“My Favorite Patients Are Addicts”

Feeling exceptionally lazy today, Idecided to post a blog containing an article I wrote for the physician magazine Medical Economics. It was published in April of 2010, and I got some great feedback from other doctors. And since I’m a wannabe writer, I also submitted it to the annual Writers Digest writing competition under magazine article, and I won 8th place. I was over the moon about this, because this is a huge competition. I got a certificate which I framed and put on the top of my bookcase at home. I’m prouder of this article than anything else I’ve written, because I was able to be heard by people in my profession. If you prefer, you can go right to the magazine’s site: http://medicaleconomics.modernmedicine.com/memag/issue/issueDetail.jsp?id=18947

Here it is:

When I was a fresh faced, newly unleashed graduate from my Internal Medicine residency nineteen years ago, I never dreamed my favorite patients would be drug addicts.

In medical school, I learned little about drug and alcohol addiction and its treatment, and in residency, even less. I was well trained in the management of acute alcohol withdrawal, acute GI bleeding from alcoholic gastritis, and antibiotic coverage of endocarditis in an injection heroin user, but I couldn’t tell any of these patients how to find recovery from the actual underlying cause of their problems. I could only treat the sequellae, and I didn’t always do that with much grace.

The addicted person caused their own miseries, I thought, and since these were the Reagan years, they should “just say no” when offered drugs. My attitudes mirrored those of the attending physicians in my residency program. When an addict was admitted twice for endocarditis, needing an artificial valve the first admission, and its replacement on the second admission for re-infection, I was just as irritated as the attending and the rest of the house staff. I remember we discussed whether we could ethically refuse him treatment if he came in a third time! We were so self-righteous, though we had offered him little in the way of treatment for his disease of addiction. We might have had a social worker ask him if he wanted to go away for inpatient treatment, he said no, and that’s where our efforts ended.

I knew nothing about medication-assisted therapies for opioid addiction. Now I know better.

I was working part time in primary care when a colleague, the medical director at a local drug addiction treatment center, asked me if I could work for him at this center for a few days while he was out of town. He was a good friend so I agreed. I thought it would be easy money, and fun, doing admission histories and physicals on addicts entering the inpatient residential program, and I was right…but I also saw patients entering the clinic’s methadone program.

This appalled me. It seemed seedy, shady, and maybe  a “fringe” area of medicine. It just seemed like a bad idea to give opioid addicts methadone.  However, I had made a commitment to my friend, so I told myself I would work those few days, tell my friend politely when he returned that I didn’t “believe” in methadone (as if it were a unicorn or some other mythical beast) and could not work there again.

But when I talked to these patients they surprised and intrigued me. Some patients were intravenous heroin addicts, but most were addicted to pain pills, like OxyContin, various forms of hydrocodone, and morphine. Most of them had jobs and families, and expressed an overwhelming desire to be free from their addiction. I was most intrigued by how the patients talked about methadone treatment. They said such things as “It gave me my life back” and “Now I don’t think about using drugs all the time” and “Methadone saved my marriage and my life”.

Huh? With methadone, weren’t they still using drugs?

My curiosity piqued, I started reading everything I could find about methadone – and to my surprise discovered that the treatment of opioid addiction with methadone is one of the most evidence-based treatments used in medicine today, with forty years worth of solid data proving its efficacy. So why had I never heard of it? I could have referred many intravenous heroin addicts that I saw during my residency, which happened to be during the height of the spread of HIV, for effective treatment of their addiction.  Because of methadone’s unique pharmacology, it blocks physical opioid withdrawal symptoms for greater than 24 hours in most patients, and also blocks the euphoria of illicit opioids. At the proper dose, patients should not be sedated or in withdrawal, and are able to function normally, working and driving without difficulty. Therefore, methadone maintenance is not “like giving whiskey to the alcoholic” as some ill informed people – like me – have accused.

For the next eight years I happily worked part time with my friend at this drug treatment center, and saw most methadone patients improve dramatically. Certainly methadone did not work for everyone, but it was a good treatment for many addicts. I did see some tough characters, but I was struck by how normal most of the patients seemed; most were not scary thugs as I had imagined, but housewives and construction workers.

