Archive for the ‘Doctors Behaving Badly’ Category

Starting Buprenorphine in the Emergency Department

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An interesting study in the April 28th Journal of the American Medical Association (JAMA) looked at three types of intervention for opioid addiction in patients presenting to the Emergency Department for care. It found that patients were more likely to be in addiction treatment and free from illicit opioids when started on buprenorphine in the emergency department, and given a referral to buprenorphine prescriber.

This study, done at an urban teaching hospital in Connecticut, screened patients in their emergency department and uncovered 329 patients with opioid addiction. Some came for help for the opioid addiction (34%) but the others came to the ER for other medical problems.

These patients were randomized to three interventions: one group was given written information about addiction treatment programs in the area. The second group was given this information, plus a brief intervention describing the various ways to treat opioid addiction. Patients in this group were linked with the referral and transportation to addiction treatment was arranged.

The third group had the same intervention as the second group, plus they were prescribed three days of buprenorphine, dosed at 8mg on day 1, and 16mg on days 2 and 3. Patients in this group were provided free office- based buprenorphine treatment for ten weeks, with visits ranging from several times per week to every two weeks, depending on how the patient was doing.

The study’s primary outcome was to compare how many patients in each of the three intervention groups were engaged in addiction treatment thirty days after their emergency department visit.

The results were what you would expect. People in the group that started actual treatment in the emergency department with buprenorphine were significantly more likely to be in addiction treatment thirty days later. In this group, 78% were in treatment. In the group given only treatment referrals, 37% were in treatment at 30 days, and 45% of the people given referral and brief intervention were engaged in treatment at 30 days.

Also, patients in the buprenorphine group reported greater reductions in the number of days of illicit opioid use than did the referral and brief intervention groups. The groups showed no significant difference in behaviors that increase risk for contracting HIV.

These patients were fairly ill, with high rates of co-occurring mental health disorders, with more than half reporting prior psychiatric diagnoses. About a fourth of these patients required acute care for a medical problem other than opioid addiction at their emergency department visit. These patients also had the expected high rates of concurrent other drug and alcohol use. In other words, these patients were about as ill as the average patient with opioid addiction.

However, this study didn’t include patients who were so sick that they required hospitalization, which may have skewed the data somewhat. Because services were free, this likely enhanced retention in treatment, though the authors say that 80% of all patients in the study were insured.
That’s an unusually high percentage, as compared with what I see in my rural area, in a state which did not expand Medicaid access.

The bottom line is that medication-assisted treatment with buprenorphine appears to be an effective way to get opioid-addicted patients into treatment and reduce illicit drug use in these patients. That would seem common sense, but we now have a study to support that assumption.

I love the idea of treatment being started in the emergency department, with close follow-up in an office setting or opioid treatment program. As the authors of this study pointed out, starting treatment for opioid addiction in the emergency department is very similar to how other chronic diseases are treated. For example, patients with new-onset diabetes or high blood pressure are often started on medication to treat the disorder in the emergency department, with a close follow up recommended with a primary care doctor.

Why do we treat the disease of addiction any differently?

My readers know the answer, of course: stigma and lack of education and understanding on the part of health care professionals.

As the authors pointed out in the discussion section of the study, even the referral group got more intervention than the average opioid addict visiting an emergency department in this country.

My patients still report being treated with derision and rudeness by emergency department staff. Not only are their medical problems including addiction not being addressed, they are shamed for being addicted. They are given powerful verbal and non-verbal messages that they are bad people, a pain in the ass to deal with, and unwelcome in the healthcare facility.

You could not invent a better recipe for continued drug addiction and avoidance of future medical care.

This study shows how easily this could be fixed. I would require emergency department doctors to get DATA 2000 certified, and the education of other healthcare professionals too. I don’t know how to initiate this solution but it can’t be done quickly enough.

I’ll say it again: we will know we are treating addiction well when it’s no longer easier to get drugs than treatment.

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

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.

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.

More about Prescription Monitoring Programs

In October, Florida’s prescription monitoring program finally became functional. This means doctors in Florida (finally) can go to this database to see if their patients are being prescribed controlled substances by other doctors. The program isn’t mandatory. Physicians don’t have to use the system if they don’t want to do so. But in my opinion, if a doctor is prescribing controlled substances to a patient, particularly in Florida, it would be sloppy medical practice NOT to use this program. Doctors who are truly interested in indentifying doctor-shopping drug seekers will use this database.

