Archive for the ‘Doctors Behaving Badly’ Category

DATA 2000: I’m Not Bitter!

Denial

Recently discussion of expansion of the one hundred patient limit has been in the news. I lost interest in this topic several years ago, when I saw DATA 2000 standards being violated with impunity in my community. Given lack of adherence to DATA 2000 requirements, people who want buprenorphine have no problem getting it.

Is this good or bad? Maybe a bit of both.

At least three physician extenders in my area prescribe buprenorphine for patients with addiction on a regular basis, despite having no “X” number. I don’t know how this happens, but I do know the North Carolina Medical Board investigated this practice, took no action, and these same extenders, still with no “X” number, continue to prescribe buprenorphine for addiction.

Since present DATA 2000 regulations are being ignored, changes in those regulations are moot in my state, or at least in my area.

Do I sound bitter? Yes, I am, or at least I am intermittently. On most days, I’ve got my own patient challenges to deal with, so I don’t have time to worry about other doctors’ practices. But occasionally I do feel some resentment. It’s hard not to fret when other practices get away with things, while I follow regulations.

I also grumble when I’ve got to pick up the pieces for patients expelled from other buprenorphine practices for doing exactly what people with addiction do – take drugs.

I’ve had multiple patients seek admission to our opioid treatment program after they were “fired’ by these other practices. Now, I know I’ll do a better job than they ever did, but it’s a real pain in the ass to try to find out exactly what went wrong. I’ve been hesitant to believe patients’ versions, since they sound incredible, but so far, my patients have told the absolute truth.

Recently I admitted several patients after they were dismissed from the other practice for misuse of their opioids. These patients had been prescribed buprenorphine by the physician extenders, and were apparently doing well. Then on one visit, the nurse practitioner or physician assistant asked the patient about pain, and after being told some pain did remain, these patients were taken off buprenorphine and prescribed powerful opioids instead.

Even the patients thought this action was odd. These patients said they knew they would relapse, but due to their disease of addiction, were unable to refuse this jackpot of opioids when offered.

Events unfolded in a predictable manner. The patients went back into active addiction, and injected the oxymorphone they were prescribed. They ran out early, and when a pill count was demanded, they of course failed. Dismissed for being a bad patient, the confused patients came to the opioid treatment program where I’m left to try to figure out what the hell has gone on.

Thankfully, the people I’ve seen survived their relapses, and were able to re-stabilize on either buprenorphine or methadone. But I wonder how many other people have had worse outcomes.

Perhaps if buprenorphine prescribers had better education about addiction, such relapses could be avoided. That’s one big downside of ignoring DATA 2000 requirements.

Doctors with Addiction

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Physicians and other medical professionals have higher rates of addiction than the general population, but they respond better to addiction treatment. That’s the conclusion of Dr. Daniel Angres, seen on the front page of the most current issue of Internal Medicine News, Vol. 49, No. 3, February 15, 2016.

I get a copy of the Internal Medicine News every few weeks, and I always skim the articles. This week, front page coverage about addiction in physicians caught my eye.

This Dr. Angres said physicians who are appropriately treated for addiction have a five-year sobriety rate of around 80%. This is, of course, much higher than seen in non-physicians.

This news isn’t that new. Similar data has been described in early studies. [1-6]

I read this present article with interest, wondering if I would see new data, but the article appears to be a summary from a doctor with decades of experience treating physicians.

Studies of data collected on physicians with addiction show they’re more likely to misuse alcohol than any other drugs, but opioids are a close second, and then sedatives. Physicians are less likely than the general population to use street drugs. Presumably this is because they have access to prescription medication and are less likely to seek drugs from the street.

Long work hours, high stress, and poor self-care are thought to fuel much of physician drug use, but this idea is based more in theory than fact. As with the general population, mental health disorders are more frequent in physicians with addiction than in non-addicted physicians. Interestingly, one study showed that tobacco use, more than any other data collected from addicted physicians, was most strongly correlated with the presence of addictive disease. [8]

In one large study of physicians diagnosed with addictive disease who were under contract with the North Carolina Physicians Health Program, 85% of the physicians were male, and the average age at diagnosis was 44years old. Around two-thirds were married. Over half were mandated to undergo treatment by an agency such as hospital, medical board, malpractice insurer, or other less formal requests from spouses and practice partners.

