Posts Tagged ‘opioid use disorder’

“Bosch” Full of Tired Clichés

Season 5: Bosch and the Opioid Crisis


(Spoiler Alert – If you haven’t seen “Bosch” Season 5, this blog post will describe events of the last episode.)

I am disappointed in Harry Bosch. Or more specifically, I’m disappointed by the writers of the “Bosch” series.

“Bosch” is now in its fifth season on Amazon Prime. I’ve always enjoyed the series, based on the books written by Michael Connelly about the adventures of a Los Angeles homicide detective names Hieronymus (“Harry”) Bosch, played on the series by Titus Welliver. I thought the writing was smart and well-paced, with interesting plots that were better than average.

This season, the writers must have thought hey, let’s do something relevant, like a case related to the opioid use disorder epidemic. I would have liked that. The trouble is, this season portrays the opioid use disorder epidemic as it was about ten years ago.

There’s plenty more going on during the season which still makes the show worth watching, but I was constantly eye-rolling at the tired clichés about people who become addicted to prescription opioids, pill mills, and approaches to treatment.

In this season, Bosch investigates the murder of a pharmacist, who had dealing with thugs who run a sophisticated pill-mill operation. Oddly, these criminal masterminds have gathered a group of people who are addicted to pain pills and shuttle them from one pill mill to another, then to multiple pharmacies to fill these prescriptions, to obtain vast amounts of oxycodone pills.

Then the crooks dole them out to the poor addicts who are physically and mentally broken down, and meek as mice. For some reason, they do whatever the bad guys tell them to do, though clearly, they could score more oxycodone on their own.

Then for some reason, the crooks put them on a small private plane and fly them to a camp in the dessert where they are housed in shoddy trailers or old buses until they are flown back for another pill mill-pharmacy outing.

California has had a prescription monitoring program for years. That system would detect people trying to see multiple providers for multiple prescriptions. This scheme could have worked before the prescription monitoring program, but not now. But the writers appear to have ignored this awkward detail.

And flying these people to and fro doesn’t seem practical to me. Private planes are expensive, no? Why fly them to and from the pill mills and pharmacies, then back to the desert camp? Why not house them in a cheap motel at the edge of town? I get that the bad guys want to keep them quiet, but all that flying about seems inordinately expensive.

It’s not even that weirdness that makes me angry. It’s how the characters of the people with addiction are portrayed. They are downtrodden, doing what they are told by the thugs. They are submissive and controllable. After getting a bottle of prescription OxyContin, they turn over the entire bottle, only to be given one or two pills doled out over time by the bad men.

Naw, this doesn’t play. A group of six or eight people with opioid use disorder would certainly be more formidable than this. In fact, given the survival skills of the average person in active addiction, I’d expect them to be running the desert camp after a day. Guns or no guns, these people are in withdrawal and very motivated to get out of withdrawal. These bad guys would be no match for them.

Part of my prediction is based on how the bad guys are shown to be bumbling fools by the end of the season. At one point, one of them, armed, is supposed to throw Bosch out of the plane. Of course, Bosch, unarmed, turns the tables throws the thug out of the plane instead. Then at the end of the season, three of these hardened thugs come to Bosch’s lovely little home in the Hollywood hills for a sneak attack. They are armed with automatic rifles. Bosch, with a handgun, and takes them all down. These guys must be the worst shots in the world, because they spewed bullets galore, but missed Bosch completely.

Then the writers have Bosch trying to help one woman, using outdated methods. Elizabeth is a lovely yet troubled woman grieving the murder of a child. She has a heart of gold but prostitutes herself for one OxyContin 80mg with one of the bad men just to feel better. Of course, Bosch must help her. This lady is a veteran, like him, and he obviously has a soft spot for her in his hard-bitten heart.

He takes her for help to small seedy agency that helps veterans. He doesn’t take her to the Veterans Administration medical system, which now has excellent treatment programs for opioid use disorder using medication-assisted treatment. No, he takes her to a cold-turkey, you-must-suffer, just-for-veterans, hole-in-the-wall kind of facility. When Bosch remarks that he wants to say goodbye before he leaves, the proprietor of the “facility” says he’d better go now, before she chews her fingernails off.

