and because he wasn’t honest with the patient. He neglected to tell her about his plans to write for less than usual the amount of pain medication. I was sad because I suspected that he looked down on this nice lady her because of her history of addiction…but not so much that he wouldn’t take her money for fixing her teeth.

It’s a shame, because that dentist could have learned something from Sally, like how she’s a funny, warm person who has courageously overcome a devastating and life-threatening illness.

More about Prescription Monitoring Programs

In October, Florida’s prescription monitoring program finally became functional. This means doctors in Florida (finally) can go to this database to see if their patients are being prescribed controlled substances by other doctors. The program isn’t mandatory. Physicians don’t have to use the system if they don’t want to do so. But in my opinion, if a doctor is prescribing controlled substances to a patient, particularly in Florida, it would be sloppy medical practice NOT to use this program. Doctors who are truly interested in indentifying doctor-shopping drug seekers will use this database.

Florida’s prescription monitoring program has been a long time coming. If you read this blog frequently, you’ll remember I was highly critical of Florida’s Governor Scott’s initial reluctance to allow a prescription drug monitoring program. His reluctance mystified me, given the tremendous numbers of pain pills being prescribed and dispensed in Florida. The pain pills prescribed and dispensed by Florida’s pill mills didn’t stay in Florida. They were exported north to states like Kentucky, Tennessee, North Carolina, and Georgia. This occurred so commonly that it became known as the “Flamingo Express.”

At present, only a few states are still dragging their feet about getting an operational program. As of now, only Missouri and the District of Columbia don’t have prescription monitoring programs, and have no plans to start one. (It seems odd that D.C., where lawmakers started the push for prescription monitoring programs, doesn’t already have a functioning program.)

In recent news reports, Florida’s Governor Scott said he felt the new laws that prevent physicians from both prescribing and dispensing pain pills are an important part of reducing Florida’s pain pill problem. Prior to these new laws, physicians were able to both prescribe and dispense opioid pain pills. This created a financial incentive for unprincipled doctors to prescribe opioids, since they then sold these opioids to their patient for more than the average pharmacy price. This practice was common in Florida’s pill mills. In 2010, Florida physicians bought 89% of all the oxycodone sold to U.S. medical practitioners.

In these recent news reports, around 80 doctors have had their licenses suspended due to their prescribing habits. These doctors often prescribed large amounts of opioids without demonstrating a clear need and without taking precautions to assure the “patients” they saw weren’t abusing the drugs.

 I believe this has already led to a relative scarcity of pain pills available on the black market in our state of North Carolina, and a subsequent increase in price. For the last month, the opioid treatment program where I work has seen a sharp increase in the numbers of addicts entering treatment. These patients say the same thing when I ask why they decided to seek help now: they’re spending too much money on pills, to the point of financial ruin, and pills are more difficult to find. One addict said, “I can’t find pills like I could. And when I do, I can’t afford them anyway.” Recently, addicts report spending more per milligram for illicit prescription opioids like oxycodone, morphine, and hydrocodone.

I don’t care whether it’s Florida’s new prescription monitoring program or their crackdown on unscrupulous doctors that’s causing fewer pills for sale on the black market in our area. I’m just thankful that it’s happening.

Readers of this blog, do any of you have opinions as to the availablility of black market prescription opioid drugs now, compared to several months ago?

Governor Scott’s Flamingo Express to Misery

Flamingo Express of Florida

All I could think was, “What can he be thinking???”

 I was reading an article about the governor of Florida and his bizarre decision to block the formation of a prescription monitoring program in his state. (1)

 Prescription monitoring programs are databases that contain lists of controlled substances a patient receives, the prescribing doctors, and the dispensing pharmacies. Usually, only approved physicians can get access to these databases. Prescription monitoring programs help prevent “doctor shopping,” which is the term describing the actions of a patient who goes from one doctor to another to get prescription pills, usually opioids, without telling the doctors about each other. Addicts do this to supply their ever-increasing tolerance for the drugs. Drug dealers do this to get pills to sell and make money.

 Forty-two states have approved the formation of prescription monitoring databases, and thirty-four states have operational databases. Florida was one of the last to approve the formation of such a program, in 2009, long after this recent wave of prescription pain pill addiction burned through the country. Now, the new Florida governor wants to cut this program out completely, before it even starts.

 How big of a deal is this?

In the latest survey, 5.3 million people in the U.S. used prescription pain pills nonmedically over the past month. This means they used them in ways not intended, or for reasons not intended by the prescriber… for example, to get high. In the last year, 2.2 million people misused these prescription pain pills for the first time. Our young people are particularly at risk; between 2002 and 2009, the percentage of 12 to 17 years olds misusing prescription opioids rose from 4.1% to 4.8%. Not all of these people will become addicted, thankfully. Some will only experiment, and be able to stop before addiction develops. Many won’t be able to stop taking pills, and will progress into the misery of addiction. Others will die of drug overdoses. (2)

 Why pick on Florida?