Combining all available studies of addicted doctors, it appears psychiatrists and anesthesiologists were over-represented, meaning there were proportionately more of these specialists than one would expect from the number of these specialists. Both pathologists and pediatricians were under-represented.

Female physicians, same as females in the general population, have a telescoping of addictive disease. They tend to develop more severe addiction earlier than males. By the time female doctors enter treatment, they tend to have more severe addiction. They are also more likely to misuse sedatives than male doctors. and are more likely to have mood disorders with suicidal ideations. Female physicians tend to have harsher sanctions from medical boards than their male counterparts. [4]

Most states have physician health programs (PHPs), which are kind of like employee assistance for doctors, only with much more power. States have their PHPs set up in different ways, but usually the PHPs are separate from the medical boards. PHPs are set up to evaluate physicians for the presence of addictive disease, refer for appropriate treatment, and monitor recovery for a period of years. They are set up to be non-punitive, but if physicians relapse or don’t follow PHP recommendations, those doctors usually get reported to medical boards, where sanctions including loss of medical license are imposed.

PHPs may not do physician evaluations, but instead refer afflicted doctors to a treatment center for this evaluation. Many times, physicians are sent to specialty treatment programs who say they have special programs for physicians. Physicians tend to spend much longer in treatment than other people with the same addictive illness. It’s not at all unusual for a physician to be recommended to undergo inpatient treatment for three to six months.

PHP monitoring contracts usually extend for five years. This monitoring usually includes frequent random urine drug screens, aftercare treatment, and participation at 12-step meetings. In North Carolina, physicians are commanded to attend at least three 12-step meetings per week for their five- year monitoring contract.

On the other hand, PHPs frequently serve as advocates for physicians doing well in recovery. They can help these doctors with their malpractice insurers, hospitals, and other insurance companies.

While PHPs exist to help addicted physicians get the help they need, medical boards exist to protect the public from impaired physicians. Medical board actions are public records, which means safety-sensitive workers like doctors and nurses are not necessarily protected by the same privacy laws as other citizens.

As the article by Dr. Angres states, physicians have excellent recovery rates compared to other groups of people recovering from addiction. Doctors with addiction who get involved with a PHP have abstinence rates of 80% at five years.

We know there are some factors that predict a poorer outcome: injection of opioids as main drug of use, co-occurring psychiatric diagnoses, and continued use of nicotine. [7]

Lower rates of relapse in these recovering physicians are seen with lack of psychiatric co-occurring illness, longer time spent in professional treatment, participation in 12-step recovery, smoking cessation, and longer monitoring contracts (five years as opposed to three years). [7]

The article by Agres does mention the use of one medication to treat opioid-addicted physicians: naltrexone, which is an opioid blocker. This long article did not contain any mention of buprenorphine or methadone, except this vague sentence: “…medication-assisted treatment may be necessary for heroin addiction.”

I know most PHPs and medical boards won’t permit a doctor on methadone or buprenorphine to practice medicine, but it is very difficult to get these agencies to go on record one way or the other with their official position.

North Carolina’s Board of Nursing is a refreshing exception. The NC BON decided several years ago to allow nurses on buprenorphine and methadone to be licensed to work, though they do require significant input and advocacy from each recovering nurse’s treating physician. I recall they had decided to collect data from opioid-addicted nurses and compare outcomes of nurses in abstinence-only programs with nurses treated with buprenorphine and methadone. I don’t know if that study is ongoing, but it could contain some intriguing data.

Most medical boards and PHPs take the position that MAT impairs licensed professionals, but there’s scant data to support such a statement. In fact, available studies show pretty much the opposite. Some addiction medicine specialists – like me – feel denying evidence-based, potentially life-saving treatments to patients who work in safety-sensitive jobs is unethical, without established evidence showing harm from these treatments.

But then PHPs counter by saying that with success rates of 80% at five years, why consider MAT with methadone or buprenorphine, since it’s obviously not needed. Furthermore, many addiction treatment specialists say that if the treatment available to doctors were available to every opioid addict, MAT would be needed in relatively few people.

