Archive for the ‘Doctors Behaving Badly’ Category

A 1980’s Flashback

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Brownish-purple bumps covered the face and torso of the patient lying in the hospital bed, and I watched as tears puddled just above a particularly prominent nodule. Then I looked at his partner, a fit young man, who had turned his face and body away from the patient. With his head propped against the wall, I could see his shoulders shaking with sobs. With a detached and distant part of my brain, I wondered if he was crying for his sick partner, or if he was crying because he had a vision of what likely lay ahead for him as well.

I didn’t know what to say. I had just informed the patient, my patient for only three days, that he tested positive for HIV. The nodules all over his body were Kaposi’s sarcoma. I knew he already suspected all of this, but now we knew for sure. Not for the first time, I thought about how ill-equipped I was at dealing with the aftermath of giving bad news. I yearned for a nurse or social worker who could come spout words of comfort to this young man and his partner.

But there were no words of comfort. In 1988, I was in my second year of my Internal Medicine residency, and the only anti-retroviral we had was AZT, zidovudine. The virus mutates quickly, so resistance developed to our only treatment. We could treat opportunistic infections as they emerged, and even give antibiotic prophylaxis to stave off some of the infections like pneumocystis, but every patient I treated progressed towards physical debilitation and death.

Patients in the late 1980’s often came to medical attention as a result of one of the many devastating infectious diseases seen with immunosuppression. If they were poor or had no established physician, they were assigned to the Staff Medicine services and we residents took care of them, under the supervision of our attending physicians. New AIDS cases were diagnosed every week by the resident physicians at Charlotte Memorial Hospital and accounted for a full fourth of our patient case load.

At morning report, where we discussed our new admissions , Cryptococci meningitis, pneumocystis carinii pneumonia, toxoplasmosis, and other opportunistic infectious diseases seen only in patients with severely compromised immune systems were as common as uncontrolled diabetes mellitus and COPD exacerbations. At morning report, it was… ho-hum… just another case of progressive multifocal leukoencephalopathy.

But then in the early 1990’s, scientists developed HAART, an abbreviation for highly-active anti-retroviral therapy. Suddenly HIV became more of a chronic disease. Though it still causes significant illness and suffering, it’s no longer the inevitable death sentence it was in the 1980’s.

My current patient had the worst case of Kaposi’s sarcoma that I had ever seen, and I’d already seen more cases in two years as a resident physician than prior generations of doctors saw in a lifetime.

My generation of physicians trained at an unusual time in history. We saw strange and exotic diseases from immunosuppressed HIV patients that hopefully no generation will see in the future, and half of those new cases were diagnosed in IV drug addicts, mostly addicted to opioids.

How is it, then, that IV opioid addicts were not given appropriate treatment?

I still plead ignorance. I didn’t know any better. I took my cue from my teachers and mentors, who communicated verbally and nonverbally that addicts weren’t sick, but “bad” people, even weak people who would not stop doing something that put them at risk for dying from AIDS, a dreadful disease caused by HIV.

I still marvel at the mismanagement of my drug-addicted patients back then. About half of the new HIV diagnoses were made in IV drug abusers, yet I don’t recall ever hearing of needle exchange programs or methadone maintenance, though there was a methadone maintenance program in Charlotte at that time.

We should have been calling to arrange intakes at that methadone maintenance program before our opioid-addicted patients even left the hospital. If they didn’t have HIV, getting them into medication-assisted treatment could have been life-saving from several points of view. Not only would they be less likely to overdose and die, but they would be three times less likely to contract HIV.

I lament all of those wasted opportunities and every patient who didn’t get the care she should have had.

Now, let’s at learn from the past, and not repeat mistakes in this generation.

At present, we’re quibbling about increasing access to medication-assisted, office-based treatment with buprenorphine, out of fear these patients won’t get appropriate counseling. Even AATOD wants to wait until precautions can be put in place to assure office-based programs will provide good counseling, which is an essential part of treatment.

It’s a legitimate concern, but perhaps not the most pressing issue of the opioid addiction epidemic when people are dying from overdoses and being put at risk for Hep C and HIV.

It’s a little like worrying about how badly your house needs painting while part of it is on fire.