Florida’s prescription monitoring program has been a long time coming. If you read this blog frequently, you’ll remember I was highly critical of Florida’s Governor Scott’s initial reluctance to allow a prescription drug monitoring program. His reluctance mystified me, given the tremendous numbers of pain pills being prescribed and dispensed in Florida. The pain pills prescribed and dispensed by Florida’s pill mills didn’t stay in Florida. They were exported north to states like Kentucky, Tennessee, North Carolina, and Georgia. This occurred so commonly that it became known as the “Flamingo Express.”

At present, only a few states are still dragging their feet about getting an operational program. As of now, only Missouri and the District of Columbia don’t have prescription monitoring programs, and have no plans to start one. (It seems odd that D.C., where lawmakers started the push for prescription monitoring programs, doesn’t already have a functioning program.)

In recent news reports, Florida’s Governor Scott said he felt the new laws that prevent physicians from both prescribing and dispensing pain pills are an important part of reducing Florida’s pain pill problem. Prior to these new laws, physicians were able to both prescribe and dispense opioid pain pills. This created a financial incentive for unprincipled doctors to prescribe opioids, since they then sold these opioids to their patient for more than the average pharmacy price. This practice was common in Florida’s pill mills. In 2010, Florida physicians bought 89% of all the oxycodone sold to U.S. medical practitioners.

In these recent news reports, around 80 doctors have had their licenses suspended due to their prescribing habits. These doctors often prescribed large amounts of opioids without demonstrating a clear need and without taking precautions to assure the “patients” they saw weren’t abusing the drugs.

 I believe this has already led to a relative scarcity of pain pills available on the black market in our state of North Carolina, and a subsequent increase in price. For the last month, the opioid treatment program where I work has seen a sharp increase in the numbers of addicts entering treatment. These patients say the same thing when I ask why they decided to seek help now: they’re spending too much money on pills, to the point of financial ruin, and pills are more difficult to find. One addict said, “I can’t find pills like I could. And when I do, I can’t afford them anyway.” Recently, addicts report spending more per milligram for illicit prescription opioids like oxycodone, morphine, and hydrocodone.

I don’t care whether it’s Florida’s new prescription monitoring program or their crackdown on unscrupulous doctors that’s causing fewer pills for sale on the black market in our area. I’m just thankful that it’s happening.

Readers of this blog, do any of you have opinions as to the availablility of black market prescription opioid drugs now, compared to several months ago?

Doctors Are Poorly Trained About Addiction and Recovery

Addiction? What addiction?

Most medical schools and residency programs place little emphasis on educating future physicians about addiction. A survey conducted by the Center on Addiction and Substance Abuse at Columbia University (CASA) revealed that physicians are poorly trained to recognize and treat addictive disorders. (1)

CASA surveyed nine-hundred and seventy-nine U.S. physicians, from all age groups, practice settings, and specialties. Only nineteen percent of these physicians said they had been trained in medical school to identify diversion of prescribed drugs. Diversion means that the drug was not taken by the patient for whom it was prescribed. Almost forty percent had been trained to identify prescription drug abuse or addiction, but of those, most received only a few hours of training during four years of medical school. More shocking, only fifty-five percent of the surveyed doctors said they were taught how to prescribe controlled drugs. Of those, most had less than a few hours of training. This survey indicates that medical schools need to critically evaluate their teaching priorities.  

Distressingly, my own experience mirrors this study’s findings. My medical school, Ohio State University, did a better job than most. We had a classroom section about alcoholism, and were asked to go to an Alcoholics Anonymous meeting, to become familiar with how meetings work. But I don’t remember any instruction about how to prescribe controlled substances or how to identify drug diversion.

Is it possible that I’ve forgotten I had such a course? Well, yes. But if I can still remember the tediously boring Krebs cycle, then surely I would have remembered something juicier and more practical, like how to prescribe potentially addicting drugs. Similarly, less than half of the surveyed doctors recalled any training in medical school in the management of pain, and of those that did, most had less than a few hours of training.

