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Where Did All the Pills Go?

On the left, number of pills per capita by county
On the right, opioid overdose death rates by county


The Washington Post has written some amazing stories this month about our present opioid epidemic. One of their articles described how they accessed data about the distribution of all the prescription opioid pills manufactured and consumed in the U.S.

This data is amazing. There’s a box where you can enter your state or county and learn how many pain pills were sold, how many that averages per person, and which pharmacy sold the most.

For my state of North Carolina, around 2.5 billion pills were sold from 2006 until 2012. Most of these pills were distributed by Cardinal Health. Omnicare Pharmacy of Hickory, NC sold the most pills of any pharmacy, at over 9 million pills.

In my county, 26 million pills were prescribed from 2006 until 2012, enough for 55 pills per person. SpecGx pharmaceutical company manufactured the most pills sold in our county. (They make Roxicodone, called “roxies” by the patients I admit to treatment.)

The data, while interesting, needs to be interpreted with caution. For example, we could jump to the conclusion that Omnicare Pharmacy of Hickory, NC, which sold more pain pills than any other pharmacy in NC, is doing something wrong or inappropriate. But this pharmacy doesn’t sell directly to the public. It supplies opioid pain medications to assisted and skilled nursing facilities. This means the pharmacy may supply pain pill to facilities where patients stay to recuperate after orthopedic surgeries, for example. For such patients, opioid pain pills may be not only appropriate but necessary. The data is also seven years old, but that’s the way data is obtained; it takes time to collect and process information.

But the data gives overall trends and shows the staggering numbers of opioid pain pills consumed by residents of certain areas.

The Washington Post website also published two maps: one shows the number of opioid pills sold, and the other shows opioid deaths by county. The overlap, though not absolute, is striking.

The Washington Post’s recent articles contain valuable information for us, if we chose to learn from them and act on them. To me, they have given us maps of where to concentrate opioid use disorder treatment programs. Unfortunately, some of the most severely affected counties are rural, with few providers who know how to treat opioid use disorder. We’ve got to continue to focus resources on these areas.

The Washington Post also published an article about which pharmaceutical companies made the most opioid pills, which corporations distributed the most prescription opioid pills, and which pharmacy chains sold the most pills. Right now, lawsuits are proceeding against all these participants in the opioid epidemic.

The biggest manufacturers include Janssen Pharmaceutical, Purdue Pharma, Endo Health Solutions, Teva Pharmaceuticals, Allergan, and Mallinckrodt. Some of the biggest distributors were AmerisourceBergen, Cardinal Health, and McKesson Corp. The biggest pharmacy chains are CVS, Rite Aid Corp., Walgreen’s, and Walmart Inc.

The lawsuits against these companies allege that they should have notified the DEA of suspicious orders for large amounts of opioids, and that they violated the Controlled Substances Act by failing to report. Some lawsuits against pharmacies allege the pharmacies had to know that medications were being diverted to the street.

Other than that, I’m not sure I understand the basis of these lawsuits.

For sure, if a company mislead physicians in its marketing, as many people feel that Purdue Pharma did, I understand that as a crime.

But I don’t know enough about what manufacturers and distributors and pharmacies are supposed to do when supplying opioids. This must be driven by physicians’ prescriptions, I would think. I doubt drug companies would manufacture opioids unless there was a demand, or that distributors would distribute and pharmacies would sell, unless there are legitimate physicians’ prescriptions.

I don’t understand how we can expect manufacturers, distributors and pharmacies to know more about good prescribing than physicians should. And physicians surely did underestimate the dangers of these medications, thanks in part to the so-called experts, who downplayed the risks of long-term opioid prescribing for chronic pain. Also, the “under-treatment of pain” movement accused doctors of being callous to suffering and encouraged them to view pain as the “fifth vital sign.”

At any rate, Washington Posts’ series of articles bring some facets of the opioid epidemic to light.





In Praise of Opioids, Part 2





Long-time readers of my blog will recall that I broke my leg – tibia and fibula – around six years ago. The point of the post was mainly to get to talk about my medical ailments, which I love, and that opioids, when used correctly, can be a huge blessing. I described how EMS personnel, on the way to the hospital, gave me a dose of fentanyl. The relief of intense pain was so miraculous.