Office-based Opioid Addiction Treatment: Raising the One-hundred Patient Limit

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The hearts of addiction medicine doctors nationwide are aflutter at rumors that the limit on office-based buprenorphine patients may be raised or lifted. As it is now, the DATA 2000 law says each doctor who prescribes buprenorphine from an office setting for the treatment of opioid addiction can have no more than one hundred patients at any one time.

DATA 2000 was a big deal. Until it passed, it was illegal for any doctor to prescribe any opioid to treat opioid addiction, unless they worked at a specially licensed opioid treatment program. In other words, doctors in an office setting had to refer opioid-addicted patients to opioid treatment centers for medication-assisted treatment. And the only medication available was methadone.

Then DATA 2000 allowed Schedule 3 opioids to be prescribed from physicians’ offices for the purpose of treating opioid addiction, as long as these medications were FDA-approved for this purpose. Thus far, buprenorphine is the only medication that meets the DATA 2000 requirements.

But the law had other limitations. For example, each physician had to get a special DEA number to prescribe buprenorphine. And as above, no physician could have any more than one hundred patients on buprenorphine at any one time.

My office gets multiple calls each week from people seeking treatment for opioid addiction in an office setting. These callers say they’ve already been to the websites that list doctors. (http://buprenorphine.samhsa.gov and http://suboxone.com . They’ve made multiple calls and discovered these doctors aren’t taking new patients because they’re already at their one hundred patient limit. This is happening all over the country; patients want treatment but can’t get it. For many such people, opioid treatment centers are geographically impractical, so that’s not an option either.

Since addiction is a devastating and potentially fatal disease, government officials feel pressure to do something to help our nation’s opioid addiction problem. Lifting the one- hundred patient limit has been suggested as one option to improve the situation. This would seem to be the best, easiest, and quickest way to get more people into treatment. At least, most Addiction Medicine doctors like me think it makes sense.

Not everyone agrees.

Opposition has come from some unexpected sources. I went to an opioid addiction treatment conference in a neighboring state lately and heard the president of AATOD (American Association for the Treatment of Opioid Dependence), Mark Parrino, MPA, speak against lifting the limit.

First let me say I admire Mr. Parrino immensely. He has been and continues to be a huge advocate for this field. He’s done more good in the field of opioid addiction treatment than most people I can think of, and has been doing this good work long before I ever even entered the field.

But that doesn’t mean I agree with him on everything.

When he spoke at the conference, he said he was opposed to expanded buprenorphine treatment in the office-based setting because patients don’t get the counseling that they need, so it really isn’t medication-assisted treatment, it’s just medication assistance. He says opioid treatment programs provide on-site counseling, drug testing, and other services that can help patients, and that most office-based programs don’t offer such comprehensive services. He also said diversion of buprenorphine from office-based practices is a huge problem, and that much of the black market use is actually abuse of the medication. He raised the uncomfortable issue of price gouging by some unscrupulous buprenorphine doctors who charge large fees and deliver little care.

You can read a statement on the AATOD website that fully describes their opposition – or at least call for caution – regarding raising the one hundred patient office based treatment limit:

http://www.aatod.org/policies/policy-statements/increasing-access-to-medication-to-treat-opioid-addiction-increasing-access-for-the-treatment-of-opioid-addiction-with-medications/

I don’t completely disagree with the points Mr. Parrino made at the conference, but I do think the same arguments can be made against OTPs if one were inclined to do so.

What about opioid treatment programs that pay lip service to the counseling needs of the patients? What about OTPs that hire people to be counselors with little or no experience in the counseling field? Just as Mr. Parrino can point to the worst examples of office-based buprenorphine treatment, I can point to OTPs who aren’t doing a great job. How can an OTP counselor provide Motivational Interviewing as a therapeutic technique if that counselor has never even heard of MI? Yet I’ve seen these problems at opioid treatment programs.

Don’t paint all office-based practices with the same brush. Many of us want to provide good treatment with adequate counseling. For example, my office has a therapist who is a Licensed Professional Counselor with a Master’s in Addiction Counseling. He does a great job, and as an added bonus has great legs. (He’s my fiancé, before you assume I’m sexually harassing him at the workplace).

Alternatively, if the patient prefers to do only 12-step meetings, I’m OK with that, so long as they provide me with a list of meetings they’ve attended each month. Or if they’re already working with a therapist, it’s OK with me if they want to continue, as long as they agree to allow me to speak with their therapist about issues directly relating to the treatment of their addiction.