Then I began hearing about a second medication to treat opioid addiction, called buprenorphine, better known by its brand name, Suboxone. The principle of this drug is the same as for methadone: it is a long-acting opioid, can be dosed once per day, and at the proper dose removes the physical withdrawal symptoms, and does not impair patients or give them a high. As an added bonus, it can be prescribed through a doctor’s office.

In 2000, the Drug Addiction Treatment Act allowed doctors, for the first time in about 80 years, to prescribe specifically approved schedule III, IV, or V controlled opioid for the purpose of treating people with opioid addiction. Shortly after this, the FDA approved buprenorphine for the treatment of opioid addiction, and the drug became available in 2003. In order to prescribe buprenorphine, a doctor must take an eight hour training course, petition the DEA for a special “X” number, and give notice to CSAT, the Center for Substance Abuse Treatment, of her intent to prescribe. Doctors prescribing buprenorphine also must have the ability to refer patients for the counseling that is so necessary for recovery from addiction.

Buprenorphine, a partial opioid agonist, is a milder opioid and there is a ceiling on its opioid effects, making it a safer and better choice for many patients than methadone. It is particularly good for addicts with relatively short periods of addiction, and fairly stable lives. Since it is a milder opioid, it is relatively easier to taper, if appropriate.

I started prescribing buprenorphine from a private office and loved it from the first. I did notice that the demographics of office patients were different from the methadone clinic; unfortunately Suboxone is expensive, at a minimum of $6 per 8mg pill, and some patients needed up to four pills per day. It became evident that only people of financial means or medical insurance were able to afford the office visit, the medication, drug screens and other lab tests, and individual counseling. At methadone clinics, most patients are self pay and could pay a day at a time, usually a fee of $10 – $15 per day. All services were bundled into that one daily charge.

The opioid addicts I met both in the methadone clinic and in a private office have not been what I expected. The vast majority are ordinary, likeable people with jobs and families. They are your hairdresser, your grocery clerk, the guy that works on your furnace. They sit beside you at the movies and behind you at church. Because they have built a tolerance to the sedating effects of opioids, they do not look impaired or high; they are able to function normally in society…as long as they have a supply of opioids.

If they are in withdrawal, without a source for opioids, they will be sick. Some people compare opioid withdrawal to having the flu, but it is not. It is like having the flu…and then being hit by a truck. Most addicts in opioid withdrawal are unable to work because of the severe muscle aches, nausea, vomiting, and diarrhea. Many of these patients are blue collar workers with physically demanding jobs who initially used pain pills to mask their physical pain so that they can work harder, better, faster…never guessing that what seemed to be helping was actually causing them more harm than they could imagine.

Some patients in the office were professionals, though not many. Most professionals can afford the more expensive inpatient thirty- to ninety- day rehabs, a luxury for many of the working middle class. But I saw some lawyers, nurses, even policemen with opioid addiction who refused to consider inpatient treatment even if they could afford it. These professionals were concerned about their livelihood if it became public that they had a problem with addiction, or because they were unwilling to take time off work. They were willing to come to a doctor’s office where no one would know why they were being seen, and they did very well on Suboxone.

I am thrilled when seeing a patient respond positively to treatment with buprenorphine.  Many return on the second visit looking like younger and happier versions of themselves. On the second visit, a common phrase is “It’s a miracle!” Many patients say they just feel normal, even though they had forgotten what normal felt like. When an addict begins to recover, the changes are usually dramatic; they begin to smile, to restore relationships, to rejoin their families and their communities. When an addict recovers, the ripple effect extends throughout the community.

We know now that addiction is indeed a chronic disease much like asthma and diabetes. Just like these diseases, there are behavior components that can make the disease worse, and there are genetic and personal factors that put some people at higher risk. Sadly, many addicts are still treated with distain and disgust by their doctors, an attitude we would not tolerate towards any other disease. This causes patients to hide addiction from their doctors, and the disease worsens.

Many people, even doctors, still object to the use of medication assisted therapies for addicts, saying “it’s trading one drug for another”, when in reality it is trading active addiction for medication, when prescribed responsibly and appropriately. Drug free recovery is the ideal, but with opioid addiction, it does patients a disservice to dismiss the mountains of evidence that medication assisted therapies of buprenorphine and methadone work for many opioid addicts who cannot or will not go to inpatient treatment programs of 30 to 90 days. Detoxification alone (usually five to seven days) does not work, and shows relapse rates of up to 96%. If detoxification alone worked, the policy of imprisonment for addicts promulgated in the 1950’s would have solved the opioid addiction problem. It didn’t.