Residency training programs did a little better. Of the surveyed doctors, thirty-nine percent received training on how to identify drug diversion, and sixty-one percent received training on identifying prescription drug addiction. Seventy percent of the doctors surveyed said they received instruction on how to prescribe controlled substances. (1)

This last finding is appalling, because it means that thirty percent of doctors received no training on how to prescribe controlled substances in their residency programs.  Could it be true that nearly a third of the doctors leaving residency – last stop for most doctors before being loosed upon the populace to practice medicine with little to no oversight – had no training on how to prescribe these potentially dangerous drugs? Sixty-two percent leaving residency had training on pain management. This means the remaining thirty-eight percent had no training on the treatment of pain.

Could it be that many of these physicians were in residencies or specialties that had no need to prescribe such drugs? No. The participating doctors were in family practice, internal medicine, OB/GYN, psychiatry, and orthopedic surgery. The study included physicians of all ages (fifty-three percent were under age fifty), all races (though a majority at seventy-five percent were white, three other races were represented), and all types of locations (thirty-seven percent urban, thirty percent suburban, with the remainder small towns or rural areas). This study reveals a hard truth: medical training programs in the U.S. are doing a poor job of teaching future doctors about two diseases that causes much disability and suffering: pain and addiction. (1)

 I remember how poorly we treated patients addicted to prescription medications when I was in my Internal Medicine residency program. By the time we identified a person as addicted to opioids or benzodiazepines, their disease was fairly well established. It didn’t take a genius to detect addiction. They were the patients with thick charts, in the emergency room frequently, loudly proclaiming their pain and demanding to be medicated. Overall, the residents were angry and disgusted with such people, and treated them with thinly veiled contempt. We regarded them more as criminals than patients. We mimicked the attitudes of our attending physicians. Sadly, I did no better than the rest of my group, and often made jokes at the expense of patients who were suffering in a way and to a degree I was unable to perceive. I had a tightly closed mind and made assumptions that these were bad people, wasting my time.

Heroin addicts were not well treated. I recall a discussion with our attending physician concerning an intravenous heroin user, re-admitted to the hospital. Six months earlier, he was hospitalized for treatment of endocarditis (infected heart valve). Ultimately his aortic heart valve was removed and replaced with a mechanical valve. He recovered and left the hospital, but returned several months later, with an infected mechanical valve, because he had continued to inject heroin. We discussed the ethics of refusing to replace the valve a second time, because we felt it was futile.

I didn’t know any better at the time. We could have started him on methadone in the hospital, stabilized his cravings, and then referred him to the methadone clinic when he left the hospital. Instead, I think we had a social worker ask him if he wanted to go away somewhere for treatment, he said no, and that was the end of that. Small wonder he continued to use heroin.

At a minimum, the attending physician should have known that addiction is a disease, not a moral failing, and that it is treatable. The attending physician should have known how to treat heroin addiction, and how to convey this information to the residents he taught. Instead, we were debating whether to treat a man whose care we had mismanaged. Fortunately, he did get a second heart valve and was able to leave the hospital. I have no further knowledge of his outcome.

 Despite having relatively little training in indentifying and treating prescription pill addiction, physicians tend to be overly confident in their abilities to detect such addictions. CASA found that eighty percent of the surveyed physicians felt they were qualified to identify both drug abuse and addiction. However, in a 1998 CASA study, Under the Rug: Substance Abuse and the Mature Woman, physicians were given a case history of a 68 year old woman, with symptoms of prescription drug addiction. Only one percent of the surveyed physicians presented substance abuse as a possible diagnosis.  In a similar study, when presented with a case history suggestive of an addictive disorder, only six percent of primary care physicians listed substance abuse as a possible diagnosis. (2)

Besides being poorly educated about treatments for patients with addiction, most doctors aren’t comfortable having frank discussions about a patient’s drug misuse or addiction. Most physicians fear they will provoke anger or shame in their patients. Physicians may feel disgust with addicted patients and find them unpleasant, demanding, or even frightening. Conversely, doctors can feel too embarrassed to ask seemingly “nice” people about addiction. In a CASA study titled, Missed Opportunity, forty-seven percent of physicians in primary care said it was difficult to discuss prescription drug addiction and abuse with their patients, for whom they had prescribed such drugs. (2).

From this data, it’s clear physicians are poorly educated about the disease of addiction at the level of medical school and residency. Even when they do diagnose addiction, are they aware of the treatment facilities in their area? Patients should be referred to treatment centers who can manage their addictions. If patients are addicted to opioids, medications like methadone and buprenorphine can be a tremendous help.