Diversion of buprenorphine to the black market is a big problem. Not all office-based buprenorphine doctors are as careful as we should be. We will never be able to get rid of all diversion of any controlled substance that we prescribe, but all buprenorphine doctors should be doing drug screens and have diversion controls in place to limit the problem.

Not as much methadone is diverted, but only because of the very strict regulations on methadone take- home doses at the OTP. Many patients – and OTP personnel – feel present regulations on methadone take- home doses are overly strict and limit flexibility of treatment for patients who are doing well. Is the answer then to regulate take -home doses of buprenorphine as closely as methadone?

What about the predatory doctors who prescribe buprenorphine just for a quick buck, sensing they can charge exorbitant fees from desperate opioid addicts? I can’t say anything in their favor. They embarrass me. As with many things in life, the actions of a few give the rest of us a bad reputation. But I do think these doctors are in the minority.

And don’t believe everything you are told about office-based practices; I’m sometimes told by patients that I’m in it “for the money” though I charge the same for an office visit for a buprenorphine patient as I would for any other medical ailment. Some patients feel like their treatment should be free, but the U.S system of medical care is not usually free for any disease.

In short, though I recognize there’s some truth in many of Mr. Parrino’s statements, I still think most buprenorphine doctors try very hard to do things right so that they provide good care for opioid addicts who can’t or won’t go to an opioid treatment program. Expanding access by raising the one-hundred patient limit will allow more people to get addiction treatment.

Opioids and Benzodiazepines Prescribed More Frequently in the South

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Last month, the CDC released information comparing rates of opioid and benzodiazepine prescriptions by state and by region. It did not surprise me to learn the South had the highest rates of benzodiazepine and opioid prescribing of the entire nation.

U.S. citizens already receive twice the number of pain pills per capita than our Canadian neighbors. But in addition to that difference, there’s a 2.7-fold difference between the state with the lowest opioid prescribing rate per capita (Hawaii) and the states with the highest rate per capita (Tennessee and Alabama tied for first place). [1]

The same held true for benzodiazepines, with even more difference in prescribing rates. In Hawaii, doctors prescribed benzodiazepines 19.3 times for every 100 people. But in Tennessee, doctors prescribed benzodiazepines 61.4 times for every 100 people. That’s over a three-fold difference between these states.

Alabama, Tennessee, and West Virginia were the top three prescribers for both opioid and benzodiazepines. We already know that higher prescribing rates are associated with higher overdose deaths rates from these medications. Incredibly, these three states were more than two standard deviations away from mean prescribing rates for the entire country.

Even more disturbing, Tennessee doctors prescribed oxymorphone (Opana) at an amount 22 times that of doctors in Minnesota.

That’s just bizarre. It could also explain why so many of the patients I admit to OTPs in the mountains of North Carolina mention Opana as their drug of choice.

The CDC authors of this report admit it’s unlikely there’s much difference in rates of disorders needing treatment with opioids or benzodiazepines. My interpretation of this statement is that it’s an indirect way of saying doctors in the South are overprescribing opioids and benzodiazepines. The authors allude to the problem of overprescribing in the South, mentioning that the South also has higher rates of prescribing for antibiotics, stimulants in children, and medications known to be high risk for the elderly.

How did my state of North Carolina compare to the rest of the nation? Our data isn’t as embarrassing as that for Tennessee, but there’s certainly room for improvement. In NC, doctors prescribed around 97 opioid prescriptions per 100 people, and 45 benzo prescriptions per 100 people.

Benzodiazepine co-addiction complicates induction onto methadone and buprenorphine done by opioid treatment programs for the treatment of opioid addiction, and this co-addiction also predicts poorer treatment outcomes. [2, 3]

This supports what I’ve long suspected: the treatment of opioid addicts with MAT is different in the South than in the West. My colleagues in California, inferring from the CDC’s report, don’t have to deal with benzodiazepine co-addiction as often as I do in the mountains of North Carolina. That co-occurring addiction changes the clinical picture, and makes induction onto methadone particularly more risky.

This is not the South’s finest hour. We must do more to educate doctors about appropriate prescribing, starting in medical school and continuing throughout the physicians’ professional careers. If doctors don’t start this change, someone else will surely do it for us.

