Archive for the ‘Doctors Behaving Badly’ Category

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.

Each State Gets a Report Card

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You have got the check this out…an organization called Trust For America’s Health, or TFAH, supported by the Robert Wood Johnson foundation, has released a report called, “Prescription Drug Abuse 2013: Strategies to Stop the Epidemic.” You can find the report at their website at: http://www.healthyamericans.org

This report grades each state on its policies for managing the prescription pain pill epidemic.

The report begins with a description of the scope of the problem: current estimates say around 6.1 million U.S. citizens are either addicted to or misusing prescription medications. Sales of prescription opioids quadrupled in the U.S. since 1999, and so have drug overdose deaths. In many states, more people die from drug overdoses than from motor vehicle accidents. The costs of addiction and drug misuse are enormous; in 2011, a study estimated that the nonmedical use of prescription opioids costs the U.S. around 53.4 billion dollars each year, in lost productivity, increased criminal justice expenditures, drug abuse treatment, and medical complications.

The report identifies specific groups at high risk for addiction. Men aged 24 to 54 are at highest risk for drug overdose deaths, at about twice the rate of women, although the rate of increase in overdose deaths in women is worrisome. Teens and young adults are at higher risk, as are soldiers and veterans. (Please see my blog of October 19th for more information about veterans.) Rural residents are twice as likely to die of an overdose as urban residents.

TFAH’s report declares there are ten indicators of how well a state is doing to fix the opioid addiction epidemic. This report grades each of the fifty states by how many of these indicators each state is using. TFAH says these ten indicators were selected based on “consultation with leading public health, medical, and law enforcement experts about the most promising approaches.”

Here are their ten indicator criteria:
 Does the state have a prescription drug monitoring program?
 Is use of the prescription drug monitoring program mandatory?
 Does the state have a law against doctor shopping?
 Has the state expanded Medicaid under the ACA, so that there will be expanded coverage of substance abuse treatment?
 Does the state require/recommend prescriber education about pain medication?
 Does the state have a Good Samaritan law? These laws provide some degree of immunity from criminal charges for people seeking help for themselves or others suffering from an overdose.
 Is there support for naloxone use?
 Does the state require a physical examination of a patient before a prescriber can issue an opioid prescription, to assure that patient has no signs of addiction or drug abuse?
 Does the state have a law requiring identification to pick up a controlled substance prescription?

 Does the state’s Medicaid program have a way to lock-in patients with suspected drug abuse or addiction so that they can get prescriptions from only one prescriber and pharmacy?

I thought several of these were bizarre. Several are great ideas, but others…not so much. For example, I think a law against doctor shopping leads to criminalization of drug addiction rather than treatment of the underlying problem. The addicts I treat knew that doctor shopping was illegal, but still took risks because that’s what their addiction demanded of them. Such laws may be a way of leveraging people into treatment through the court system, however.

And where are the indicators about addiction treatment? Toward the very end of this report, its authors present data regarding the number of buprenorphine prescribers per capita per state, but make no mention of opioid treatment program capacity per capita for methadone maintenance. Buprenorphine is great, and I use it to treat opioid addiction, but it doesn’t work for everyone. And there’s no data about treatment slots for prolonged inpatient, abstinence-based treatment of opioid addiction.

Expanded Medicaid access for addiction treatment is a nice idea… but not if doctors opt out of Medicaid because it doesn’t pay enough to cover overhead. If expanded access is not accompanied by adequate – and timely! – payment to treatment providers for services rendered, having Medicaid won’t help patients. Doctors won’t participate in the Medicaid system. I don’t. I have a few Medicaid patients whom I treat for free. It’s cheaper for me to treat for free than pay for an employee’s time to file for payment and cut through red tape.

In one of the more interesting sections in this report, each state is ranked in overdose deaths per capita, and the amount of opioids prescribed per capita.

The ten states with the higher opioid overdose death rates are: West Virginia, with 28.9 deaths per 100,000 people; New Mexico, with 23.8 deaths per 100,000; Kentucky with 23.6, then Nevada, Oklahoma, Arizona, Missouri; then in eighth place is Tennessee, with 16.9 deaths per 100,000. In ninth and tenth places are Utah and Delaware. Florida came in at number 11, with 16.4 deaths per 100,000.