Well, now I get to talk about my latest medical adventure.

I had a tibial intramedullary rod placed when I broke my leg. It worked beautifully and allowed my broken leg to heal much more quickly. I was ultimately able to get back to my usual activities after what could have been a devastating accident, had good medical treatment not been available.

But starting a few years ago, I had some swelling right at the middle of the tibia, with some pain. I went back to see the orthopedic surgeon, who X-rayed it, and said there was a bone callous forming there due to irritation from the tibial rod. He said he could remove the rod, and that would take care of the problem.

I asked him how big of a deal it was to remove the rod, or “nail” as it’s sometimes called, and he said, “Oh, about as much as putting it in.” That was enough for me to decide against surgery. Well, I also made the mistake of watching YouTube videos of removal of tibial intramedullary nails. Yikes. Let me just pause to tell readers that if you have an upcoming surgery, DO NOT Google or YouTube your procedure. It’s a bell you can’t un-ring.

Over the last few years, after moving to the country, I’ve been much more active, and pain at this area of my leg has bothered me more and kept me from being as active as I’d like. So, this summer I got fed up, went back to the orthopedist, got my surgery scheduled and had it done yesterday.

I was confident I could handle any pain after the surgery, since it certainly couldn’t be as bad a breaking a leg, right? Only as soon as I woke up in the Recovery Room, I had intense pain from my knee down, and started groaning and mumbling. The nurses were attentive and asked if I needed something for pain. I said yes. I’m no martyr. I had one injection of hydromorphone (Dilaudid) and it relieved all pain. I think I had one more injection of the same about a half hour later and didn’t need any more. By that time, I was awake and eager to get out of there.

Thankfully the surgeon injected the incision areas with Marcaine, a long-acting medication similar to Novocain that we get at the dentist. My leg felt numb, but that was good.

I really haven’t had much pain since leaving the surgical center. Of course, my leg is sore at the places where the screws were removed, and my knee is sore, where they withdrew the rod.

My biggest problem has been bleeding. I didn’t notice anything on the ride home, since I was drowsing in the back seat with my leg elevated on two pillows. Then when I got home, I noticed blood soaked my sock, through the wrap they’d placed.

I went to my recliner, got the two pillows, and slept, with my leg extremely elevate. I still felt a little goofy from either anesthesia or the Dilaudid, or both. I slept for a few hours, then woke to find the pillows covered with blood. In fact, the whole lower dressing was soaked, and I had to remove it, despite directions that say to leave dressing in place for 48 hours.

There was a stream of blood coming from the lower leg incision, where screws had been removed. I got some gauze and held pressure on the area with a bag of frozen corn, and the bleeding slowed to an ooze, then eventually to drops. It took nine hours to get this bleeding to stop.

As a physician, I do understand that a little bit of blood looks like a lot of blood, when it’s your blood. I put off calling the 24-hour number, thinking I was overreacting, and that the person I talked to would tell me to hold pressure, keep it elevated, and put ice on it. Still, by 10pm, I was worried enough to call, estimating I’d lost about a unit of blood.

A very nice physicians assistant returned my call, listened to my detailed report, and said if it was still bleeding in the morning, come to the Urgent Care. He also suggested elevation, pressure, and ice.

Eventually, I was so tired and sleepy that I put loads of gauze around it, replaced the pressure bandage and hoped for the best. I went to bed.

So far today, all is well. If there’s bleeding under there, I’m blissfully ignorant of it, and at least it’s not as bad as yesterday, when it soaked through the dressing.

I was given a prescription for hydrocodone, but I don’t think I’ll need it. I just took a few Tylenol and all the soreness is gone. I will keep my leg elevated, which I believe does more than anything to assist in healing, and gradually get back to normal.

Again, I think how grateful I am to have health insurance, and to have access to a great orthopedic surgeon. I feel blessed to have had good anesthesia throughout the procedure and in the recovery room, when my moderate pain was immediately addressed. I’m grateful I was given the option of taking post-operative opioids, even though I don’t plan to fill the prescription.