Florida is infamous for its pain clinics. As a reporter for Time Magazine pointed out, there are more pain clinics in South Florida than there are McDonald’s franchises. In 2009, 98 of the top 100 prescribers of oxycodone in the nation were all located in Florida. Altogether, these doctors prescribed 19 million dosage units of oxycodone in 2009. Estimates of the numbers of pain clinics located in South Florida vary, but most sources say between 150 and 175. (3, 4) Many of these clinics are “pill mills,” where doctors freely prescribe controlled substances with little regard to usual prescribing standards and guidelines.

 Are all these clinics pill mills?

No. Some of the pain clinics are legitimate, and their doctors follow best practice guidelines, providing quality care to patients with pain. But careful monitoring and screening for adverse events, including the development of addiction, takes time. A conscientious doctor, trying  to do a good job, isn’t going to be able to see fifty pain patients in one day.

 I’ve talked to addicts who were previously patients at these pill mills. They describe how they were shuffled through rapidly, sometimes not even seeing the doctor. Some addicts say they were asked what pills they wanted, and quickly written that prescription, with little or no conversation beyond that. That was the extent of the visit. 

But Florida’s problem doesn’t stay in Florida. Appalachian states like Kentucky, West Virginia, and North Carolina all have addicts who buy these prescription pain pills after they’re transported out of Florida. The DEA sees so many pain pills being transported from Florida to Appalachian states that they call it the “Flamingo Express.” In one of the methadone clinics where I work, I’ve noticed a peculiar upswing in the reported use of Opana, a brand name for the drug oxymorphone. It’s not a drug I’ve seen prescribed much in NC. When I ask patients where the pills come from, many say, “Florida.”

 Governors of several states, including West Virginia and Kentucky, along with congressmen from New York and Rhode Island, have sent a letter to Florida’s Governor Scott, urging him to reconsider his decision to torpedo plans for a prescription monitoring program. Since the leading cause of death in West Virginians for those under the age of 45 is drug overdose, I can see why this governor is protesting Governor Scott’s poor decision. (4)

 It’s estimated that setting up a prescription monitoring program costs about one million dollars. The Florida Prescription Drug Monitoring Program Fund, Inc., a non-profit organization dedicated to raising money for the program, says on their website that they’ve already raised at least half of that from donations. Other states have received the Harold Rogers grant money, available from the federal government to set up these monitoring databases. This leads me to question the excuse of “budget cuts” as the reason for Governor Scott’s poor decision.

 I’ve also seen internet stories that mention the governor’s fear of invasion of privacy. This is a legitimate concern, but there are ways to safeguard the information in such a database, and laws that can regulate who has access. I’m no fan of the government peering into my business, but this database is essential, given the overwhelming numbers of people struggling with pain pill addiction. For a description of the ways in which the North Carolina prescription monitoring database has helped me help my patients, please see the preceding blog entry. It’s been a lifesaver.  

1. http://articles.sun-sentinel.com/2011-03-05/news/fl-prescription-drug-forum-20110305_1_pill-mills-prescription-drug-monitoring-program-attorney-general-pam-bondi (accessed 3/6/11)
2. Substance Abuse and Mental Health Services Administration (2010). Results from the 2009 National Survey on Drug Use and Health: Volume I. Summary of National Findings (Office of Applied Studies, NSDUH Series H-38A, HHS Publication No. SMA 10-4586Findings). Rockville, MD.
3. Thomas R. Collins, Invasion of the Pill Mills in South Florida, Time, Tuesday, Apr. 13, 2010,  Ft. Lauderdale, FL
4.  http://manchin.senate.gov/public/index.cfm/press-releases?   ContentRecord_id=f62482b4-f6dd-4adc-8b49-1563d8fa605b&ContentType_id=ec9a1142-0ea4-4086-95b2-b1fc9cc47db5&Group_id=e3f09d56-daa7-43fd-aa8b-bd2aeb8d7777&MonthDisplay=2&YearDisplay=2011 (accessed 3/8/11)

Medical Community Stigma Against Methadone

Educating Doctors

Not many physicians in our communities are familiar with what methadone clinics do or how they work. Some physicians criticize their patients on methadone, even if the patients are doing well and are in stable recovery. Some physicians are unyielding in their opposition to methadone treatment, even though they know little about it.

When given an opportunity, I try gently to educate these doctors, and offer them information. Sometimes I’m pleasantly surprised at the desire of other doctors to learn more about the treatment of opioid addiction with methadone. Sometimes, I’m not surprised at their resistance.