That may be true. None of the opioid-addicted patients I see can access three months of quality inpatient treatment, followed by aftercare for one year, and five years of monitoring with serious consequences for relapse. Even the ones with insurance may be able to go to inpatient treatment for several weeks, even one month if they are lucky. Maybe if all people could get the gold standard of opioid addiction treatment, we wouldn’t need to use MAT as much. I still believe some patients would require MAT. But right now, that’s not a realistic option for any of my patients.

I see both sides of the issue. And I also wonder what has happened to the 20% of medical professionals who had the gold-standard of treatment, and still relapsed. Did anyone talk to them about methadone and buprenorphine, if their main drug was opioids? Given the strongly 12-step oriented mindset of many PHPs, I suspect they weren’t told about this option.

  1. Dupont et al, “Setting the standard for recovery: Physicians’ Health Programs,” Journal of Substance Abuse Treatment, 2009, Vol. 36(2)159-171.
  2. Ganley et al, “Outcome Study of Substance Impaired Physicians and Physician Assistants Under Contract with North Carolina Physicians Health Program for the Period 1995-2000,” Journal of Addictive Diseases, Vol. 24(1) 2005, pp1-12.
  3. Paul Earley MD, FASAM, “Physician Health Programs and Addiction among Physicians,” Principles of Addiction Medicine, Fifth edition, 2014, WoltersKluwer pp602-621.
  1. Penelope Zeigler: PCSS-O – archived webinar 5/15: “Treating Substance Use Disorders in Health Professionals”
  2. Berge, K. H., Seppala, M. D., & Schipper, A. M. (2009). Chemical Dependency and the Physician. Mayo Clinic Proceedings, 84(7), 625–631.6.
  3. Boyd et al, “Ethical and managerial Considerations Regarding State Physician Health Programs,” Journal of Addiction Medicine, 2012, Vol. 6(4)243-2468.
  4. Stuyt et al, “Tobacco Use by Physicians in a Physician Health Program, Implications for Treatment and Monitoring,” American Journal on Addictions, 2009; Vol 18(2)103-108.

 

 

After the Overdose

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I just read an astounding and completely believable study in a recent issue of the Annals of Internal Medicine. [1]

This study, done by Dr. Larochelle and associates at Boston University Medical Center, did a retrospective study of prescription opioid overdoses. They looked at patients who were being prescribed opioids long-term for non-cancer pain who had a non-fatal overdose. The study lasted from May 2000 until December 2012, and included over twenty-eight hundred patients. All of these patients had commercial insurance, and were between 18 to 65 years old.

This study found that after having a non-fatal overdose, 91% of these patients resumed getting prescription opioids, and that 70% got them from the same doctor.

The lead author said he was shocked to find so many survivors continue to be prescribed opioids after having an overdose from these very opioids. He had hoped after a near-fatal experience, prescribers would do something different to address pain, in order to prevent future overdose.(https://hereandnow.wbur.org/2016/01/13/opioid-prescriptions-after-overdosing)

From other studies, we know that the best predictor of a future overdose is a past overdose, which is why I ask every patient entering the opioid treatment program (OTP) if he has ever had an overdose.

The author of this study postulated that with our fragmented healthcare system, the prescribers may not have known the patient had an overdose. Not knowing about any problems, the doctor continued to prescribe opioids.

I have no problem envisioning how this happens.

Not long ago, one of my opioid treatment program (OTP) patients missed two days of dosing. Per our protocol, her counselor called her on the first day she missed dosing. The patient told her counselor that she had been admitted to the hospital for trouble breathing, and was being treated for asthma.

Also per out protocol, we request hospital records for every patient of ours who gets admitted to the hospital, and our patient gave permission for this.

When I got the records four days later, imagine my surprise when I read that she had respiratory failure due to an overdose. Her drug screen at the hospital was positive for methadone and also benzodiazepines, and indeed she was now positive for benzos at the OTP too. This information lead to a drastic change in this patient’s treatment plan.

If we had not called to see where our patient was, she could have returned in several days and not told us about her hospital admission.