Yesterday I started to wonder if one of my patients, having the same procedure I had, would have been treated any differently. I hope not. Quite often, I must advocate for my patients on medication for opioid use disorder and tell their surgeons or providers that even though patients are taking a maintenance opioid, they still need short-acting opioids for acute pain situations. I hear – all too often – that patients prescribed buprenorphine or methadone are treated with judgmental attitudes, and this sort of bias has no place in modern medicine. I hope all my patients will be treated as well as I was treated yesterday, when they have medical events.

Opioids are a godsend, when we use them in the right way. The key is to use good judgment, and not to prescribe too long of a course (something that the NC STOP Act addressed) and get dependable family or friends to help a patient with opioid use disorder manage an opioid prescription for acute pain.

I’ll keep you updated with my progress. You know I will, since I love talking about my medical ailments, which are thankfully very few at this time.

My “Hopeless” Patient






(Details have been changed to protect patient identity)

I have a patient in my office-based practice whom I see only every two months. If you had told me ten years ago, when I first met him, that he would become a stable and productive member of society, I would have scoffed. If you told me he would someday have over three years of freedom from active addiction, I would have rolled my eyes in disbelief.

I think of this person when I’m tempted to write off any patient as hopeless.

He was one of the worst. I first met him when I worked at an opioid treatment program (OTP) over ten years ago. He was often impaired and belligerent. At least once he had to be transferred to another OTP, due to aggressive behavior towards the staff and other patients. He was belligerent with me too, and I dreaded my appointments with him. He had a terrible cocaine addiction, and almost all his drug screens were positive for cocaine and benzodiazepines. On several occasions I referred him to a local inpatient program, but he left against medical advice or was asked to leave.

A few years after I left that OTP, he called my office-based practice to ask if he could switch to buprenorphine. The woman making appointments scheduled him with me.

The next week, looking at my schedule, I remember saying, “Oh HELL no. I’m not seeing this guy. He’s not going to stabilize in an office-base practice.” But he had already paid to hold his appointment slot, so I felt obligated to see him. My plan was to tell him he wasn’t appropriate for an office-based program, and to recommend inpatient treatment, as I had so many times in the past.

At the first visit, he was less belligerent than I recalled, and had been free from cocaine for several months. He appeared to have a little more insight into his behavior and his addiction. I sensed he had a strong desire for change. Skeptically, I agreed to start him on buprenorphine, secretly assuming he would drop out of treatment after a few weeks.

From the start, his use of illicit opioids dropped impressively. From that point of view, he made immediate progress.

However, during his first year in treatment in my office-based practice, he had periodic relapses to cocaine. He’d come into my office, fling himself into a chair, and say, “Don’t bother giving me a drug screen. I messed up. I got high on cocaine and then took benzos to come down.” I was impressed with his honesty and I was impressed by how much his relapses bothered him. I was also impressed when he made – and kept – appointments with a psychologist for addiction counseling. He was dismayed and frustrated, because he said he didn’t really enjoy using drugs anymore, but still couldn’t stop using them. This angered and baffled him.

He’d get so frustrated with his own behavior that he would start crying. The first time it happened, I was uncomfortable and worried. He was the ultimate tough guy, more likely to yell than cry. I worried the tears meant a severe mental illness. As time went on, we both got more comfortable with his tears. I saw he was experiencing the pain of his powerlessness over addiction.

He’d been in and out of 12-step recovery for years, and didn’t feel like the meetings helped him much, but he’d go once in a while. He kept going to counseling, though he was only able to afford sessions once or twice per month. He kept his frequent appointments with me. Above all else, he kept his appointments.

I had moments of grave concern, worried he really wasn’t stable enough for me to be treating him in an office-based setting, and on several occasions mentioned my concerns to him.

In my own mind, I also worried about how someone reviewing his chart would view me as a doctor. If someone from the DEA or Department of Health and Human Services wanted to review his chart, they would think I was careless with this patient, and that I should have referred him back to the methadone clinic. During his relapse years, I worried that I was giving this patient inadequate treatment, yet knowing him as I did, I didn’t think he would ever go back to an OTP or inpatient treatment. I also really believed he was going to make progress in recovery, though I didn’t have much to justify my belief.