North Carolina placed 30th in overdose death rates. We’ve had a big problem with prescription drug overdose deaths. From 1999 until 2005, the death rate rose from4.6 per 100,000 to 11.4 per 100,000. But at least our rate has not increased since 2005. The rate in 2010 was still 11.4. It’s still way too high, but many agencies have been working together over the past six years to turn things around. In a future blog, I intend to list the factors I think helped our state.

Use of the ten indicators does appear to correlate with reduced rate of increase of overdose deaths. In other words, states with more laws and regulations have had a slower rise in overdose deaths than states with fewer laws and regulations, though there are some exceptions.

This report also compares states by the amount of opioids prescribed per year, in kilograms of morphine equivalents per state per 10,000 people. Florida, not surprisingly, came in at number one, with 12.6 kilograms per 10,000 people. Tennessee and Nevada tied for second and third place, with 11.8 kilos per 10,000 people. The next seven, in order, are: Oregon, Delaware, Maine, Alabama, West Virginia, Oklahoma, and Washington. Kentucky was 11th, with 9.0 kilos per 10,000. North Carolina doctors prescribe 6.9 kilos of opioids per 10,000 people per year, in 27th place and less than the national average of 7.1 kilos.

It appears to me that amount of opioid prescribed per capita does correlate, somewhat, with overdose death rates.

Let’s look closer at Tennessee, the state who, just a few months ago, rejected a certificate of need application for an opioid treatment program to be established in Eastern Tennessee. In 1999, Tennessee had an overdose death rate that was relatively low, at 6.1 per 100,000 people. By 2005, it zoomed to 10.4 per 100,000 people, and by 2010, rocketed to 16.9 per 100,000 people, to be in the top ten states with highest overdose death rates. Furthermore, Tennessee is now second out of fifty states for the highest amount of opioids prescribed per 10,000 people. Only Florida beat out Tennessee. And lately Florida has made the news for its aggressive actions taken against pill mills, which may leave the top spot for Tennessee.

West Virginia is no better. It was the worst state, out of all fifty, for overdose deaths, at 28.9 per 100,000 people in 2010. Wow. If you think lawmakers are asking for help from addiction medicine experts…think again.

West Virginia legislators recently passed onerous state regulations on opioid treatment programs. That’s right, lawmakers with no medical experience at all decided what passed for adequate treatment of a medical disease. For example, they passed a law that said an opioid addict had to be discharged from methadone treatment after the fourth positive urine drug screen. In other words, if you have the disease of addiction and demonstrate a symptom of that disease, you will be turned out of one of the most evidence-based and life-saving treatments know to the world of medicine. West Virginia passed several other inane laws regulating the medical treatment of addiction.

Getting back to the TFAH study, the report calculates that there are 21.6 million people in the U.S. who need substance treatment, while only 2.3 million are receiving it. This report identifies lack of trained personnel qualified to treat addiction as a major obstacle to effective treatment.

This report makes the usual recommendations for improving the treatment of addiction in the U.S… They recommend:

 Improve prescription monitoring programs. Nearly all states have them, except for Missouri and Washington D.C.

States should be able to share information, so that I can see what medication my North Carolina patients are filling in Tennessee. Right now, I have to log on to a separate website to check patients in Tennessee, so it takes twice as much time. Tennessee is already sharing data with several other states, but not with North Carolina, or at least not yet.

TFAH also recommends linking prescription monitoring information with electronic health records.

 Easy access to addiction treatment.

Duh. The report accurate describes how underfunded addiction treatment has been, and says that only one percent of total healthcare expenditures were spent on addiction treatment. We know how crazy that is, given the expense of treating the side effects of addiction: endocarditis, alcoholic cirrhosis, hepatitis C, gastritis, cellulitis, alcoholic encephalopathy, emphysema, heart attack, stroke, pancreatitis, HIV infection, gastrointestinal cancers, lung cancer…I could go on for a page but I’ll stop there.

Access to treatment is limited by lack of trained addiction professionals. Doctors abandoned the field back in 1914, when it became illegal to treat opioid addiction with another opioid. Even with the dramatic success seen with methadone and buprenorphine treatment of opioid addiction, there are relatively few doctors with expertise in this treatment.