This show perpetuates that tired idea that a person with opioid use disorder must suffer in order to be redeemed, gain recovery, and be worthy of respect again. This is not only an outdated concept, but dangerous. We’ve known since the 1950’s that a detox alone doesn’t do much good unless it’s followed by other treatment, but Bosch offers none of that information. The expectation is that if Elizabeth is tough and brave, she will beat her addiction.

Addiction isn’t like that.

In another scene, J Edgar, Bosch’s partner, is talking with this same woman, and she asks for relief from withdrawal. J. Edgar says a doctor will see her soon. She scoffs, “What and give me, Suboxone? I might as well snort Splenda.”

So, the show also downplays the effectiveness of medication-assisted treatment.


I hereby announce that I am available for consultation on television and movie scripts. I can keep shows relevant and current with information about opioid use disorder and its treatment. Hollywood, I can help you.

Call me. We’ll do lunch.



Buprenorphine in the Primary Care Setting






I was asked to participate in a project to help primary care doctors provide buprenorphine in office-based settings. This grant, awarded to some very smart people at the University of North Carolina, uses the ECHO model to help physicians in the community become more comfortable with treating patients with opioid use disorder in their offices.

This ECHO model, originally conceptualized at the University of New Mexico, uses a hub-and-spoke model to connect experts at UNC and other locations with primary care doctors at their North Carolina locations. The ECHO model can help not only the physicians and physician extenders, but also nurses, social workers and other staff members who are a part of patients’ treatments, using teleconferencing.

Other hub-and-spoke models have placed physicians and the hub and patients at the spokes, so this is a little different. It’s also different from telemedicine, since the participants at the hub and spoke are all care providers, not providers and patients.

It’s a great program, and gives free continuing medical education hours to the physicians who participate, at the same time they get help with problematic situations in their practice.

Our group is prepared. We’ve done practice sessions and we’ve gotten comfortable with the technology (no small achievement for me!).

Now all we need are providers to participate.

We’ve had some interest, but of course would like to reach as many providers as possible. We had some brainstorming sessions about how to get more participants. We would like to reach primary care providers who have a waiver to prescribe buprenorphine, or who may be interested in prescribing.

As it turns out, many physicians who get the waiver to prescribe buprenorphine don’t end up prescribing, or only prescribe to a few patients. These providers could see more patients with opioid use disorder, and help our nation’s situation with the treatment gap.

This treatment gap is the number of people who need treatment compared to the number of people who are able to receive it. At present, experts estimate that only about 20% of people who need treatment for opioid use disorder actually get it. Of course, some of the remaining 80% aren’t yet interested in treatment, but many are desperate for help, and can’t access it.

Due to changes in the DATA 2000 law, physician extenders like nurse practitioners and physicians assistants will be allowed to prescribe buprenorphine to treat opioid use disorder, after they take a 24-hour course. Of course…many extenders in my area have been prescribing buprenorphine for years, off-label “for pain” with a wink and a nod, but the new law will allow them to be legitimate prescribers. This may expand the number of prescribers a great deal, and help to close the treatment gap.

So why do providers, after getting the training to be able to prescribe buprenorphine, not end up prescribing?

A study done by Walley et al., published in the Journal of Internal Medicine, 2008, surveyed all 356 physicians in Massachusetts who were waivered to prescribe buprenorphine. The study was done in 2005, so that was relatively early in the history of office-based treatment. Out of that total, 235 responded to the survey. Of the 235 that answered the survey, 66% had prescribed at least once, and 34% had never prescribed buprenorphine.

Of the non-prescribers, around half said they would prescribe if some barriers were removed. Nearly a third of these doctors felt like they had insufficient office support. Other barriers, in rank of descending importance, were insufficient nursing support, lack of institutional support, insufficient staff knowledge, low demand for services, and payment issues. So this study showed physicians didn’t feel like they had the support staff that they needed.

Of the physicians who were already prescribing buprenorphine in their office-based practices, the biggest barriers, in descending order of importance, were payment issues, insufficient nursing support, insufficient office support, insufficient institutional support, and pharmacy issues.

Some additional tidbits of data emerged from this study. For example, psychiatrists were less likely to prescribe buprenorphine than were primary care physicians, and physicians in solo practice were more likely to prescribe than those in group practices.