I also leaned on him to consider an inpatient program. He was set against both an opioid treatment program and an inpatient program, saying he was sick of being treated like a child, and that he didn’t do very well when people told him what to do.

I saw what he meant.

In opioid treatment programs, sometimes a milieu of “us versus them” can be pervasive. Despite using kind and collaborative counseling approaches, patients often feel they are unfairly told what they can and can’t do.

They are right, of course. Opioid treatment programs have to follow an amazing number of state, federal, and local regulations in order to stay open. These rules rankle patients, who feel like they’re being treated like children by irrational parents.

I do get that.

In an office-based setting, there’s more freedom to individualize treatment. By that I don’t mean patients can or should get by with less care. But I have more flexibility, and more opportunities to build rapport with patients in my office than in the OTP.

Addiction treatment literature describes a type of counseling known as motivational interviewing (MI), or motivational enhancement. I’ve read books about this practice, and though I’m a beginner compared to experienced therapists, I do try to use MI methods where I can.

MI encourages treatment providers to listen closely to the patient, clarify what the patient is saying, and ask the patient to participate in solving problems. MI is a collaborative type of counseling, believing patients know more about how to help themselves than more traditional counseling techniques give them credit for knowing. MI also teaches that confrontations with patients aren’t usually helpful.

At the OTP, this patient had a hard time controlling his temper when an authority figure (me) confronted him about drug use and bad behavior. In my office setting, I didn’t confront him but asked him to describe how his relapse happened, and asked him what he thought triggered the overwhelming desire to use the drugs. I asked him what he thought could be helpful for next time, and he had some good answers.

This approach worked well. The time between relapses grew longer, and he appeared to have more and more insight into what caused him to relapse and how he could avoid those situations.

For example, in the past, he got into physical fights at his work place, would get fired, and go use cocaine. At one session, he told me how he’d love to punch his boss in the face. He said it would feel good, but only for a few minutes, and then he would lose another job. He didn’t like his job, but wanted to leave it on his own terms.

Eventually, that’s what he did – he gave a 2 week notice, and left with another job already lined up. Sadly, he couldn’t afford health insurance at his new work. I told him to petitioned Reckitt-Benckiser’s program of free medication for one year for patients in dire financial conditions, and he met their requirements. I also agreed reduced my office fee temporarily, until he got back on his feet.

Then his mother was diagnosed with end-stage cancer. He worked at night so he could help take care of her during the day. He was less angry but more depressed, and he finally agreed to start taking an antidepressant medication. During her prolonged illness, he still struggled with occasional illicit drug use, but he was able to work full time and also help care for his mother. He was very distraught when she died, but happy he’d been able to spend time taking care of her at the end of her life. Ironically, the rest of his family, who had once written him off as the black sheep, came to depend on him during this difficult time for them all.

Since then, he’s been diagnosed with several chronic medical problems, but he has a good job that he likes, and he has good insurance coverage. This allows him to see his primary care doctor regularly. He helps his father around the house and helps financially when he can.

He gradually transformed into a productive member of society.

I have come to enjoy his visits. He’s actually very funny, with a droll sense of humor. His last positive urine drug screen was more than three years ago, and this was his last illicit drug use.

His life isn’t perfect. He has problems with relatives, and has some unmet goals in his life that he’s working on, but looking at him now, you wouldn’t guess he once had serious and life-threatening issues with addiction.

A couple of times a year, we discuss whether he wants to taper off buprenorphine. So far, he said he doesn’t want to risk it, and prefers staying on buprenorphine. I agree with him; he’s doing so well now, I don’t want to risk making changes that could harm him.

What helped this patient? Was it relief from an overly authoritarian opioid treatment program system? Did he age out of his addiction and youthful antics, as so many people do? Did he benefit from the motivational enhancement counseling I tried to provide? Or was he sick of the addiction, and just needed a little help while he got better on his own? I don’t know, but it’s been a delight to be even a small part of his recovery.

When I’m tempted to write off a patient as hopeless, I think of him.

Pharmacists and Insurance Companies



Over the past few years, pharmacists have become important allies to my patients in medication-assisted treatment. I’m thankful for that, since it makes my patients’ lives easily, and mine. But recently, there have been some minor bumps in the road, made more pronounced because of their decreasing frequency.