This reports shows that two-thirds of the states have fewer than six physicians licensed to treat opioid addiction with buprenorphine (Suboxone) per 100,000 people. Iowa has the fewest, at .9 buprenorphine physicians per 100,000 people, and Washington D.C. had the most, at 8.5 physicians per 100,000 people.

North Carolina has 3.2 buprenorphine physicians per 100,000 people, while Tennessee has 5.3 physicians per 100,000. This makes Tennessee look pretty good, until you discover than many of Tennessee’s physicians only prescribe buprenorphine as a taper, refusing to prescribe it as maintenance medication. If these doctors reviewed the evidence, they would see even three month maintenance with a month-long taper gives relapse rates of around 91% (1)

I’m really bothered by the lack of attention to the number of methadone treatment slots per capita. That’s information I’d really like to have. But the authors of this report did not deign to even mention methadone. Even with forty-five years’ worth of data.

**Sigh**

 Increased regulation of pill mills.

 Expand programs to dispose of medications properly. In other words, make sure citizens have a way to get rid of unused medication before it’s filched by youngsters trying to experiment with drugs.

I know many tons of medications have been turned in on “drug take-back” days. But I’ve never seen any data about how much medication is addictive and subject to abuse, versus something like outdated cholesterol lowering pills.

 Track prescriber patterns. Another benefit of prescription monitoring programs is that officials can identify physicians who prescribe more than their peers. Sometimes there’s a very good reason for this. For example, a doctor who works in palliative care and end-of-life care may appropriately prescribe more than a pediatrician.

I get uneasy about non-physicians evaluating physicians’ prescribing habits, though. I think this is best left up to other doctors, enlisted by the state’s medical board to evaluate practices. Other doctors are better able to recognize nuances of medical care that non-physicians may not understand.

 Make rescue medication more widely available. In this section, the report’s authors make mention of Project Lazarus of Wilkes County, NC, a public health non-profit organization dedicated to reducing opioid overdose deaths, not only in that county, but state-wide. Project Lazarus is well-known to me, since I work at an opioid treatment program in Wilkes County.

 Ensure access to safe and effective medication, and make sure patients receive the pain medication they need. Obviously, we want opioids available to treat pain, especially for acute pain. Hey, you don’t have to convince me – read my blog from this summer about how grateful I was for opioids after I broke my leg. Opioids were a godsend to me in the short-term, and knowing what I do about opioids, I didn’t use them after the pain subsided.

It was an interesting report, though I saw some unfortunate gaps in their information, particularly regarding opioid addiction treatment availability.

But at least this is another agency looking at solutions and making some helpful recommendations.

1. Weiss et al, “Adjunctive Counseling During Brief and Extended Buprenorphine-Naloxone Treatment for Prescription Opioid Dependence,” Archives of General Psychiatry, 2011;68 (12):1238-1246.

Guest blogger, Dr. Fedup

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I’d like to introduce my guest blogger for today, Dr. Fedup. I was talking to him about the insurance companies who decided not to cover treatment expenses of buprenorphine (Suboxone) patients who have had relapses. These companies are refusing to pay if the patient has positive urine drug screens or if they aren’t following counseling recommendations. I have three patients who now have to pay for their office visits and medication without any help from their health insurance company.

Dr. Fedup wanted to comment on the situation, so here’s his take:

“So insurance companies have decided addicts who don’t toe the line and follow their doctor’s instructions shouldn’t be covered by their insurance. About bloody time, I say. If those addicts still selfishly decide to indulge in illicit drug use, why should they have health insurance coverage at all? If a drug addict is still using drugs, paying for treatment would be enabling, and endorsing illicit drug use. If those addicts can afford drugs, they can afford their own medication.

“While we’re on the topic of personal responsibility, let’s talk about my own non-compliant patients. In my practice, I have patients with high blood pressure who don’t follow my recommendations. Instead of losing weight, they gain weight. They don’t diet; they don’t exercise, and they still eat salt. They don’t take their pills every day. Those patients should also be dropped from coverage from their insurance company. If someone doesn’t take a stand for personal responsibility, patients all over the U.S. will feel like they can ignore the health instructions given to them by their hard-working doctors like me.

“And don’t get me started on the overweight diabetics. If a patient refuses to lose the prescribed amount of weight, or refuses to follow a strict low-carbohydrate diet, that patient is acting irresponsibly. What insurance company would want to pay for expensive medication when the patient doesn’t care enough about herself to do her part? That also would be enabling.