I suspect it’s easier to implement changes to medical practice when you are the boss and the lone provider. In groups of physicians, it’s probably harder to change the status quo to take on new projects and ideas, even when more support staff are presumably available.

This trend, where many of the physicians waivered to prescribe buprenorphine don’t end up prescribing, or prescribe for very few patients, has continued through the last fifteen years.

A study from 2014 by Hutchinson et al., published in the Annals of Family Medicine, looked at 120 physicians in Washington State who received training in 2010 and 2011, to prescribe buprenorphine for opioid use disorder. Out of the 120 providers trained, 92 participated in the post-training survey. Of those providers, some were excluded because they were still in their residencies, or were prescribing buprenorphine before they took the course, leaving 78 physicians newly qualified to receive a waiver to start prescribing buprenorphine for opioid use disorder

Of these 78 physicians, only 64% actually applied for the waiver. Of these 50 physicians, only 22 actually ended up treating at least one patient with buprenorphine. In other words, only about a fourth of physicians who could start prescribing to treat opioid use disorder actually did so. Of these 22 physicians, half prescribed for only three or fewer patients.

Physicians in a practice where there was already another physician prescribing buprenorphine were significantly more likely to actually start prescribing than physician in practices where no other physicians prescribed. Younger physicians were more likely to prescribe buprenorphine than older physicians. Fewer than half of these physicians were willing to have their names listed on SAMHSA’s buprenorphine treatment locator site. (

Another study by DeFlavio et al., Rural Remote Health, 2015, was done with an anonymous survey of all of Vermont’s primary care doctors. As it turns out, 10% were buprenorphine prescribers, while 80% said they saw patients addicted to opioids. The barriers that these physicians saw for buprenorphine treatment were inadequately trained staff, insufficient time, insufficient office space, and cumbersome regulations.

Interestingly, Vermont also used a “hub and spoke” model, where experts at the hub stabilize patients newly starting buprenorphine, and after stabilization they transfer to the “spokes” which are primary care providers who continue the prescribing for these patients. This model seemed to work well for the patients and physicians who participated.

As of today, SAMHSA’s website ( accessed 6/6/17) says there are almost 38,000 physicians with waivers to prescribe buprenorphine from an office setting to treat opioid use disorder. Around 3200 have permission to treat up to 275 patients; nearly 9000 can treat up to 100 patients, and around 26,000 can treat up to thirty patients.

In other words, if all of these physicians were prescribing to their maximum, and were located in areas with the highest rates of opioid use disorder, we’d have enough manpower to treat all patients who wanted help.

But these providers aren’t at their maximum.

How can we convince these doctors to prescribe for more people? How can we recruit new providers, who will follow through with a commitment to treat people with opioid use disorder? How can we remove the barriers, which largely appear to fall under the category of insufficient support to give good care?

Some smart people have been working on this for some time, and we now have several models available to assist buprenorphine providers help patients with opioid use disorders.

“Collaborative Care Model,” also known as the Massachusetts model, uses nurse care managers to expand access to treatment. This model is based on how patients with other difficult chronic diseases are managed, such as diabetes and HIV infection. In other chronic illnesses, nurse care managers help the patient with day-to-day care management. This helps the physician know what is going on with the patient and gives the doctor much-needed support to manage the health of these patients.

Studies done on this model showed that patients did as well or better than patients managed only by physicians. This program expanded into community health centers, and the numbers of waivered physicians participating increased by 375%, though this was at a time when buprenorphine was first taking off anyway. The patients treated under this model also had significantly fewer hospital stays.

In this model, nurse managers were doing much of the medical management: doing inductions, doing follow-up on patients, and troubleshooting any problems the patients were having. Providers participating in the model mentioned that RNs can’t charge as much for the care they provide as physician extenders or physicians, so that’s a possible problem.

This year at the American Society of Addiction Medicine’s annual conference, Dr. Andrew Saxon spoke during a session which addressed how to engage practitioners to treat opioid use disorders. He treats patients in the Veterans Administration system, and describing an intriguing method that he called “academic detailing” that they use at the VA.