1. http://www.cdc.gov/vitalsigns/opioid-prescribing/index.html
2. Brands et al, 2008, Journal of Addictive Disease
3. Eiroa-orosa et al, 2010, Drug and Alcohol Dependence

Drug Arrest for Doctor

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Last week, news outlets in my area were all aflutter about a physician in a small town who was arrested for prescription medication fraud. It was alleged that he prescribed opioid pain pills to seven of his wife’s friends and acquaintances, none of whom were his patients, so that they could pick up the pills and deliver them to the doctor and his wife.

I’m not giving the name of the doctor, his wife, or the other people arrested, though you can get those if you click on the link below. I figure all of them are getting enough bad press without me piling on too. Besides, this bizarre situation has addiction written all over it. [1]

The SBI investigated this case for four months and finally arrested the eight involved people last week.

The doctor’s wife was a teacher, and she was accused of convincing coworkers at her school to become involved in the illegal activity. These people were teachers, teacher’s assistants, or administrative aides at the school. The illegal prescriptions were filled from late 2012 until early 2014, and totaled around 200 prescriptions and 25,000 doses of hydrocodone. According to the news reports, some of the people filling the prescriptions were using some of the pills, and delivering some back to the doctor and his wife. Others say they thought they were helping people get access to pain pills by using their names.

If this news report turns out to be true, I have a hard time believing the doctor and his wife would take such a risk unless one or both are addicted to opioids. No one is immune to addiction, as we know. And I doubt the people filling the prescriptions would participate in this mess unless they were getting something out of it, too. Claiming to have filled phony prescriptions just to help someone out…I call bullshit on that. These people could also be pill abusers or addicts, or maybe were getting paid to pick up the pills, but I can’t imagine anyone would do this highly illegal thing without some sort of remuneration.

This was a big news story because people were shocked that this drug ring (allegedly) involved a doctor and schoolteachers. But as we know, addiction is an equal opportunity destroyer. For too long, society has imagined that drug addicts are people lying in the gutter with a needle hanging out of their arm. In reality, opioid addicts today look like our next door neighbors.

I reacted to the story with sadness, and with curiosity. I was sad because I think it’s highly likely all the people who were arrested suffer from addiction, and are in need of treatment. But maybe they’ll get lucky, and will be mandated to treatment instead of jail.

I was curious because I wonder why the doctor prescribed only hydrocodone. Why not advance to a more powerful opioid, if you are going to break the law anyway? If you know what you are doing is illegal, why not splurge, and prescribe Dilaudid, or OxyContin? Or maybe he’s smart, thinking that higher powered opioids would call more attention to the scheme. But surely he knew this could not remain secret, with seven other people involved.

This story may illustrate, again, that we don’t do our best thinking in the midst of addiction.

1. http://www.wtvm.com/story/25968161/dr-orrin-walker-abby-walker-rss-bostian-elementary-drug-scheme

My Occupational Pet Peeves

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I feel like venting. It’s my blog, so I can if I want to. These things annoyed the stuffing out of me this week:

 Opioid treatment programs who list themselves as capable of dosing patients with both methadone and buprenorphine, but when the counselor calls to set up guest dosing for her bupe patient, they don’t really use buprenorphine.

That’s false advertising. Why do you waste everyone’s time by advertising something you don’t provide?

 Pharmacies who list prescriptions for patients in the North Carolina Controlled Substance Reporting System (my state’s prescription monitoring program) BEFORE the patient picks up the prescription.
I called the patient in to see me, and she denied filling the prescription listed on the NC CSRS. I called the pharmacy, and the patient is right. This pharmacy chain enters data as being filled before it’s picked up by the patient because they can’t do it any other way with their computer system.

If this database is worth doing, isn’t it worth getting it right?

 Patients being prescribed controlled substances by the VA (Veterans Administration) in my state don’t have their medication listed on our prescription monitoring site.
This is a patient safety issue. Why won’t the VA protect their patients?

 I call the doctor for one of my opioid treatment programs to discuss how best to coordinate his care. After spending five minutes on hold on the phone, a nurse comes on the line and says “Doctor is in with a patient right now. He can call you when he’s done.”
What the flip does Doctor think I’ll be doing when he calls me back? Sitting with my feet on the desk, playing free cell on my computer, waiting breathlessly for his phone call? No, I’ll be talking with my next patient.

This is doctor one-upmanship. When Doctor does call me, I’ll interrupt the patient I’m with, come to the phone, and it will be Doctor’s receptionist who says, “Hold for Doctor, please,” and I’ll have to wait a few more minutes if I’m lucky.