“Then there are all those people mewling about being sick with the flu. Didn’t bother to get your flu shot on time? Then don’t come crying to me when you’re sick. Take some responsibility and get out of my office. Hopefully you’ll survive, and then you’ve learned a valuable lesson about following doctors’ instructions. (Unless it turns into pneumonia, in which case you’ll be too dead to have learned any lesson.)

“Some of those asthmatics really chap my hide, too. If they still smoke, cut them off from medical care. They’re choosing to be sick. The same thing applies with asthmatics with allergies, who carelessly allow exposure to dust, pollen, etc. If the patient can’t manage to stay away from something that will make her sick…don’t come crying to me. Learn to act responsibly.

“In fact, all people who refuse to follow present medical recommendations are acting irresponsibly. When they get sick, why do they expect someone else to pay for their lazy lack of diligence? If they don’t live healthy lives, don’t pay for treatment when they get sick. As an added bonus, this will really cut down healthcare expenditures, since fewer than 2% of U.S. adults follow all heart-healthy dietary recommendations (http://www.webmd.com/heart-disease/news/20120316/too-few-keep-heart-healthy-habits ) Think of all the money that will be saved!

“And those people who get into accidents and don’t wear seatbelts…let’s refuse to pay for their treatment too. They should have known better. Ditto for people injured when they’re driving over the speed limit. Insurance companies shouldn’t cover these scofflaws. It’s a great way to cut medical costs. Because when you think about it, few medical expenses are incurred by patients who behave perfectly.”

Thanks for letting me guest blog,
Dr. Fedup

Dr Fedup has a wee problem with irritability but he makes a point. If insurance companies don’t cover buprenorphine treatment if the patient is non-compliant, why would they cover treatment for other conditions if the patient is non-compliant? And because non-compliance is part of the human condition for most of us, many of us would be out of luck.

In Praise of Opioids

My leg, six weeks after surgery, with intramedullary rod placement.

My leg, six weeks after surgery, with intramedullary rod placement.

Yes. That’s an odd title for a blog about opioid addiction, but my recent experience with a broken leg gave me some new insights into opioids

While walking my dog four weeks ago, I fell and broke my tibia and fibula (both bones of the lower leg). The break was obvious; I had to hold my foot to keep it from moving to an odd and painful angle. I sat on the ground, thinking, “Oh shit. This is going to hurt, and I’m going to have to go to the hospital emergency room on a Friday night to get a cast.”

And of course it did hurt. It was the worst pain I’ve ever had. I couldn’t get into a car to go to the hospital, since both hands were busy holding my foot. If I let go, my foot drooped to a sad angle. I wasn’t going anywhere under my own steam. So my fiancé called 911.

First to arrive was a huge fire truck, with ladders, hoses, etc. One of three or four firemen took my blood pressure, asked me a few questions, and said EMS would be there soon. When EMS arrived, three or so more young men sprang from their vehicle. They asked the same questions all over again. At one point there were five or six burly young men who all responded to the 911 call, standing around me in a semi-circle. It felt like a bit of overkill, but I didn’t mind.

The worst part of my whole ordeal was when EMS workers tried to splint my leg with a device obviously meant for a much taller person. Putting the splint on caused my foot to move to an angle that God did not intend. The grinding of my bones made me sick to my stomach, to the dismay of EMS personnel. I’m told my screaming and cursing, punctuated by intermittent vomiting, gave neighbors quite a show.

Once I finally got inside the ambulance, the EMS worker easily slid an IV into my arm and gave me a dose of fentanyl.

I have never taken any IV opioids, to my knowledge. Immediately, I felt hot all over, and then started weeping with relief. I wouldn’t say I felt euphoria, so much as a profound relief that the pain no longer hurt. That also sounds odd; I still had pain… but it didn’t bother me, and I felt like everything was going to be OK. In that moment, I had a better idea what my opioid-addicted patients describe when they tell me of the allure of opioids. Under the influence, I felt like nothing would bother me, physically or emotionally. Then my eyes felt like they were spinning around in my head like pinballs, but I didn’t care about that, either. Then I got very chatty and talked nonstop to the hospital.