He said that pharmaceutical companies have already found a model that works, when it comes to getting doctors to prescribe new medications. These companies hire charming people to go to doctors’ offices to spend time talking with the physicians and physician extenders, explaining the new medication and giving them brochures with information.

Dr. Saxon started doing the same thing with VA doctors. Experienced providers make an appointment to speak with a doctor, and bring him or her information, perhaps bring lunch, and generally talk about the process and pleasures of treating opioid use disorders in an office setting. This one-on-one approach appears to work well, and the VA increased treatment availability a great deal using this approach.

The VA made a slick brochure, called “Opioid Use Disorder Provider Guide” which is a pretty good summary of information needed by providers starting to prescribe buprenorphine. Since it’s in the public domain, you can access this document at:

I think this academic detailing idea is a winner. It makes sense – pharmaceutical companies wouldn’t have used this method for years if it didn’t work.

To veer off-topic for a moment…it strikes me that I’ve been trying to “detail” local providers for five years, not to get them to prescribe, but just to get them to stop telling patients to get off buprenorphine and methadone. It would be a huge relief if local doctors encouraged these patients, rather than belittling them.

I exaggerate, of course. There are many physicians in my area who are great to work with, but I guess the more difficult doctors tend to stand out in my mind.

Maybe local doctors need detailing from a physician with credentials and/or clout. Perhaps I lack the credibility or personal charisma that makes other doctors listen to me. I’d like to enlist that kind of doctor to “detail” in my area.

Back to the topic at hand.

The VA isn’t the only agency that’s created guidelines.

The American Society of Addiction Medicine (ASAM) has had a similar document, composed by experts as a guide for prescribers:

There’s also information published by SAMSHA (Substance Abuse and Mental Health Services Administration):

However, the last time I tried to download this one, there seemed to be a glitch.

So there’s plenty of information available for new prescribers, and there’s a nationwide support network called PCSS MAT, for Providers’ Clinical Support System. It’s an organization dedicated to training and mentoring medical providers in the treatment of opioid use disorders with medication-assisted therapies.

If you go to their website, ( you can access archived trainings about various topics relating to MAT. They have online modules, podcasts, and basic information. It’s possible to be connected with a one-on-one mentor with experience treating the disease. This helps the provider feel connected and supported, particularly with difficult issues that often arise.

So currently, there’s a ton of data and support for providers who want to treat patients with opioid use disorders, more than there’s ever been before.

With our ECHO UNC launch, providers can get specific recommendations for managing complex patients (with patient privacy protected, of course). Their staff can learn how to support the prescriber, and it’s all free, paid for under grant money. The prescriber can even earn continuing education credit hours, so it’s a win-win-win prospect for them.

I’ll keep my readers updated about how it’s going.

If you are a provider or know a provider who’d like to take advantage of this opportunity to learn, get help with issues that are vexing you, and get free credit hours for doing so, send me an email so I can connect you with the ECHO UNC hub. The technology is free and easy to use.

Guest Blogger: Thoughts on Roadside Suboxone Signs

This is not a picture of Daniel Rhodes. But if he were a dog, he might look like this.


It is with delight that I present a guest blogger who has volunteered to give his thought on the roadside Suboxone signs that I blogged about several weeks ago.

I’m also delighted that I get to take a week off blogging, and hope all my readers have a great holiday weekend.

Daniel Rhodes is an LCAS-A and LPC-A working in both an OTP and a private Office Based Practice. He had a background in Abstinence-Based treatment models, and has, over the years, come to believe strongly in MAT. He believes in the importance of both approaches and that each has much to learn from the other.

When I first saw a sign on the side of the road advertising Suboxone, I reacted strongly enough to take a picture to show at work and marvel over. I discussed the issue with Dr. Burson, and realized my initial reaction was incomplete.  My gut told me that there was something off about the situation, that there was something unethical or below-board happening, but I could not understand why that might be.  I believe pretty strongly in a Harm-Reduction approach to addiction treatment, first managing the dangers of overdose and disease then trying to help addicts address the issues underlying their disease. I think wider availability of the combination buprenorphine/naloxone product is a good step towards that goal of Harm-Reduction.  In fact, I have been known to argue for the combo product to be available in vending machines. While this is an extreme example and there are many reasons it is not a feasible option, I do think it illustrates a valid principle: Buprenorphine saves lives, prevents the spread of disease, and is a remarkably safe medication. Expanded availability is a good thing.