Our local hospital did not call our OTP to tell us our patient was hospitalized with an overdose. Indeed, they didn’t call to tell us she was in the hospital. To my patient’s credit, she did tell them she was a patient of ours, since it was recorded in her hospital record.

When our patients are admitted to the hospital for medical reasons, the admitting doctors continue to prescribe the usual dose of methadone, and I am happy about that, but they don’t call us to confirm the dose. They take the patient’s word for what the dose has been, instead of making a quick phone call. I worry that someday, one of our patients, in a misguided effort to feel an opioid effect, will tell his hospital doctor he’s been dosing at a higher dose than he actually is, and catastrophe could ensue.

In contrast, the big teaching hospital an hour away, which is where our patients go when they are really sick, routinely calls to confirm each patient’s dose.

The Larochelle study seems to indicate there’s a lack of communication in other medical communities as well. Emergency department physicians may administer Narcan and revive a patient, but no one thinks to take the next essential step: call that patient’s prescriber about the drug overdose.

We can’t assume the patient, now revived from a near-death experience, will tell her doctor about what happened. If that patient has an addiction, she might keep quiet about prescription mishaps, fearing her supply of opioids may be cut off.

Family members might tell the prescribers, and that’s very helpful, but often patients are told the doctor can’t release any information. That is true, but the family can certainly give information to the doctor.

I know hospitals and emergency departments are busy. Healthcare professionals are all busy. We are being asked to do more and more in less and less time. But this is a communication issue, and it need not be a physician- to- physician communication. A nurse or even a social worker from the hospital could call or fax valuable information quickly. Privacy laws can be blamed for some lack of communication, but there are exceptions in life-threatening situations.

And please, let’s make medical records readable. Even when I finally get local emergency department records about one of my patients, I have a hard time deciphering them. I’ll admit to being a bit of a Luddite when it comes to electronic medical records, but partly because most electronic records are not all that helpful.

For example, on our local emergency department records, I quickly can find the results for Ebola screening (it’s on the first page, at the top), but often I am left scratching my head about what the doctor’s final diagnosis and treatment plan was for the patient.

We’ve got to fix this communication problem. It’s great when an overdose is treated and prevented. But let’s do just a little more, and communicate to the prescriber of the overdose medications.

It is life and death.

  1. Ann Intern Med. 2016;164(1):1-9. doi:10.7326/M15-0038

Mandating Physician Education

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In May of this year, Massachusetts Senator Ed Markey proposed a new bill titled the Safe Prescribing of Controlled Substances Act. This Act, among other things, calls for mandatory education of the nation’s physicians about, as the name implies, safer prescribing of controlled substances. It also calls for mandatory education about identifying patients with substance use disorders.

Physicians get very little education about this tremendously important problem. Some medical schools and residencies have added addiction trainings, but change happens slowly. Plenty of doctors in the U.S. are still mis-prescibing

Physicians are not going to like this legislation. We hate being told we have to do anything, especially by politicians. But obviously, the present generation of physicians is NOT able to prescribe controlled substances properly, as evidenced by our epidemic of prescription drug addiction.

The bill extends to any prescriber of controlled substances, meaning that physician assistants and nurse practitioners will also be required to take this training, at least in states where they are allowed to prescribe controlled substances.

Senator Markey’s bill says the Department of Health and Human Services is responsible for producing this training and that it will be free and available online.

The bill specifies the training should include, “methods for diagnosing, treating, and
managing a substance use disorder, including the use of medications approved by the Food and Drug Administration and evidence-based non-pharmacological therapies.”

If everyone interprets this paragraph as I do, this would mean all doctors who want to prescribe controlled substances should be educated about medication-assisted treatments of opioid addiction, among other things.

That would be wonderful. How nice it would be for my patients to go to their other doctors, and hear, “So glad you are on methadone for the treatment of addiction. Good job.” instead of the usual insults about being on of MAT. How nice for me to be able to call other doctors who don’t think I’m a drug pusher for prescribing MAT!

Also, Senator Markey sent letters to the VA, Defense Department, and IHS, urging them to included prescribing information to their patients on their state’s prescription monitoring program. Many patients being cared for by these agencies are prescribed controlled substances, but doctors outside those systems have no way to know what is being prescribed. Presently, they don’t report to the prescription monitoring programs. I hope these military agencies chose to participate in the PMPs. It would be a way to keep those patients safer when they seek care outside the military system.

On May 15, 2015, the Huffington Post had an online article about another bill, the Recovery Enhancement for Addiction Treatment Act, also sponsored by Senator Markey and Senator Rand Paul. This legislation would lift the one-hundred patient limit placed on office-based buprenorphine doctors.

In the past, I supported lifting the one-hundred patient cap, but I’ve come to believe the cap isn’t all that relevant, at least in my area. Around here, I think the only physicians who honor the cap are conscientious doctors who would do a good job without legislation.

Around here, physicians have more than one hundred buprenorphine patients, and skirt the regulations by saying some of them are prescribed it “for pain.” Physician extenders without DEA “X” numbers already prescribe buprenorphine in this state. When the North Carolina medical board was notified about this, they declined to take any action.

In other words, the present regulations are flouted without consequence, so lifting them isn’t going to make a big difference. (That may not be the case in all areas of the country.) But mandating education about addiction and its treatment may help treatment providers deliver better care.

The Benzo Conversation

Glass head full of pills

Not all of my patient interactions are easy. One of my colleagues, after reading my blog, remarked, “It sounds like you have really easy patients.” While that’s true for the most part, of course there are more difficult patients, as in any practice. Some patients, eager to get into treatment to stop opioid addiction, may not be at all ready to stop other drugs of addiction. That’s not a deal-breaker for me, unless those drugs could be fatal when mixed with methadone or buprenorphine. This means the use of alcohol, benzodiazepines, and sedatives of other kinds must be discussed in detail.

I’ve noticed a conversational merry-go-round that I call “the benzo conversation.” I’ve had versions of this conversation more times than I can remember.

This conversation occurs during my initial assessment of a new patient presenting for medication-assisted treatment. I always look on my state’s prescription monitoring program for each new patient on the day of admission. If they have prescriptions for benzodiazepines (like Xanax, Valium, or clonazepam), or other sedatives (Soma, Ambien, etc.) I need information about the pattern of use. Is my patient taking his prescribed daily dose? Is he then physically dependent on benzodiazepines? Is he selling them? Is he giving part of the prescription away, and taking the rest? Does he binge on benzos for the first few weeks of the month, and then run out for several weeks? Or is he bartering the benzos for opioids, and not taking any of them, despite filling a large prescription each month?

I really don’t care if the patient is breaking the law or not; I just want to get the complete picture of my patient’s health status.

Following is a typical conversation with a new patient whom I will call “Bob.”

Bob sought admission to our methadone maintenance treatment program for his opioid addiction. He had snorted pain pills for six years, and wanted help. He had little if any denial about his opioid addiction. He denied taking any prescription medications, saying he got all his opioids off the street, used no other drugs or medications, and had no other medical problems.

However, when I checked his name on my state’s controlled prescription monitoring program, he was filling a prescription for Xanax 2mg, ninety per month, from a local Dr. Feelgood. This prescription had been filled every month for the last four years. My patient’s admission urine drug screen also tested positive for benzodiazepines.

As part of my initial history and physical, I asked him about the Xanax prescription. I explained to Bob that benzos have the potential to cause a fatal overdose when mixed with opioids. I told him that benzos are especially risky with methadone, and I was concerned about his use of them.