Sometimes, I get cranky.

I got a message from my office staff person that a pharmacy had called because I didn’t write any dosing instructions on a prescription I had just written. “Wow,” I thought, “I must be losing my mind.”

We copy all prescriptions, so I looked at our copy. It looked complete, except under instructions, I’d written 1 ½ SL. I had neglected to write “Qd” which means once daily.

My bad. I should have written it. How else would a pharmacist be able to guess what the instructions are…except I wrote for #45, a month’s worth. And the patient has filled prescriptions for 1 ½ SL qd for about three years now, all filled every month at this pharmacy. Nope, no way for the pharmacist to decipher this riddle.

Well, I can’t really blame them; it was my mistake.

Last night I got a call from a patient who was enraged because the pharmacy was refusing to fill his prescriptions. I know this patient very well, and though he’s been doing well in recovery for about ten years, he can get angry if he misunderstands things. I told him I would call the pharmacy to try to figure out the problem.

I see this patient every two months, and my last prescription was written with a refill. He filled the first prescription a few days after I saw him. When I finally got to speak to the pharmacy manager, he said they had ordered the medication for the patient, and he would be able to pick it up the next day.

OK, I said, but that’s actually five days late, due to the pharmacy not having the medication in stock. The pharmacist didn’t seem disturbed that his patient would have been out of a life-sustaining medication for five days, so I asked why it was that the medication couldn’t be ordered so that it would be in stock when the patient was due to pick it up.

The answer shocked me with its honesty. He said the pharmacy didn’t want to risk getting ‘stuck” with the medication if the patient decided to go somewhere else to fill it, and that “these patients” flew from one pharmacy to another all the time, in order to save one dollar.

What I should have said…was something along the lines of, “You’re an asshole who shouldn’t be in the helping professions. Do you do the same thing to diabetics on insulin?”

What I did say was…nothing. I was so stunned at the lack of compassion that I didn’t say anything. I’m disappointed in myself for this, since I’m usually a little spicier. His honesty took me completely by surprise, as did his naked disregard for the well-being on my patient.

Then there was the phone call last week from a pharmacist who wanted to make sure the patient hadn’t changed the prescription. Again, this was a patient in recovery for years, whom I see every two months. I wrote her prescription for Suboxone 8mg films, one per day, #30, and I printed out “ONE” under the line for refills, as I’ve done for the past four years.

The pharmacist wanted to know if I had written a zero and the patient falsified and wrote the “NE” after it.

I suppose that’s possible, but I except I print very clearly, and the “O” that the pharmacist thought could be a zero was way on the left side of the blank for number of refills.

This problem that will go away after electronic prescribing, mandated by the state of North Carolina, is in place. I’ve stuck with old-school paper records and hand-written prescriptions for as long as I can, but that will be a thing of the past by January 1, 2020.

I’ve saved the most insane for last.

A local pharmacy called, stating that my one-month written prescription for a patient for suboxone films was partly voided because of the insurance company’s decision.

Huh? How does this happen, I wondered.

I’m still not sure, but here’s what I was told that the pharmacist was told by the insurance company representative.

The visit prior to this one, I had written only a two-week prescription. I don’t recall what was going on, but I needed to keep a closer eye on the patient, and changed from my usually monthly prescription.

Apparently, this was the root of the problem. I wrote for #45, a 2-week prescription. Then at this last next visit, two weeks later, I decided the patient could go back to monthly visits and wrote for #90. This caused a red flag on the patient, because he had now was trying to fill #135 films within a thirty-day period. Yeah…except for the patient already took the forty-five films during a two week period that was already past.

I can’t make this stuff up.

So his insurance company said nope, you can only get #45, which will make only #90 in a thirty-day period. And the pharmacy “cancels” the rest of my ninety day prescription.

Insurance companies would make the Buddha want to bitch slap someone.

I told the staff member who took the call, “Please get the insurance company’s physician reviewer on the phone. I’ve got to hear this logic. I also need to speak to the pharmacist. I want to know exactly who thought they had the right to cancel a prescription, written by a physician, for no medical reason.”