The emergency room doctor ordered X-rays that showed the tib/fib fracture. I thought I would get a cast, and then go home. Wrong. The nurse told me I was being admitted for surgery on my broken leg. I wasn’t happy about this, especially since I hadn’t even talked to the orthopedic surgeon who would operate. I had questions. Why couldn’t I go home with a cast? What was he going to do at surgery, and why was it better than a cast?

So I stayed in the hospital that night, edgy about what surgery was proposed and full of questions. My leg hurt, but the emergency room staff had placed a plaster-type splint, or partial cast, on my leg, which kept the bones from moving around. As long as I kept it still and elevated, the pain wasn’t too bad. I had several shots of morphine through the night. I didn’t feel high from the morphine, but the shots put me to sleep, a good thing.

The surgeon came into my hospital room mid-morning, and talked to me about the advantages of having an intramedullary rod place through the center of my tibia to hold the broken sections together. This sounded extreme, but the surgeon said in “someone your age,” with simple casting the bones would take longer to heal. At my age, there was a relatively high rate of non-union, which would result in surgery at a later date anyway.

It took me longer to process the information than it should; I was stuck on that “someone your age” comment. I’m a young-looking 52, and finally realized I had to be much older than this young surgeon. Maaaaaybe the comment fit.

Anyway, I agreed to the surgery. Pre-op, the anesthesiologist gave me fentanyl, and again I had the feeling my eyeballs were spinning in circles and I got chatty. Then he must have given me something else that put me out completely, because the next thing I remember I was waking up back in my hospital room. I was upset when I didn’t see a cast, because I thought that meant I didn’t have the surgery. I didn’t know that an intramedullary rod takes the place of a cast…kind of like having a cast on the inside.

Since that surgery, I haven’t had much pain. I took my last morphine injection the night after surgery.

I’m no martyr. If I have pain, I want pain medication. The surgeon, knowing what I do for a living, asked me if I wanted to go home with any opioids. I said yes. I told him please prescribe what you would for anyone else. He prescribed twenty-five Percocet. I took two the morning after I got home, and they relieved the pain, but left me a little groggy and sleepy. I’d had enough of that in the hospital, and was eager to do some reading and writing, so that was the last dose of opioids that I have taken for my broken leg. After making it a week with no opioids, I flushed the remaining twenty-three pills.

I had one bad spell after falling on my crutches, twisting the broken leg a little. The rod held my tibia in place, but the fibula hurt intensely for about twenty minutes before I was able to calm the pain with elevation, ice, and ibuprofen.

I think I’ve done well during my recovery from the broken leg. This surgery allowed me to heal much faster. It’s now almost six weeks since my surgery, and the above x-ray was taken today. My leg hurts only when I walk around. Ibuprofen and Tylenol have worked fine. I’ve been careful, especially during the first few weeks, to keep my leg elevated and use ice for swelling. I’m convinced elevation and ice helped a great deal.

This week I can walk with the help of a cane. It does hurt to walk, but it’s the kind of hurt that’s necessary to build back my muscles. If the pain gets too bad, I sit down and elevate my leg again.

I know I’m very lucky. The fracture happened in a place where help was readily available. It was less than thirty minutes from the time I broke my leg until I got a shot of a powerful opioid, fentanyl. This medication was a godsend to me.

I have health insurance, and could afford to get the surgery to help my leg heal quickly. My surgeon did a wonderful job, even if I do have underwear older than he is. I was able to take several weeks off work to keep my leg elevated for better healing and less pain. I have a loving fiancé who didn’t mind being my legs for a few weeks. Some people don’t have any of those things, so I’m very grateful.

What is the point of this blog, other than to blather on about my surgery and broken leg? It’s this: opioids are great when used the in the right situation. For acute pain, they are truly a blessing to mankind. But these drugs produce pleasure, and anyone can get addicted to that intensely good feeling.

Doctors have to find a balance between empathy and caution. Let’s not be stingy with opioids during acute medical situations with intense pain. Even in a patient with known addiction, opioids shouldn’t be withheld for an acutely painful medical situation, because that would be unethical. But we can’t ignore the dangers of addiction, particularly if opioids are used for more than a few weeks. Even if we feel uncomfortable talking about addiction, we have to have those conversations with our patients. And please, fellow doctors, see patients with addictions as people with a treatable disease, who deserve the same respect as patients with any other disease. You don’t need to kick them out of your practice; you do need to refer them for help.

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.

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