Bob said, “Oh, I don’t use benzos now. I haven’t used Xanax for years.
“But you’ve been prescribed it every month and picked up the last prescription of ninety pills just two weeks ago.”
“Yes, but I don’t take them. I quit them long ago.”
“And you do have benzos in the urine sample you gave us.”
“Well, that’s probably from a little piece of Valium I used four days ago.”
“Ummm…, Valium’s also a benzo, in the same family as Xanax, so when you say you’ve stopped, that doesn’t make sense to me.…”
“As I told you, I don’t take benzos anymore.”
“But four days ago is pretty recent.”
“No,” he said, getting a little worked up. “As I’ve already told you, I stopped benzos years ago!”
“So what do you do with the Xanax pills you pick up at the pharmacy every month?”
“I don’t know. They’re in the house somewhere. But I don’t take them.”
“So you have…how many bottles do you have at home?”
“Bunches, I don’t know.”
I could tell I was annoying him, but this as an important clinical issue, so I pushed on.
“Would you be willing to bring all those bottles in tomorrow so the nurse can watch you dispose of them?”
He sighed deeply, annoyed by my questions. “Yes. I suppose I can. Now can I get my dose?”
“No, I’ll leave an order for you to be able to start tomorrow after you bring in the medication to dispose, since you tell me you haven’t taken them. I worry about a fatal overdose if methadone were combined with all that Xanax you have at home.”
Now he was mad. “I don’t have any Xanax at home! I’m not going to overdose! I know what I’m doing.”
“Will you give me permission to call the doctor prescribing the Xanax, so we can talk about your entry into treatment here? Maybe your doctor would be willing to taper your dose so that we can make it safer for you to be in treatment with us.”
“No! I don’t want everybody to know my business. My doctor is friends with my ex-wife and if she finds out I’m being treated for addiction, she’ll cause trouble. He can’t find out.”
“I’m sorry, but that’s a deal-breaker for me. I’m not going to prescribe methadone for you unless I can talk to your other doctor. It’s just too risky. All of your doctors need to know all medications that you’re on.”
“So you’re telling me to go back out there and use drugs? That I can’t get help unless my ex-wife finds out I’m an addict?” The veins in his neck were standing out.
“No. I’m not telling you to use drugs. I’m telling you…
“I want my money back, since I’m gonna have to go buy dope again ‘cause you won’t help me. It’s just not right. I came here to get help.” He stalked off toward the receptionist, where I heard him demanding his money back, despite the hour he spent with a counselor and the time spent with me in an evaluation. (For some reason, patients who don’t get admitted to the program don’t feel they should have to pay for their evaluation)

This was a difficult, tense conversation, and one I’ve had too many times to count. This patient wasn’t a bad guy, but he was not ready to address his benzodiazepine use. The outcome wasn’t what I’d hoped, and this patient didn’t come into treatment.

There’s no way I could know what this patient was doing with his benzodiazepine prescription. I couldn’t tell if this patient was telling the truth, in denial, or lying. Without being able to talk to his prescribing doctor, I wasn’t willing to start medication-assisted treatment. This didn’t mean he didn’t need treatment, only that perhaps a different form of treatment will be safer for him. I wish I could have given him information about other treatments, but he left too quickly and too angrily.

Sometimes patients tell me I’m violating their privacy by looking at their information on the prescription monitoring database. I tell them I don’t see it that was at all, since they are asking me to prescribe a medication that could have a fatal interaction with other medications. Not only is it my business, it’s my responsibility.

Some doctors would fault me for not admitting this patient despite his refusal to allow me to talk to his prescribing doctor, given the increased risk of death for patients in active opioid addiction who are not in any treatment. But I would feel terrible if I’d admitted this patient and he died during the first few weeks of a methadone/benzodiazepine overdose. Either way, there’s a lot at stake, and I feel stress about these decisions.

The Billionaire Pill

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In a recent Forbes magazine article about this nation’s twenty richest families, the Sackler family was number sixteen on the list. The Sacklers are estimated to be richer than the Mellons, Rockefellers, and Busches. (http://www.forbes.com/sites/alexmorrell/2015/07/01/the-oxycontin-clan-the-14-billion-newcomer-to-forbes-2015-list-of-richest-u-s-families/

You say you don’t know the Sackler family? I’ll remind you. They own one-hundred percent of Purdue Pharma, a pharmaceutical company best known for manufacturing their block-buster drug OxyContin.

This is a bitter pill for me to swallow.

I started working in the field of opioid addiction treatment in 2001. At that time, nearly every opioid addict I saw was using OxyContin as their main drug. Opioid addiction in general and OxyContin addition in particular plagued many small towns and rural areas where I worked.

OxyContin was widely prescribed for pain. This powerful drug was advertised as “The one to start with and the one to stay with,” during sales pitches to rural physicians. OxyContin flooded the black market. Opioid addict quickly discovered OxyContin’s time-release coating could be easily defeated, and the pill was often snorted or injected for the rush of opioid euphoria it produced.

I was certainly not the only doctor to notice the rise of OxyContin addiction.