For most patients, their big question is: “How soon can I get off of this drug?” Most express a desire to be completely drug free at some point, but I try to get them directed into a recovery program of some sort for counseling first. This can be through an intensive outpatient program at a treatment center, an individual therapist, or through 12-step recovery. Many patients who chose 12-step recovery seem to be able to taper off buprenorphine (or methadone) and remain abstinent from all drugs; they also seem to be the most satisfied with their lives in recovery.

Some patients, particularly those with both opioid addiction and chronic pain, prefer to remain on buprenorphine indefinitely as the safest treatment for both problems, and these patients also seem to do very well.

As for me, I plan to continue treating addicts of all types. These patients have been among the most grateful that I have encountered in primary care, and show the most improvement. When I treat addicts and see peace return to a face that had been filled with shame, I get a unique feeling of accomplishment. These are events I am honored to witness.

Advertisements

3 responses to this post.

  1. Posted by lilgirllostn1980 on September 25, 2011 at 5:00 pm

    There is no words to adequately compliment your article, but AWESOME will have to do. IMO you should have gotten FIRST place on this one in the Writer’s Digest Competion.

    My heart aches from wishing that all doctors had this outlook on pts on ORT. I am dealing with a situation now where I have been stable on ORT for 12 years and I am dealing w/kidney stones. They are too large to come out on their own and I have bilateral stints in while I wait for surgery. The doctor who is in charge of my care (I go to a “charity” clinic/hosp because I don’t have health ins……course we miss being eligible by 180 bucks so I am still having to pay for the care!) sorry, got off topic……the “free” clinic is run by the University Medical Center so all of these doctors are fresh from medical school, doing their rotations just like you described yourself in the beginning As soon as I told the doctor about my ORT & past addiction, I saw “that look” come over her face for just a split second. Now she won’t prescribe me anything stronger than vicodin (what a laugh!) for my pain. I am legitimately in pain, it’s not like I am just complaining of back pain which can’t be proven legit. The doctor I see for my ORT has tried to help, but she can only do so much as she is not my primary care doc and I only see her at the ORT clinic.

    Even though my physical pain is bad, it hurts me worse each time I think about the shame I felt when I saw the look on the doctors face when I told her about my addiction and being on ORT. What made it even worse was knowing that that look and her personal feelings about addicts on ORT are the ONLY reason I am having to be in such pain when there are perfectly safe drugs that I can be given to manage my pain during this time.

    Thank you for sharing, at least now it reminds me that there ARE doctor’s out there who do care and want to try and help addicts and recovering addicts like me.

    Reply

    • I have several ideas about your situation.
      First, I think your ORT doctor has a responsibility to communicate directly with your University doctor(s). You have a difficult and tricky combination of medical problems: recurrent pain from kidney stones and opioid addiction. Ideally one treatment shouldn’t interfere with the other treatment. If someone is on ORT, then they usually need a higher dose of opioids for acute severe pain, not lower. But that has to be done with safeguards so that the addiction doesn’t get worse. When one of my patients on ORT has surgery, broken bones, or kidney stones and has acute pain, I prefer the patient allow me to talk with the other doctor. I recommend closer supervision while on pain medications, and I ask the patient get a dependable non-addict to hold the pill bottle. I often ask to talk to this person to make sure he or she is reliable. The doctor treating the pain may want to give fewer pills at a time and require more frequent follow ups. I ask the patient to tell everyone close to them what is going on so that other people hold them accountable, like sponsor, other recovery group members. I recommend the patient go to more recovery meetings than usual, if possible, or call more recovering people if they are home or hospital bound.

      Your doctors at the University clinic probably have good hearts and want to do the right thing. Residents beginning their careers are usually trying really hard not to kill people. (I know I was.) The problem is that they probably haven’t been taught about addiction or opioid replacement therapy. So maybe this is an opportunity for you, if you care to undertake it, to educate a few new doctors. I agree you shouldn’t have to do this, but in many residency programs, they may not learn any other way.