I was riled, and kind of looking forward to what could be a very interesting conversation. But it was not to be. When my staff called the pharmacy, this situation mysteriously resolved itself. No problem now. Patient can come by to get the other #45 films, and insurance won’t give him a hard time when he comes next month with a month’s prescriptions.

Despite these experiences, most pharmacists know how important buprenorphine products are to the recovering person, and are positive and supportive of my patients on medication-assisted treatment. There are far more of these than the pharmacists who have biases against patients on MAT. It’s just that the troublesome ones stand out by their behavior.

I am a peaceful person. I intensely dislike confrontation and can get along with almost anyone. But there are times, large and small, when I have to get out of my comfort zone and make some noise.


Stigma and Substance Use Disorders




I’ve been thinking a lot about stigma lately.

Recently I was asked to do a short presentation about stigma against people with substance use disorders. I thought I could put something together easily to satisfy the intended audience.

But as I created power point slides with all the usual stuff, I dug a little deeper. I thought about how everyone in my intended audience probably already agrees that stigma is bad. What would I be telling them? Everyone was opposed to stigma, right?

But then I thought, if that is so, then why is there stigma? Or perhaps there’s only stigma in people who don’t have knowledge about the nature of substance use disorders. Perhaps the problem is lack of education, and after hearing facts, people won’t support stigma against those with substance use disorder.

I did internet searches about stigma in general and stigma specific to substance use disorders.

I went down some interesting rabbit holes, as one can easily do on the internet. I came across web pages that reminded me of something I’d read about ten years ago, by a physician, that was pro-stigma. I found it on my bookshelf and re-read it.

It was a peculiar chapter in a book about substance use disorder treatment, titled, “Addiction Treatment: Science and Policy for the Twenty-first Century,” edited by Henningfield et al. Just as I recalled, there was a chapter in that book that stood out from all the others, titled, “In Praise of Stigma,” by Dr. Sally Satel.

I’ll try to summarize her viewpoints without the sarcasm that begs to be included. In that chapter, Dr. Satel says stigma against substance use, and people that use substances, is a good thing because stigma discourages deviant behavior and has a civilizing effect on society. She says it’s a normal and necessary part of society. She views the behavior of people with substance use disorders as irresponsible and says it’s bad policy to “cleanse the addict’s image.”

She feels stigma encourages people to get help for substance use disorders, and that eliminating stigma will not make it more likely for people to get help for substance use disorders.

She says people who relapse back to drug use repeatedly is “…a behavior almost always under one’s control…”

Aha, I thought. That’s the key to understanding her point of view. She believes people with substance use disorders have at least some degree of control over their drug use. However, loss of control over substance use is one of the hallmark criteria for the diagnosis of substance use disorder.

It is confusing. Some people who use substances heavily can stop on their own, if given a good enough reason. Most Addiction Medicine experts don’t feel those people meet criteria for diagnosis of substance use disorder. But those are the people Dr. Satel is thinking of, and she fails to make a distinction between those two very different people. Of course, her conclusions are different from most of the rest of the field. She’s talking about apples and the rest of us are talking about oranges.

Her ideas may have some validity for people in the early stages of drug use. Just like the “Just say no” campaign of the 1980’s, early intervention can prevent formation of substance use disorder. But they are of little use when addressing substance use disorder.

To further complicate things, sometimes people with substance use disorders can partially control their substance use, or control it for a short time. Or they may have full control over one drug for a time, but no control over another drug. That’s confusing, and is why friends and family of a person with substance use disorder can become frustrated and puzzled by the behavior of the affected person.

It’s not as confusing when we think about other chronic medical problems. Nearly all have behavioral components, just like substance use disorders, and often we see the same partial/total loss of control over these behavioral aspects.

For example, a diabetic may be able to refrain from eating sweets on most days, but occasionally, perhaps on a stressful day, may eat several servings of sweets. Such a person usually faces less judgment from others, probably because so many of us have tried and failed to control our eating, and commiserate.

But imagine how much harder it is to control use of a substance that produces more intense feelings of pleasure – using substances that stimulate the pleasure centers of the brain much more intensely than eating or not exercising.