Barry Meier’s book Pain Killer: A “Wonder” Drug’s Trail of Addiction and Death (Rodale Books, 2003), tells the story of small town doctors trying to get the attention of Purdue Pharma, the government, or anybody else who could help change the destruction OxyContin was doing to Appalachia around that time.

I remember attending a pain and addiction conference around sometime around 2003 or 2004. At the end of the lecture explaining how opioids could be prescribe safely, a doctor from Virginia dared to ask the experts something along the lines of, “What are we going to do about OxyContin?” I thought to myself that I was glad someone had finally said what I was thinking.
This was a long time ago; I don’t remember exact words, but my memory is that he was soundly rebuffed for daring to mention one specific drug by name. He was scolded and told that the real problem was with opioids in general, and one drug company (who happened to have some of the lecturers on their payroll) should not be singled out as the problem.

I remembered wishing those experts could spend a day at my treatment program talking to the OxyContin addicts.

Eventually, the U.S. General Accounting Office asked for a report about the promotion of OxyContin by Purdue Pharma. By 2002, prescriptions written for non-cancer pain accounted for 85% of the OxyContin sold, despite a lack of data regarding the safety of this practice. By 2003, primary care doctors, with little or no training in the treatment of chronic non-cancer pain, prescribed about half of all OxyContin prescriptions written in this country. By 2003, the FDA cited Purdue Pharma twice for using misleading information in its promotional advertisements to doctors. [1, 2] Purdue Pharma also trained its sales representatives to make deceptive statements during OxyContin’s marketing to doctors. [3]

Testifying before Congress in 2002, a Purdue Pharma representative said the company was working of re-formulating OxyContin, to make it harder to use intravenously. This representative claimed it would take several years to achieve this re-formulation. The re-formulated OxyContin was finally approved by the FDA in 2010, eight years later. Currently, this medication forms a viscous hydrogel if someone attempts to inject or snort the medication. It isn’t abuse-proof; probably no opioid will ever be so, but it is much more abuse-deterrent than the original.

Did Purdue Pharma drag their feet in this re-formulation? Experts like Paul Caplan, executive director for risk management for the drug company, said there were issues about the safety of incorporating naloxone into the pill to make it less desirable to intravenous addicts. He also pointed out that some delay in approval was due to the FDA.

For comparison, Sterling Pharmaceutical, when it became widely known patients were abusing their pain medication Talwin, re-formulated within a year, adding naloxone to the medication and reducing its desirability on the black market. Since this was in the 1980’s, I would assume there was less technology to help back then, compared to 2002.

I’ll let readers draw their own conclusions.

In May of 2007, three officers of Purdue Pharma pled guilty to misleading the public about the drug’s safety. Their chief executive officer, general counsel, and chief scientific officer pled guilty as individuals to misbranding a pharmaceutical. They did no jail time but paid $34.5 million to the state of Virginia, where the lawsuit was brought.

The Purdue Pharma Company agreed to pay a fine of $600 million. Though this is one of the largest amounts paid by a drug company for illegal marketing, Purdue made 2.8 billion dollars in sales from the time of its release in 1996 until 2001.

None of the Sackler family members were charged, because they were not involved in the day to day running of the company.

And now the Sackler family is worth billions.

1. General Accounting Office OxyContin Abuse and Diversion
report GAO-04-110, 2003.
2. United States Senate. Congressional hearing of the Committee
on Health, Education, Labor, and Pensions, on Examining
the Effects of the Painkiller OxyContin, 107th Congress, Second
Session, February, 2002.
3. Washington Times, “Company Admits Painkiller Deceit,”
May 11, 2007, accessed online at http://washingtontimes.
com/news/2007/may/10/20070510-103237-4952r/prinnt/ on
12/18/2008.

Dr. Drew Snafu

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Oh, Dr. Drew. You disappoint me. Again.

Pontificating about the most recent episode of gun violence, Dr. Drew just spewed some gross inaccuracies about the medication buprenorphine.

After listening to his blather, I realized I was going to need to write him an angry letter. Again. I’ve written him twice in the past, back when he had “Celebrity Rehab” on television, but I’ve never received a response. But this time, instead of writing a letter and mailing it, I’m going to post it on my blog.