 New patients who don’t keep their appointments with me.
I don’t have many office- based Suboxone openings, what with the 100 patient limit. I can’t take every new patient who calls, so if you call at the right time and do get an appointment, please keep it, or at least call to let me know you won’t be there. There are other people I could see during the hour I set aside for you. And if you don’t keep that first appointment or call to cancel it, don’t call for another. I can’t afford to have you in my practice. Sounds harsh? Yes, maybe so, but I have financial realities to meet.

 Insurance denials of coverage for buprenorphine products (Suboxone, Subutex, Zubsolv, etc.)
Coventry (that’s right, I’m calling you out, you lame excuse for an insurance program) recently denied coverage for Suboxone films because my patient was found to have received a prescription for tramadol from a dentist.

First of all, my patient told the dentist not to prescribe any opioids because he was in recovery from addiction and had to be careful. My patient took the prescription his dentist gave him, on which was written both tramadol and an anti-inflammatory medication. He called my office and asked if he could take the anti-inflammatory. He didn’t ask about the tramadol because he didn’t intend to take it.

When we found his insurance company refused to pay for his monthly Suboxone prescription because he had filled a tramadol prescription, he told me he still had the tramadol at home, if it made a difference. I said yes, and asked him to bring it in, which he did. I did a pill count. All the pills were there, and I watched him discard those pills, and wrote a letter to his insurance company, appealing their decision to stop paying for his Suboxone.

That was last week. I haven’t heard back. For now, my patient is paying out of pocket for his medication, which as readers know, is not cheap.

Ah, I feel much better now….

A Really Good Book – For Free

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If you haven’t read CASA’s (Center on Addiction and Substance Abuse, at Columbia University) masterpiece publication from June, 2012, titled “Addiction Medicine: Closing the Gap between Science and Practice,” you should do so. This publication can be downloaded for free, and has essential information about addiction and its treatment. http://www.casacolumbia.org/addiction-research/reports/addiction-medicine

Casa also has other free and informative publications about other issues, like how to reduce the risk of addiction in teens (“The Importance of Family Dinners” series), the cost and impact of untreated addiction on society (“Shoveling Up”), substance abuse and the U.S. prison population (“Behind Bars” series), and the availability of drugs on the internet ( “You’ve got Drugs” series). All of these contain useful and thought-provoking data.

“Addiction Medicine: Closing the Gap between Science and Practice” outlines all aspects of what is wrong with addiction treatment in the U.S., along with recommendations about how we can fix this broken system. When it was published in June of 2012, I thought it would be would be widely read and discussed. However, I’ve only heard it mentioned once, and that was at an ASAM meeting. I wish popular press, so eager to write sensationalistic pieces about addiction, would write more fact-based information.

Every politician should read it. Every parent should read it. Physicians and treatment center personnel should read it. Anyone who is concerned about the extent of addiction and its poor treatment in the U.S. should read it.

CASA describes their key findings of the drawbacks of the U.S. system – or non-system – of addiction treatment. This nation is doing many things wrong, to the detriment of people afflicted with addiction, their families and their communities. Our mistakes are based on ignorance, misperceptions, and prejudice. All of these impede our ability to help our people with addiction. The CASA report describes these factors and how they have contributed to our present situation.
Our nation hasn’t waged a war on drugs, but rather on people who use drugs.

The CASA report describes how public opinion about addiction isn’t based on science. Science proves addiction is a brain disease, yet this fact is still debated. We know that continued use of addicting substances alters the structure and function of the brain, affecting judgment and behavior about the continued use of drugs even when bad consequences occur. We know that half of the risk for developing addiction is determined by genetic makeup. Yet surveys show that about a third of U.S. citizens still feel addiction is due to lack of willpower and self-control. Why are public attitudes so disconnected from science?

Addiction is a complicated diagnosis, existing as it does at the end of the continuum from occasional drug use to regular use to compulsive use. People often compare a drug user with a drug addict. They say that since the drug user was able to stop when he wanted that the drug addict should be able to stop when he wanted. This compares apples to oranges. If someone can comfortably stop using drugs when given a good enough reason to do so, this person isn’t an addict. They may be a drug abuser, a problem user, and at high risk for addiction, but they haven’t crossed the line into uncontrollable use.