      Why don’t you go to the NIDA website and print out some reading material for them? You can find it at http://international.drugabuse.gov/sites/default/files/pdf/methadoneresearchwebguide.pdf
      This is written by other doctors, so maybe your doctors will be willing to read it.

      The other thing is maybe you should ask your urologist what’s causing the stones, and do what you can to prevent them in the future. Usually drinking large amounts of water can help, but ask your doctor.

      Reply

      • I was going to respond back to you via private email, but I couldn’t find a link to do so!

        My ORT doctor did speak w/the University doctor several times. I have to go back a bit and tell you that 7 yrs ago when I went through this then, the doc at the University Hosp then was very helpful and worked w/my ORT doc. She took the time to listen to me and she never once treated me differently. During that time, she ended up giving me a duragesic patch to get me through to my surgery. This time, obviously I wouldn’t see the same doctor at the U hosp, so I brought several short articles that I usually share w/medical staff who have to treat me as well as a letter from my clinic explaining things.

        Before they put my stints in, the U doc and I talked because since we have to pay for treatment, there was a certain amt of money I would need up front to do surgery. She didn’t want to put stints in if I wasn’t going to have enough money to go through w/the surgery. I told her we would come up w/the money, I had to have this done so do whatever we need to do.

        After she put my stints in, I calmly asked to speak w/her in private before I left for the day (I remember from last time from having the stints in that it hurts worse than just the stones) I explained to her about my MMT, asked her if she would like to read the things I brought and/or the letter from my clinic. I explained to her that last time, because of my MMT, the doc prescribed me a duragesic patch which helped control the pain enough so I could deal with it. She started shaking her head no from the beginning when I said duragesic patch. She told me “we don’t prescribe that here” then she remembered that I told her that is what they gave me from here before and said “well, normally we don’t” She said she didn’t feel comfortable using it and it was an absolute no. She also said “I will give you opiates all day long, but I won’t give you anything else stronger than the percocet that we prescribe for everyone else”. Long story short, I would have asked her to contact my clinic right then, but my clinic closed at 11AM and even though I had an appt at the U hosp @ 8am hoping to get seen before my clinic closed, that didn’t happen. It was 4:30 in the afternoon when I got seen.

        So I went home (3 hours one way) and didn’t do so hot. I am elig for once a month take homes, but I ended up using some of my TO’s to help me get through the pain. I realized I was making things worse and spoke w/my clinic doc as soon as I could. My clinic doc spoke w/the U doc several times in the next several days (after she was finally able to get the U doc to call her back) and the first time the U doc said that I never made it clear to them if I was a self pay patient or if I was going to be an idigent patient and THAT is why she didn’t give me anything else (it shouldn’t make a difference!) and the second time she said they didn’t know if I was going to go through w/the surgery or not……Now come on. I allowed them to put kindey stints in me! If I wasn’t going to go through w/the surgery, WHY would I go through all of that? They have to come out eventually so what did she think I was going to do about that? I NEVER would have gone ahead w/the bilateral kidney stints if I had no intentions of going through w/the surgery.

        Finally, the 3rd time my MMT doc talked to her, I don’t know what was said. The next thing I know my MMT doc gave me a script for toradol, which she said she wasn’t suppose to do. Now that has helped some, but I am still in quite a bit of pain. I have levsin for the spasms, but I am constantly in pain from the two stones that are stuck in the ureter and I have another one blocking my left kidney which causes me flank pain, and one in my right kidney which thankfully isn’t bothering me……..yet.

        I go back in the morning for my preop stuff and I plan to try and talk to the U doc again. The only thing I know to do if she won’t do something then is ask her to talk to whatever doctor is in charge and/or try to go that route which I guess is not the best way to go because I might make her angry, but I really don’t know what else to do. I don’t even care if what she gives me isn’t an opiate, I will take whatever she will give me as long as it helps me with this pain and gets me through till surgery. Of course, just like last time, since it’s the U hosp, I may have to wait another 3 or 4 weeks. Even though one of my kidneys is blocked, and she even said all the stones are way too big to pass on their own, I am not considered an emergency.

        Thanks so much for listening and for giving me some advice. I am sorry to have posted this in your comments section.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

%d bloggers like this: