Happy Anniversary to Me







This blog entry is about random thoughts careening through my brain today.

Last week marked the eight-year anniversary of this blog. I started it in 2010, to promote a book I had written. The book did OK, but it’s out of date now. Things happen rapidly in the field of opioid use disorder treatment.

My blog has turned into a bigger thing than I ever planned. I enjoyed writing it more than I thought I would, and people were more receptive to the type of information I presented than I imagined they would be. People tell me my blog filled a void by providing information about medication-assisted treatment of opioid use disorder.

I’m glad. This makes me happy.

While there are other blogs about Suboxone, most are oriented towards patient problems and questions. I hope my blog entries help patients and their families gather more information, but I also want to edify treatment professionals, including other physicians, nurses, therapists, and counselors. To be able to do this, I must keep reading the latest information and going to conferences in the field of Addiction Medicine. Since this field is my passion, that’s been no sacrifice to make; plus, it keeps me up to date for my own patients.

But the writing can be vexing. Sometimes writing flows like lava down the side of a volcano, but sometimes I write a sentence three times before I’m happy with it. This has improved with more consistent writing, but there are days that I still sumo-wrestle with sentences.

Terms we use in this field have changed over eight years. If I want to re-blog something from more than six years ago, I need to read it carefully before posting again. I’ve missed a few “opioid addiction” phrases and readers have pointed out my error with some enthusiasm. Fair enough. Language is important. The proper term now is “opioid use disorder,” and patients are not “addicts.” They are people with opioid use disorder.

Some blog entries are informational and don’t change, so I recycle them: how to treat insomnia without medications, how clonidine works, and the like. Other blog entries are out of date within in year, like statistics on opioid use disorders and overdose deaths, and state laws around opioid and buprenorphine prescribing.

Buprenorphine’s reputation has changed. In 2010, many fewer people knew what this drug was. Now we have internet memes about Suboxone, and plenty of websites with data and opinion. We’ve had some excellent news pieces about the medication buprenorphine, and some websites set up only to tell the world how awful buprenorphine is. Everyone has an opinion, it seems.

Diversion of buprenorphine products has become a frequent topic, fueled by the perception that much of this medication is making its way to the black market.

My own opinion about medications for opioid use disorder and how treatment should be organized have changed. I’ve become more avid about harm reduction, but more conservative about where patients start treatment. I’ve also come to believe most new patients with opioid use disorders should be started on medication at opioid treatment programs, then referred to office-based programs once they stabilize, like the Vermont hub-and-spoke model. I realize those two views aren’t consistent.

We have too many lawmakers trying to legislate the care provided at treatment programs, but I understand why they feel it’s necessary. Some treatment programs cry “harm reduction” as an excuse for sloppy patient care while making large profits. Medicine in the U.S. is a for-profit enterprise, and no doctor should be blamed for making a profit; however, there’s profit and then there’s obscene profit.

I’ve met some of the best, brightest, and most dedicated people in the world in this field of medicine. I’ve also met some real con artists and shady characters in this field, working only for personal prestige and money. It seems to draw people from both extremes, and I try to maximize my contact with the former and minimize my contact with the latter.

I’ve developed a thicker skin writing the blog. I don’t post the worst of the comments, like the woman who commented that I would burn in hell for prescribing medication for opioid use disorder. She’s entitled to her opinion, but it’s my blog and I don’t have to air her view, particularly since it seemed spew-y and irrational.

I don’t post comments insulting to people with opioid use disorder, unless it’s to educate readers about how much misinformation still exists in the world.

Patients sometimes write negative comments about their care providers, and I usually encourage them to talk to their physician. If they don’t get satisfaction with that, I tell them to vote with their feet and go elsewhere. The trouble is, there may be only one provider in their area. What does the patient do then?

We do need more primary care physicians prescribing buprenorphine, but they must be respectful of the patients they treat. If as a physician you can’t understand that some behavioral issues are associated with opioid use disorders, you shouldn’t be working in the field.

The nation must educate physicians in all fields about medication-assisted treatment for opioid use disorder. Treatment for opioid use disorder has for too long been in its own silo, far away from mainstream medicine. Most physicians don’t know anything about MAT, except that they are opposed to it. These physicians MUST be educated. Our patients must be able to get good medical care without judgment.

Negative comments from other physicians about MAT undermine our patient’s progress and their self-esteem. It also prevents my patients from getting good medical care from primary care providers, surgeons, and especially emergency department physicians.

Physicians must start referring people with the illness of substance use disorder for treatment, rather than telling these patients they are bad people because they haven’t stopped yet. They must be taught to give my patients the same understanding and forbearance as patients with other chronic medical illnesses with behavioral components.

I’m happy with all the attention that new outlets have been paying to opioid use disorder and its treatment over the past several years. I also wish this attention could have been started around fifteen years ago, before thousands died from this problem.

11 responses to this post.

  1. Posted by Scott on April 23, 2018 at 1:58 am

    I appreciate the blog. Whilst my Doctor is great and spends all the time necessary with me, it is good to hear about the treatment process “from the other side” from a Doctor not involved in my treatment.

    The way things are done in the USA are different to here (Australia), but the general motivations and thoughts of medical providers are quite similar (I think).

    One comment about then above. Yes, medicine is for profit in the USA, and I agree with your point about obscene profits.

    What I think would be a good addition to that is that obviously there are ways to make ridiculous amounts of money treating addiction, but it shouldn’t come at the expense of the patients well-being and/or treatment. These patients are some of the most vulnerable members of society.

    The patient should come first, and if by treating the business this way it is not profitable, then it’s not viable and they should look into some other area of practice.

    Or maybe I’m too biased due to “socialism”.


  2. Posted by Mark Essex on April 23, 2018 at 10:19 am

    Congrats on the 8-year anniversary. Keep up the good work!


  3. Posted by Brooke Stanley on April 23, 2018 at 5:53 pm

    Happy Anniversary! I loved your book and I love the blog. Thank you for being a fierce advocate for MAT. I am so thankful for you!


  4. Posted by Trudy Duffy on April 24, 2018 at 5:56 pm

    I always look forward to reading your blog. Congratulations on your anniversary.


  5. Posted by Sparky on April 29, 2018 at 3:05 am

    congratulations on 8yrs,here’s to 8 mores day hopefully a lot of lives will be saved


  6. Posted by Eric M on April 30, 2018 at 3:47 am

    I’ve read your blog now for about a month. In my opinion it’s one of the best out there about addiction (I agree that language is important – I also think using established language has value and changing the name every time a word gets stigmatized doesn’t solve anything).

    I had about a two year period of time with heroin, under unusual circumstances (I intentionally started using it to solve a specific problem, but took me longer than planned to stop using). I spent a week in hospitalized detox to transition to Suboxone after being unsuccessful transitioning to it as an outpatient three times (each time I waited well into COWS scoring but when I took it, my withdrawal stopped except I couldn’t stop vomiting for days until I resumed heroin – I’m guessing I should have waited longer, but it was confusing that the rest of symptoms disappeared and that vomiting lasted more than 36 hours), then tapered off in about three weeks from date of last use.

    Then I spent several weeks in a rehab program for good measure, one that happened to have a lot of physicians as patients. At least one who I got to know decided to get his bup license after talking to me about my experience – just trying to do my part.

    Anyway, thank you for this blog and keep up the good work.


  7. Posted by candoitbetter23 on May 4, 2018 at 6:53 pm

    Your viewpoints are very progressive
    Staying up to date on medicine
    Treating patients like people and caring about their life
    The world needs more MAT doctors like you


  8. Posted by nspunx4 on May 11, 2018 at 3:12 pm

    We may not always agree on every topic but you are an excellent physician and you are a role model of what every physician working in MAT should aspire to.

    Your BLOG is compelling and educational. Thank you for putting so much time and effort into it. I look forward to reading the next eight years worth of great BLOG entries!


  9. Posted by A Odom on May 26, 2018 at 7:45 am

    Congratulations! I truly appreciate your work!


  10. Posted by Lisa Brawley on June 7, 2018 at 4:58 pm

    Congratulations, and thank you. I have been treating patients with buprenorphine for 15 years now, and your blog is so encouraging. I have often felt like a voice in the wilderness, and sometimes like a fool for working so hard to advocate for patients with (at times) so little personal and financial reward.


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