  1. Missed Opportunity: A National Survey of Primary Care Physicians and Patients on Substance Abuse, Center on Addiction and Substance Abuse at Columbia University, April 2000. Also available online at http://www.casacolumbia.org

2. Under the Rug: Substance Abuse and the Mature Woman, Center on Addiction and

Substance Abuse at Columbia University, 1998. Available online at http://www.casacolumbia.org

The Pain Management Movement

 In the late 1990’s, organizations like the American Pain Society and the American Academy of Pain Management declared that doctors in the U.S. were doing a lousy job of treating pain, and were under-prescribing opioid pain medications, due to a misguided fear of causing addiction. As a result, there was a national push to treat pain more aggressively. Some states even passed pain initiatives, mandating treatment for pain. Lawsuits were brought against doctors who didn’t adequately treat pain. The Joint Commission on the Accreditation of Healthcare Organizations (JACHO), the organization that inspects hospitals to assess their quality of care, made the patient’s level of pain the “fifth vital sign,” after body temperature, blood pressure, heart rate, and respiratory rate. Pain management specialists encouraged more liberal prescribing of pain medication. These experts told their primary care colleagues that the chance of developing addiction from opioids prescribed for pain was about one percent.

With these limited facts, the pain management movement was off and running. Many pain management specialists, some of whom were paid speakers for the drug companies that manufactured powerful opioid pain medications, spoke at seminars about the relative safety of opioids, used long term for chronic pain. Pain management specialists taught these views to small town family practice and general medicine doctors, who were relatively inexperienced in the treatment of either pain or addiction.

The problem was…the specialists were wrong.

These specialists, in their well-intentioned enthusiasm to relieve suffering, used flawed data when reciting the risk for addiction. The one percent figure came from a study looking at patients treated in the hospital for acute pain, which is quite different from treating outpatients with chronic non cancer pain. (1) In other words, they compared apples to oranges.

To many addiction specialists, an addiction risk of only one percent seemed improbable, since the general population has an addiction risk estimated from six to twelve percent. Surely, being prescribed pain pills would not lessen the risk for addiction. Yet the one percent figure was often cited by many pain management professionals, as well as by the representatives of the drug companies selling strong opioids. 

Some pain management specialists even took a scolding tone when they spoke of some primary care physicians’ reluctance to prescribe strong opioids. They often muddied the waters, and grouped patients with cancer pain, acute pain, and chronic non-cancer pain together, and spoke of them as one group. This can feel insulting to doctors who, though reluctant to prescribe opioids endlessly for a patient with chronic non cancer pain, are adamant about treating end-of-life cancer pain aggressively with opioids. No compassionate physician limits opioids for patients with cancer pain or with acute, short term pain. However, chronic non-cancer pain is different, with different outcomes than acute pain or cancer pain.

 We didn’t learn from history, or we would have learned that when many people have access to opioids, many will develop addiction.  We are scientifically more advanced than one hundred years ago, but we still have the same reward pathway in the brain. The human organism hasn’t changed physiologically. The present epidemic of opioid addiction is reminiscent of the early part of the twentieth century, just after the Bayer drug company released heroin, which for a short period of time was sold without a prescription, before physicians recognized that over prescription of opioids caused iatrogenic addiction.

 Few pain patients intended to become addicted. Some addicted people blame their doctors for causing their opioid addiction, but most doctors were conscientiously trying to treat the pain reported by their patient, and the pain management experts had told these doctors the risk of addiction was so low they didn’t have to worry about it.

Certainly many patients made bad choices to misuse their medications, either from curiosity or peer influence, pushing them farther over the line into addiction. Patients need to recognize their own contribution to their addiction. But with opioid addiction, as the disease progresses, the addict loses the power of choice that he once had. If the addict is fortunate enough to have a moment of clarity, before the disease progresses too far, he may be able to stop on his own, without treatment.

 By their very nature, opioids produce pleasure. Any time doctors prescribe something that causes pleasure, we should expect addiction to occur. Some people, for whatever reason, feel more pleasure than others when they take opioids, and seem to be at higher risk for addiction. As discussed in previous chapters, genetics, environment, and individual factors all influence this risk.