 I’ve felt frustrated by these doctors, but I need to remember that before I knew much about methadone, I opposed it too. Back then, it just seemed wrong to give an addict methadone. I didn’t have any reason for my belief, not being familiar with actual data.  I try to remember my past actions and beliefs, and have compassion for other doctors. They probably know as little about methadone as I did, before I worked at an opioid treatment center.

            A doctor does not work at methadone clinics because of the professional prestige. If subspecialty prestige were a totem pole, and cardiovascular surgeons and neurosurgeons were at the top, then addiction medicine doctors would be the part of the totem pole that is underground.

Our colleagues know little about what we do, and tend to think of us as on the fringes of “legitimate” medicine, even though, as I’ve said before in this blog, we have more evidence-based data to support what we do than perhaps any other specialty.

Occasionally, I encounter a physician who refuses to take care of a patient who is prescribed methadone by a treatment center. One doctor, a bariatric (weight loss) surgeon, told a patient who was doing well on methadone that she would have to taper off of methadone before he would schedule her weight loss surgery. The patient asked me why she needed to be off methadone. Since I knew of no good reason, I called the surgeon. I tried to advocate for my patient, and explain that methadone patients can, and do, undergo all sorts of surgeries. I explained the usual method of maintaining the same methadone dose while in the hospital, and giving short-acting opioids for management of pain after surgery, but this surgeon didn’t relent. He didn’t give me a reason for his decision, and since this was elective surgery, he had the right to refuse to do the operation.

The patient, eager to have this surgery, tapered off methadone. It took months, and I don’t know what happened to her after surgery. I do know she was at high risk for a relapse back into active addiction, particularly since she would need prescription opioids during the post-operative period. I hope she did well.

Recently, a prescription pain pill addict, also being treated for an anxiety disorder, entered treatment at the methadone treatment center where I presently work. She was seeing a psychiatrist who, in addition to counseling this patient, was prescribing alprazolam (Xanax) for anxiety. The patient hadn’t told the psychiatrist about the pain pill addiction, due to shame and embarrassment. When she started methadone, I asked her permission to contact her psychiatrist, so that we could coordinate our treatments. When I spoke to this psychiatrist, she said this patient would be kicked out of her practice. The psychiatrist said, “Going on methadone goes against what I’ve been trying to do for her.” I pressed about what she meant by this remarkable statement, but she wouldn’t, or maybe couldn’t, elaborate. Because this patient entered treatment for opioid addiction, she had to find a new psychiatrist.

These are extreme examples. Most doctors are hesitant to prescribe anything for a patient on methadone, but are grateful if I call them with information, and offer to work with them. After becoming more informed, many doctors are willing to work with, and not against, the opioid treatment center helping their patient.

Doctors Are Poorly Trained About Addiction and Recovery

Addiction? What addiction?

Most medical schools and residency programs place little emphasis on educating future physicians about addiction. A survey conducted by the Center on Addiction and Substance Abuse at Columbia University (CASA) revealed that physicians are poorly trained to recognize and treat addictive disorders. (1)

CASA surveyed nine-hundred and seventy-nine U.S. physicians, from all age groups, practice settings, and specialties. Only nineteen percent of these physicians said they had been trained in medical school to identify diversion of prescribed drugs. Diversion means that the drug was not taken by the patient for whom it was prescribed. Almost forty percent had been trained to identify prescription drug abuse or addiction, but of those, most received only a few hours of training during four years of medical school. More shocking, only fifty-five percent of the surveyed doctors said they were taught how to prescribe controlled drugs. Of those, most had less than a few hours of training. This survey indicates that medical schools need to critically evaluate their teaching priorities.  

Distressingly, my own experience mirrors this study’s findings. My medical school, Ohio State University, did a better job than most. We had a classroom section about alcoholism, and were asked to go to an Alcoholics Anonymous meeting, to become familiar with how meetings work. But I don’t remember any instruction about how to prescribe controlled substances or how to identify drug diversion.

Is it possible that I’ve forgotten I had such a course? Well, yes. But if I can still remember the tediously boring Krebs cycle, then surely I would have remembered something juicier and more practical, like how to prescribe potentially addicting drugs. Similarly, less than half of the surveyed doctors recalled any training in medical school in the management of pain, and of those that did, most had less than a few hours of training.

Residency training programs did a little better. Of the surveyed doctors, thirty-nine percent received training on how to identify drug diversion, and sixty-one percent received training on identifying prescription drug addiction. Seventy percent of the doctors surveyed said they received instruction on how to prescribe controlled substances. (1)

This last finding is appalling, because it means that thirty percent of doctors received no training on how to prescribe controlled substances in their residency programs.  Could it be true that nearly a third of the doctors leaving residency – last stop for most doctors before being loosed upon the populace to practice medicine with little to no oversight – had no training on how to prescribe these potentially dangerous drugs? Sixty-two percent leaving residency had training on pain management. This means the remaining thirty-eight percent had no training on the treatment of pain.

Could it be that many of these physicians were in residencies or specialties that had no need to prescribe such drugs? No. The participating doctors were in family practice, internal medicine, OB/GYN, psychiatry, and orthopedic surgery. The study included physicians of all ages (fifty-three percent were under age fifty), all races (though a majority at seventy-five percent were white, three other races were represented), and all types of locations (thirty-seven percent urban, thirty percent suburban, with the remainder small towns or rural areas). This study reveals a hard truth: medical training programs in the U.S. are doing a poor job of teaching future doctors about two diseases that causes much disability and suffering: pain and addiction. (1)

 I remember how poorly we treated patients addicted to prescription medications when I was in my Internal Medicine residency program. By the time we identified a person as addicted to opioids or benzodiazepines, their disease was fairly well established. It didn’t take a genius to detect addiction. They were the patients with thick charts, in the emergency room frequently, loudly proclaiming their pain and demanding to be medicated. Overall, the residents were angry and disgusted with such people, and treated them with thinly veiled contempt. We regarded them more as criminals than patients. We mimicked the attitudes of our attending physicians. Sadly, I did no better than the rest of my group, and often made jokes at the expense of patients who were suffering in a way and to a degree I was unable to perceive. I had a tightly closed mind and made assumptions that these were bad people, wasting my time.

Heroin addicts were not well treated. I recall a discussion with our attending physician concerning an intravenous heroin user, re-admitted to the hospital. Six months earlier, he was hospitalized for treatment of endocarditis (infected heart valve). Ultimately his aortic heart valve was removed and replaced with a mechanical valve. He recovered and left the hospital, but returned several months later, with an infected mechanical valve, because he had continued to inject heroin. We discussed the ethics of refusing to replace the valve a second time, because we felt it was futile.

I didn’t know any better at the time. We could have started him on methadone in the hospital, stabilized his cravings, and then referred him to the methadone clinic when he left the hospital. Instead, I think we had a social worker ask him if he wanted to go away somewhere for treatment, he said no, and that was the end of that. Small wonder he continued to use heroin.

At a minimum, the attending physician should have known that addiction is a disease, not a moral failing, and that it is treatable. The attending physician should have known how to treat heroin addiction, and how to convey this information to the residents he taught. Instead, we were debating whether to treat a man whose care we had mismanaged. Fortunately, he did get a second heart valve and was able to leave the hospital. I have no further knowledge of his outcome.

 Despite having relatively little training in indentifying and treating prescription pill addiction, physicians tend to be overly confident in their abilities to detect such addictions. CASA found that eighty percent of the surveyed physicians felt they were qualified to identify both drug abuse and addiction. However, in a 1998 CASA study, Under the Rug: Substance Abuse and the Mature Woman, physicians were given a case history of a 68 year old woman, with symptoms of prescription drug addiction. Only one percent of the surveyed physicians presented substance abuse as a possible diagnosis.  In a similar study, when presented with a case history suggestive of an addictive disorder, only six percent of primary care physicians listed substance abuse as a possible diagnosis. (2)

Besides being poorly educated about treatments for patients with addiction, most doctors aren’t comfortable having frank discussions about a patient’s drug misuse or addiction. Most physicians fear they will provoke anger or shame in their patients. Physicians may feel disgust with addicted patients and find them unpleasant, demanding, or even frightening. Conversely, doctors can feel too embarrassed to ask seemingly “nice” people about addiction. In a CASA study titled, Missed Opportunity, forty-seven percent of physicians in primary care said it was difficult to discuss prescription drug addiction and abuse with their patients, for whom they had prescribed such drugs. (2).

From this data, it’s clear physicians are poorly educated about the disease of addiction at the level of medical school and residency. Even when they do diagnose addiction, are they aware of the treatment facilities in their area? Patients should be referred to treatment centers who can manage their addictions. If patients are addicted to opioids, medications like methadone and buprenorphine can be a tremendous help.

1. Missed Opportunity: A National Survey of Primary Care Physicians and Patients on Substance Abuse, Center on Addiction and Substance Abuse at Columbia University, April 2000. Also available online at http://www.casacolumbia.org

2. Under the Rug: Substance Abuse and the Mature Woman, Center on Addiction and

Substance Abuse at Columbia University, 1998. Available online at http://www.casacolumbia.org