Dear Dr. Drew,
Just shut up. You make my ears bleed.

If you can’t add anything positive to a conversation, just don’t say anything, please. I shouldn’t have to tell you this nation is in the middle of an opioid addiction epidemic, and there you are on television, demonizing one of the medications proven to be life-saving for this condition.

In an interview about the Charleston, SC, church shooting, you say Suboxone has been linked to violence in its users, and people get “strung out” on it, making it impossible for them to have the personality changes necessary for recovery from addiction.

First of all, don’t use the term “Suboxone.” Please use the more generally accepted way of referring to a medication, by its generic name, since there are so many companies making both generics and name-brand preparations of this medication. That medication is buprenorphine.

Next, I challenge you to present one scrap of scientific evidence for what you said in that interview. What data can you show me indicating personality changes can’t be made while an opioid addict is being treated with buprenorphine?

Of course, it all depends on how you define personality change, but we know patients on buprenorphine are more likely to stop using illicit opioids, have improved physical and mental health, and more likely to become employed than opioid addicts who get non-medication-assisted treatments. They have better relationships with friends and family. These patients’ lives no longer revolve around getting and using opioids in order to get high.

Sure looks like recovery to me.

You criticize this medication because it is difficult to withdrawal from. True, some patients have an extraordinarily hard time tapering off of it, but that’s not a universal experience. I’ve had a few patients say they had no withdrawal at all. Most say they have a withdrawal, and generally it’s not as bad as withdrawal from full opioids.

Besides, I don’t start this medication with the intention of stopping it any time soon. We know the patients who are doing the best are the ones that stay on this medication indefinitely. That’s not a popular opinion, but it IS based in fact. It doesn’t help anyone to ignore what the evidence shows us, and replace knowledge with wishful thinking. Patients should plan to stay on medication-assisted treatments with buprenorphine and methadone indefinitely.

You say Suboxone has been known to cause violence. On what data do you base this? Stories on the internet? Maybe you’ve been in Hollywood so long that you’ve forgotten that stories on the internet aren’t considered medical research.

Just as a reminder, we doctors generally prefer to base our statements on scientific data. To my knowledge, not one of the dozens of studies done on buprenorphine patients over the past twenty to thirty years, both here and in Europe, found any increased tendency toward violence in patients taking the medication. So stop trying to pass off stories on the internet as real data.

Sadly, several news outlets took what you said in that interview and parroted your mistake. Now all sorts of news outlets are saying this drug makes you violent. You and I both know buprenorphine wasn’t the cause of this shooter’s dysfunction. It was highly unprofessional for you to imply that it was.

I understood from watching your unfortunate show “Celebrity Rehab,” which is now, mercifully, off the air, that you were not going to help the viewing public understand opioid addiction and its successful treatment, except to say the only acceptable recovery is drug-free recovery.

Look, I get where you are coming from. I come to this profession from a strongly 12-step, abstinence-only mindset. But time, experience, and medical literature have convinced me that abstinence-only treatment isn’t available or acceptable to many people with addiction. So let’s not deny life-saving treatments with buprenorphine and methadone to people who need them in order to recover. If an opioid addict can get off – and stay off – all opioids and have a contented, happy recovery, huzzah! That person is fortunate, and I’m happy for them that they don’t need medication. But do NOT criticize other patients who do need buprenorphine or methadone in order to live a normal life. Their recovery is just as real as the abstinence-only patients.

If anecdotal evidence is all you care to consider, I can introduce you to hundreds of patients, on methadone or buprenorphine, who are living happy, successful lives in recovery. You dishonor these patients and their journeys when you say they aren’t in real recovery.

But by now, with ever more data, and at a time when our citizens are dying from opioid overdoses in record numbers…if you can’t be helpful, please be quiet.

Sincerely,
Jana Burson M.D.

P.S. If you want to continue to promote yourself as some sort of recovery expert, please get some education. Go to some ASAM meetings, read a book like “Principles of Addiction Medicine,” or read some journals. You are embarrassing yourself, misleading your listeners, and ruining my life with your drivel. (OK, you aren’t ruining my life. But you are irritating me.)

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