The CASA report pointed out that most addiction treatment and prevention isn’t done by physicians and health professionals. Most addiction treatment is provided by counselors who, for the most part, aren’t required to have any medical training. Only six states require a bachelor’s degree to become an addiction counselor, and only one (Alabama, go figure) requires a master’s degree.

Even when physicians are involved in the treatment of addiction, most of us have very little, if any, training in medical school or residencies about addiction prevention or treatment. Ironically, most of our training focuses on treating the consequences of addiction.

In medical school and residency, I spent countless hours learning about the proper treatment of cirrhosis, gastritis, anemia, pancreatitis, dementia, and peripheral neuropathy from alcohol addiction. I had little if any training about how to treat alcohol addiction, and none about how to prevent it.

We know brief interventions by physicians during office visits can reduce problem drinking and are an effective way to prevent problems before they occur. Yet few physicians are trained to do this brief intervention. Even if they are trained, primary care physicians and physician extenders are being asked to do more and more at each visit with patients, and asked to do it with less and less time. Primary care providers may not be adequately paid for screening and brief intervention for problem drinking and drugging, and valuable opportunities are lost. Yet that same patient may consume hundreds of thousands of healthcare dollars during only one hospital admission for medical consequences of problem alcohol use.

When I practiced in primary care, I often thought about how I never got to the root of the problem. I would – literally – give patients with serious addiction strikingly absurd advice. “Please stop injecting heroin. You got that heart valve infection from injecting heroin and you need to quit.” I could see it was ineffective, but I didn’t know any better way at the time. I assumed if there was a better way to treat addiction, I’d have learned about it in my training.

Wrong. The doctors who trained me couldn’t teach what they didn’t know themselves.

In my Internal Medicine residency, I admitted many patients to the hospital for endocarditis (infected heart valve) contracted from IV heroin use. Each time, this required six month of intravenous antibiotics. Back then we kept such patients in the hospital the whole time. You can imagine the cost of a six week hospital stay, not that these addicts had any money to pay. Just a fraction of that amount could have paid for treatment at a methadone clinic, the most effective way to treat heroin addiction, and prevent dozens of medical problems.

But I never referred them to the methadone clinic available in that city. I didn’t know anything about methadone or the medical-assisted treatment of opioid addiction, and apparently my attending physicians, responsible for my training, didn’t know about it either. It was a shame, because in those years, the late 1980’s, we were making new diagnoses of HIV almost daily among IV drug users. Since then, a study showed a patient using IV heroin drops his risk of contracting HIV by more than threefold if he enrolls in a methadone clinic.

I didn’t learn about the evidence-based treatment of opioid addiction until I agreed to work at a methadone clinic for a few days, covering for a friend of mine when he wanted to go on vacation. I was amazed to learn about decades of evidence showing the benefits of such treatment.

Most addiction-related medical expenses are paid for from public funds. In fact, over ten percent of all federal, state, and local government dollars are spent on risky substance use and addiction problems. Sadly, over 95% of this money is spent on the consequences of drug use and abuse. Only 2% is spent on treatment or prevention.

Untreated addiction costs mightily. People with untreated addiction incur more health care costs than nearly any other group. An estimated one third of all costs from inpatient medical treatment are related to substance abuse and addiction. Untreated addicts (I include alcohol addicts with drug addicts) go to the hospital more often, are admitted for longer than people without addiction, and require more expensive heath care than hospitalized non-addicts. The complications these people suffer could be from underlying poor physical health and lack of regular preventive healthcare, but most of the cost is incurred treating the medical problems directly caused by addiction and risky substance use.

Family members of people with untreated addiction have higher health costs, too. Families of people with addiction have 30% higher health care costs than families with no addicted member. I presume that’s from the stress of living and dealing with a loved one in active addiction. Often family members are so caught up in trying to control the chaos caused by active addiction that they don’t take time for routine health visits.

The costs of untreated addiction aren’t only financial. Addiction and risky drug use are the leading causes of preventable deaths in the U.S. Around 2.9 million people died in 2009, and well over a half million of these deaths were attributable to tobacco, alcohol, and other drugs. Overdose deaths alone have increased five-fold since 1990.