We can talk about whether stigma is deserved or not, but what about its effects? Does stigma make it more likely that people will enter treatment for substance use disorders? No, according to the limited studies done on this issue.

Studies of stigma towards people with mental illnesses show it results in unemployment, housing problems, impaired social functioning, lowered self-efficacy, and lowered self -esteem. One study (Joy et al., JAMA, 10/18/16) showed that people with mental health diagnoses are less likely to get appropriate medical care when they go to an emergency department for care for health problems.

Pregnant women with substance use disorders face the most intense stigma. They encounter harsh judgment from friends, family, law enforcement, and even medical care providers. The ultimate stigmatization is criminalization, and around half of the U.S. states have laws that say drug use during pregnancy is child abuse.

The trouble is, it’s harder for pregnant women to get treatment for substance use disorders. Pregnant women using drugs make doctors nervous. Either medical providers lack confidence in their ability to treat substance use disorder in women, or they are anxious about their legal responsibilities to report drug use during pregnancy.

Tennessee provides the best example of the harm that laws can do. In 2014, Tennessee passed the Fetal Assault Law, which said drug use during pregnancy was a crime. Over the two years this law was in effect, around thirty women were charged, almost all were poor and/or minority race. Some of the women who were charged had tried, multiple times, to access substance use disorder treatment, but were turned away. Only two of Tennessee’s one-hundred and seventh-seven treatment programs (at that time) provided pre-natal care and allowed children to stay with expecting moms, so there were few places for women to go when they did ask for help.

At the end of the two years, fewer women sought treatment for substance use disorder, and the law was allowed to sunset in July of 2016. Criminalizing drug use during pregnancy did not push women toward treatment, but away from it, out of fear they would face criminal charges if they sought health care during pregnancy.

It is interesting that Tennessee’s law covered illegal drugs, and not nicotine or alcohol. Ironically, we have more data about the harms caused by both legal drugs than about the illegal drugs.

Alcohol consumption during pregnancy is the number one cause of developmental disabilities and birth defects in the U.S. If the motive for Tennessee’s law was fetal protection, they might have included alcohol. But they didn’t; some drugs have more stigma against them than others, and some drug users have more stigma against them than others.

Thinking about stigma for my small presentation got me thinking about my own tendencies to stigmatize. I wish I could say that I don’t ever look down on other people for who they are or what they do, but that’s not true. I’m better than I used to be, and sometimes have enough insight to know what I’m doing and adjust my thinking, but the tendency towards judgmentalism is still with me.

When I stigmatize, I’m usually feeling fear – fear of people who behave differently than me. Stigmatization gives me the false sense that I’m superior to a certain group, that I’m protected from the judgment that they deserve. Stigmatization can be used to oppress certain people, or suppress a certain point of view. These motivations are not healthy. They damage the people I stigmatize, but they mostly damage me. It turns me into someone I don’t like, and that doesn’t feel good at all.

When I read Toni Morrison’s book “Paradise,” years ago, it helped me see why we stigmatize and scapegoat. That book, for me, vividly illustrated the human tendency to stigmatize and the tremendous damage it does to all concerned.

I wish all of us could resist the tendency to stigmatize, not only against people with substance use disorders, but against all groups. I pray at this difficult time in our history, we will resist the temptation to reject and stigmatize groups with whom we don’t agree. To use a quote from twelve step fellowships: “as long as the ties that bind us together are stronger than those that would tear us apart, all will be well.”



Diagnostic Overshadowing




I was trying to get through a pile of non-Addiction Medicine journals when I came across an article titled “The Ethics of Behavioral Health Information Technology: Frequent Flyer Icons and Implicit Bias,” in the October 18th, 2016, issue of the Journal of the American Medical Association.

According to the authors, Michelle Joy M.D. et al, at least one electronic medical record (EMR) system provides a way to display an icon shaped like an airplane, as a way to inform treating physicians that the patient is a “frequent flyer.” This term has long been used to describe patients who repeatedly come to emergency departments or other providers on a regular basis.

This term has been used for decades. I’ve used it myself in the past. It’s a short-hand phrase that usually means, “This patient is a pain in the ass because he/she keeps coming back for inappropriate reasons.” More elegantly and succinctly, the authors of this article say the term frequent flier is short-hand for “problem patient.”