Opioids treat pain – both physical and emotional. Many of the neuronal pathways in the brain for sensing and experiencing pain are the same for both physical and psychological pain. For example, the brain pathways activated when you drop a hammer on your toe are much the same as when you have to tell your spouse you spent the rent money while gambling. Opioids make both types of pain better. Chronic pain patients with psychological illnesses are at increased risk for inappropriate use of their pain medications.

 In a recent study, the rate of developing true opioid addiction in patients taking opioids for chronic pain was found to be increased fourfold over the risk of non-medicated people. (2) Instead of a one percent incidence, as estimated by pain medicine specialists in the past, it now appears eighteen to forty-five percent of patients maintained long-term on opioids develop true addiction, not mere physical dependency. (3) If this information had been available in the late 1990’s, doctors may have taken more precautions when they prescribed strong opioids for chronic pain.

 Researchers have identified the risk factors for addiction among patients who take opioids long-term (more than three months) for chronic pain. Studies now show that a personal past history of addiction is the strongest predictor of future problems with addiction, as would be expected.  A patient with a family history of addiction is also at increased risk for addiction, as are patients with psychiatric illness of any kind, and younger patients. (4)

However, at the height of the pain control movement, there were no good studies of the addiction risk when opioids were used for more than three months. The little information that did exist was misused, resulting in an incredible underestimation of the risk of addiction in patients with chronic pain, who were treated with opioid medications for more than three months.

 With the momentum of the movement for better control of pain, both acute and chronic, the number of prescriptions for opioid pain pills increased dramatically. In the years from 1997 through 2006, prescription sales of hydrocodone increased 244%, while oxycodone increased 732% during that same time period. Prescription sales for methadone increased a staggering 1177%. (5)

It’s not just patients who are at risk for abuse and addiction. The increased amount of opioids being prescribed meant there was more opioid available to be diverted to the black market. When an addicting drug is made more available, it will be misused more often.

  1. Porter and Jick, New England Journal of Medicine, 302 (2) (Jan. 10, 1980) p. 123.
  2. Michael F. Fleming, Stacey L. Balousek, Cynthia L. Klessig, et al. “Substance Use Disorders in a Primary Care Sample Receiving Daily Opioid Therapy,” Journal of Pain, 207; Vol. 8, issue 7: 573-582.
  3. 7. Steven Passik M.D., Journal of Pain and Symptom Management, Vol. 21 No. 5, (May 2001), pp.359 – 360.
  4. Chou, R, Fanciullo, G, Fine, P, et. al., “Opioid Treatment Guidelines: Clinical guidelines for the use of Chronic Opioid Therapy in chronic, non-cancer pain.” The Journal of Pain, 2009, Vol. 10, No. 2. pp. 113-130

5. Andrea Trescott, MD, Stanford Helm, MD, el. al., “Opioids in the Management of Chronic Non-cancer Pain: An Update of American Society of the Interventional Pain Physicians’ Guidelines,” Pain Physician 2008: Opioids Special Issue: 11:S5 – S 62.

Why Does Dr. Drew Hate Methadone???

The short answer is: I don’t know. I have tried to find out; I have sent him two letters, one in care of the Pasadena Recovery Center, the site of his “Celebrity Rehab” show, and one to Hazelden, the well-known addiction recovery center in Minnesota that published his book “When Pain Pills Become Dangerous.” Pasadena sent my letter back to me, with a haughty “recipient not at this address” scrawled across it, and I got no answer at all from the letter I sent to Hazelden.
Judging from the remarks I’ve heard on his shows, I’m guessing he dislikes methadone because it is so difficult to taper off of, and the withdrawal lasts longer than other opioids. I agree with him about this. But he is treating different patient types than I am. He is treating celebrities, who seem to have the money to spend prolonged time in an inpatient treatment setting. This is a wonderful option for the people who can afford it. But many addicts don’t have this luxury, and to condemn a medication that can be life saving for so many suffering addicts is irresponsible.
For patients without financial resources, methadone can be life-saving, and Dr. Drew should be aware of the forty years’ studies that prove this.
I wish Dr. Drew could talk to some of my patients, to hear from them how much these medications can help. There are thousands of people in this country leading perfectly normal lives, who take a daily dose of methadone or buprenorphine (Suboxone). No one knows they are on these medications, because they don’t want to hear the negative comments stemming from the persistent stigma against these medications.

So Dr. Drew…if you’re out there, I’d like to hear from you.