We know addiction is a chronic disease, yet we spend far less on it than other chronic diseases.
For example, the CASA report says that in the U.S., around 26 million people have diabetes, and we spend nearly 44 billion dollars per year to treat these patients. Similarly, just over 19 million have cancer, and we spend over 87 billion for treatment of that disease. In the U.S., 27 million people have heart disease, and we spend 107 billion dollars on treatment.

But when it comes to addiction, we spend only 28 billion to treat the estimated 40.3 million people with addiction, and that includes nicotine!

Most of the money we do spend is paid by public insurance. For other chronic diseases, about 56% of medical expenses are covered by private payers, meaning private insurance or self-pay. But for addiction treatment, only 21% of expenses are paid from private insurance or self-pay. This suggests that private insurance companies aren’t adequately covering the expense of addiction treatment. Indeed, patients being treated with private insurance for addiction are three to six times less likely to get specialty addiction treatment than those with public insurance such as Medicaid or Medicare. Hopefully we will see a change since the parity law was passed. (which told insurance companies they had to cover mental health and substance addiction to the same degree they cover other health problems)

In the U.S., we don’t treat addiction as the public health problem that it is. Some people still don’t believe it’s an illness but rather a moral failing. Doctors, not knowing any better, often have an attitude of therapeutic nihilism, feeling that addiction treatment doesn’t work and it’s hopeless to try.

Families and medical professionals often expect addiction to behave like an acute illness. We may mistakenly think addiction should be resolved with a single treatment episode. If that episode fails, it means treatment is worthless. Families want to put their addicted loved one into a 28-day treatment program and expect them to be fixed forever when they get out. They’re disappointed and angry if their loved one relapses.

This reminds me of an elderly man I treated for high blood pressure many years ago. I gave him a month’s prescription of blood pressure medication, and when he came back, his blood pressure was good. I was pleased, and I wanted to keep him on the medication. He was angry. He said he was going to find another doctor. He thought the one prescription should have cured his high blood pressure so that he would never have to take pills again, and was disappointed with my treatment.
If we keep our same attitude toward addiction treatment, we are doomed to be as disappointed as my patient with high blood pressure. Addiction behaves like a chronic disease, with period of remission and episodes of relapse.

We have a lot of work to do. As this CASA publication shows, we have to change public attitudes with scientific information and do a much better job of training physicians and other health care providers. We should pay for evidence-based, high-quality addiction treatment, rather than spend billions on the medical problems caused by addiction as we are now doing.

Check out this landmark publication at CASA’s website: http://www.casacolumbia.org

Inspired at AATOD

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I just got back from the AATOD (American Association for the Treatment of Opioid Dependence) conference, and I feel inspired, enthusiastic, and relaxed.

Several days before I left for the conference, I talked to a pregnant patient at one of the opioid treatment programs where I work. This patient, dosing on methadone, said her obstetrician insisted she taper down on her dose during pregnancy. When she told me that, my shoulders slumped with fatigue and disappointment. This was a doctor I’ve called on the phone a few times, and met in person once. We’ve talked collegially, and I physically, personally handed her a copy of ACOG/ASAM (American College of Obstetrics and Gynecology, American Society of Addiction Medicine) position paper on the treatment of opioid-addicted pregnant patients.

Needless to say, that document does NOT advise taper of methadone during pregnancy. When I talked to this obstetrician, I’d explained why we usually need to increase the dose during pregnancy. Yet now she’s telling a patient to lower her dose. This is not best practices.

I felt tired, and hopeless about improving physician education in my area. Do these doctors have Teflon brains, and all the information I’ve been trying to provide keeps sliding off their cortexes, into the ozone somewhere?

Yesterday at the AATOD conference, I heard a lecture by one of the main authors of the MOTHER (Maternal Opioid Treatment: Human Experimental Research) trial, Dr. Karol Kaltenbach. I’ve posted blogs about this trial (see Dec 16, 2010, March 23, 2013), which randomized opioid-addicted pregnant women to treatment with either methadone or buprenorphine. The goal was to compare outcomes of the babies born to moms maintained on methadone versus buprenorphine.

Dr. Kaltenbach opened her lecture by making an excellent point: use of legal drugs such as alcohol and tobacco during pregnancy are viewed as public health problems, even though they cause as much or more harm to the fetus as illicit drugs. Yet the general public demonizes moms who use illegal drugs. Pregnant women who use illegal drugs are faced with harsh moral judgments, and punitive responses.