This article points out the ethical harms of stigmatizing patients in this manner, and presents the term “diagnostic overshadowing.” This means a physician’s attitude towards a patient can be skewed by the idea that the patient is seeking care for inappropriate reasons. The article goes on to cite studies showing patients with mental health conditions are less likely to get appropriate medical care compared to patients without mental health issues, likely due to this diagnostic overshadowing.

I see this every week in my patients with opioid use disorder. Even my patients who are in recovery and doing well say they are treated differently when they go to our local hospital emergency departments, or even to their primary care doctors. After they reveal they’re on buprenorphine or methadone to treat opioid use disorder, they detect changes in the attitudes of their care providers.

Often, the patient will say, “I know I’ve tried to score drugs from him before, but this time I didn’t get a chance to say anything before the doctor accused me of being a drug seeker.” The doctor, reading the past records, jumped to the conclusions that this person is only in the emergency department to get pain pills. The doctor shuts down further communication because of his diagnostic overshadowing. The patient doesn’t get a chance to receive appropriate care. Maybe just as bad, that patient is given the message that they don’t deserve respect, due to their diagnosis of opioid use disorder.

If this happens to patients years after they’ve been in recovery, just think about what happens to people in active opioid use disorder. They are pre-judged as drug seekers, and the emergency department doctors sometimes decide, before gathering information, that the addicted person has no valid medical problems. The doctor starts with an assumption that the patient is a bad person, rather than a sick person.

This attitude leads to medical disasters. Patients with current intravenous drug use are more likely, not less likely, to have serious medical problems.

I’ve seen two patients who had serious infectious medical emergencies that were missed by local emergency room doctors. Both patients were seen multiple times at two local hospital emergency departments. Both said they were treated with distain by personnel. One was seen a total of four times before she went, on her own, to the emergency department of a nearby teaching hospital, where she was immediately diagnosed, and taken for emergency surgery.

I believe these two patients encountered doctors who experienced the diagnostic overshadowing described in the JAMA article, because they had opioid use disorders. Their doctors assumed they only wanted pain pill prescriptions and weren’t all that sick.

What do we do about diagnostic overshadowing?

We must educate physicians more completely about addiction and mental health disorders. I’ve written in previous blog posts about the lack of training, at least in the past, for physicians about substance use disorders. Specific training in medication-assisted treatment of opioid use disorders wasn’t taught at all. This is slowly changing, and medical schools now teach students about these vital medical problems. This will help younger physicians, who are getting their training now.

What about older doctors, already in practice? I think all of us working in substance use disorder and mental health disorder fields have an obligation to educate our peers. I know I held significant bias against methadone before I knew anything about it. One doctor friend encouraged me to read and learn. When I did, I found piles of information supporting this evidence-based treatment.

Now I try to pass along what I’ve learned. Sometimes I’m successful, sometimes not. I’ve talked to doctors in my community, with a wide range of results. Some physicians have become allies, supportive of the patients we share. Others have not been willing to listen or learn about MAT. One doctor told me if I prescribe MAT for one of his patients, he will dismiss that patient from their practice.

The only difference between this doctor and me was in our willingness to learn. Had I not agreed to read some of the tons of studies showing that methadone helps patients with opioid use disorder, I’d still be opposed to methadone, as he continues to be. It’s a reminder to remain teachable.

It’s easy to become frustrated with my colleagues. For example, I can’t remember even one patient being referred to our opioid treatment program by the local hospital’s emergency department physicians. I have not been successful at educating these doctors.

Up until last year, we didn’t get referrals from our local substance abuse and mental health treatment provider for the county. One patient specifically asked them to refer her to a methadone clinic, and was told, “We don’t do that.” Fortunately, she had friends who told her where to find our treatment center.

Our program manager, nurse manager, and I met with the treatment program’s supervisors, who said they had no idea their facility was trying to prevent patients from accessing opioid treatment programs. They promised to fix the situation, and we now get referrals from this program.

So things do change, but not quickly. All of us advocating for MAT need to be patient, yet persistent. Maybe then we can eliminate diagnostic overshadowing for our patient populations.