Alcohol, a legal drug, causes harm to 40,000 kids per year, and is the leading preventable cause of developmental disabilities. Consistently, research shows physical and behavioral effects in the children born to moms who drink alcohol. Even though researchers have stated that there’s no safe amount of alcohol during pregnancy, according to the 2011 NSDUH (National Survey of Drug Use and Health), 9% of pregnant women said they were current drinkers, 2.6 said they were binge drinking, and .4% were heavy drinkers.

Pregnant smokers of tobacco are more likely than non-smokers to have a variety of complications, including spontaneous abortions, placenta previa and placental abruption, retardation of fetal growth, low birth weight babies, and preterm labor and birth. After delivery, the risk of SIDS (Sudden Infant Death Syndrome) is six times higher than for babies of non-smoking moms. Their babies are more likely to have ADHD, inattention disorders, ear and respiratory infections.

Yet newspapers now publish sensational articles about “addicted babies” born to mothers with opioid addiction, while ignoring the more common and more harmful effects of alcohol and tobacco. Remember the “crack baby” scare of the 1990’s, which was a media creation with no backing by science?

From the MOTHER study we learned that babies born to moms on buprenorphine have about the same risk of withdrawal, called neonatal abstinence syndrome (NAS), as babies born to moms on methadone. In both groups, fifty percent of the babies had NAS severe enough to need medication to treat opioid withdrawal. The babies were scored on the Finnegan scale, which grades the babies on many signs of withdrawal to indicate when treatment is needed. (By the way, at the AATOD conference I sat near Loretta Finnegan, creator of the Finnegan scale and internationally recognized for her many contributions to the field of alcohol and drug abuse!)

So in both groups, about half of the babies needed medication for withdrawal symptoms. However, the babies with NAS born to the moms on buprenorphine required 89% less medication (morphine solution) and spent 43% less time in the hospital as compared to the babies with NAS born to moms maintained on methadone. The babies born to moms on buprenorphine also spent 58% less time being medicated to treat their NAS.

That’s a significant benefit.

This study was very important for many reasons, but after these results, buprenorphine is slowly becoming the standard of care for pregnant opioid-addicted moms, if it’s available. True, there was a higher drop out of the moms on buprenorphine, but it was not statistically significant, and the moms didn’t leave treatment; they dropped out of the study for whatever reason.

Now for the exciting part: a supplemental study of these children is being completed. This data hasn’t yet been published, but Dr. Kaltenbach says it will show that kids of moms on methadone and buprenorphine were compared and assessed at three months, six months, twelve, twenty-four, and thirty-six months. A standardized scoring system for infant development called the Bayley Scale was used to study these children, and the groups were compared to scores for normal children.

Dr. Kaltenbach says there are no differences between the babies born to methadone versus buprenorphine, and better yet – both groups showed scores in the normal ranges on this scale. The scale measured things like language and motor skills, cognitive abilities, and conceptual and social skills.

The kids are alright!

This data is going to be a huge comfort to worried moms, dosing on methadone or buprenorphine.

And I got inspired at the AATOD conference. I heard one speaker tell the audience “you do it until they get it. You tell them over and over and over again. Whatever it takes.” And I thought to myself, this is correct. I can’t give up on the obstetricians in my area. Maybe they don’t agree with me, but I am not out on a limb with what I’m saying. It’s backed up with fifty years of studies and science. I am listening and reading information from the experts in the field. I need to be persistent, and keep repeating the data, mailing the data…skywriting the data…whatever.

It’s refreshing to be around people who understand opioid addiction and its treatment. It’s encouraging to hear how workers in the opioid addiction field are finding new ways to help our patients and advocate for them.

I’m going to call this OB – again –and re-inform her – nicely – about what’s found in that position paper, co-authored by doctors from her own specialty. I’m also going to suggest she direct some of her concern towards her patients who use the legal drugs of alcohol and tobacco, since they cause significant harm to infants.

And yes, I know most of the patients enrolled in OTPs also smoke, and I am going to help them with that, too…if they want it.

1. http://www.asam.org/docs/publicy-policy-statements/1-opioids-in-pregnancy—joint-acog-4-12.pdf?sfvrsn=2

2. “Neonatal Abstinence Syndrome after Methadone or Buprenorphine Exposure,” by Hendree Jones, Karol Kaltenbach, et. al., New England Journal of Medicine, December 9, 2010, 363;24: pages 2320-2331.

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