                So why did this mobile Suboxone van raise my hackles?  Surely, this would increase access to the potentially life-saving medication, and should therefore line up perfectly with my philosophy!  In part, of course, it does; however, I have been able to articulate for myself several ways it does not, several reasons for my misgivings.

                First, as Dr. Burson has said many times, it should be no more expensive for a doctor’s appointment addressing addiction than it is for any other appointment. In the affluent area of Lake Norman, were I to pay out-of-pocket for a routine follow-up visit with my primary care MD (without applying insurance), my cost would be $65. According to their website, the Mobile Suboxone practice charges $175 for an office visit, making their per-appointment charge roughly 270 percent what my primary-care MD charges. While there is certainly nothing wrong with making a profit, I have to wonder if the price differential is warranted, or if it is taking advantage of a relatively desperate population.

                Second, since their website does not identify the person (people?) seeing the patients, there is no way to assess the legitimacy of the practice. In my previous example of buprenorphine in a vending machine, there could be no pretense of legitimate medical practice. However, in a Mobile Suboxone unit, a patient might leave believing he or she had received sound medical advice when this was not the case. There is little on their own website that points to more than a veneer of sound medicine; there are many claims, but paltry sourcing (Wikipedia among them) and seemingly no accountability. As far as I can find, they make reference to a Physician Assistant and “physicians throughout the state,” but attach no names to their practice. In short, even though the practice might expand access to buprenorphine, it seems to be doing so in a way that potentially bills their service as more than it is.

                Third, and following on my point about the medical quasi-legitimacy, the website compares their service to Methadone clinics in a way that I do not believe is fair or even reasonable. They claim that Methadone clinics are too expensive, that they disrupt life too much. While it is certainly true that daily dosing in a clinic can be a burden, particularly if a patient lives far away, a clinic offers a vital component seemingly lacking in the model of the Mobile Suboxone practice: accountability. While they make claims of daily electronic interaction, the daily in-person contact of a Methadone clinic provides a much better picture of a patient’s progress than any electronic communication could. A Methadone clinic mandates and provides counseling for its patients, typically included in the daily fee. The website for the mobile practice offers counseling electronically, the frequency of which is “between you and the counselor,” at a cost of an additional dollar per minute. It seems like an apples-to-oranges comparison: Yes, Methadone might be more expensive than their service, but it comes with much more intense support.

                Finally, that the signs mention “micro-loans” is worrisome. I am not sure how this will work, and I find no mention of the loans on the site. “Micro-loan,” however, evokes images of payday lenders, pawn shops, and other outlets associated with active addiction. It is hard to imagine a scenario in which no one is taking advantage.

I believe the idea of the Mobile Suboxone practice risks losing the ground we have fought so hard to gain in the discussion of the “opioid crisis.” At last, MAT is something being discussed in political circles, and funding is finally opening up to expand access to treatment. Poorly run practices, profiteering, and anything that risks damaging the perceived legitimacy of MAT risks lives. If the practice is not well-run, I fear it might prove an impediment to treatment rather than the expansion it claims to be.

                In conclusion, I may be completely wrong. The Mobile Suboxone practice may be exactly what we need to help more patients get access to life-saving treatment. I sincerely hope my misgivings prove unfounded and that the people behind the roadside signs are creating a new way to combat the disease of addiction. At this point, however, I believe the onus of proof lies on them to show the rest of us how their treatment will work, and that they are not taking advantage of a population that so desperately needs the help offered by well-administered MAT.



The Difference a Day Can Make




News about the cause of Prince’s death was released last week. According to numerous news reports, he died from an overdose of a synthetic opioid called fentanyl, an opioid so potent that it’s measured in micrograms instead of milligrams.

This is the same drug that anesthesiologists and anesthetists get addicted to. It’s such a powerful drug that often the deceased is found with the needle still in his arm.

News stories don’t say how Prince took the medication, only that it was self-administered and that it killed him. Reports didn’t say whether it was prescribed for him or obtained illicitly.

I came of age in the 1980’s and like so many of my friends, loved Prince’s music. He was such a great musician that he managed to remain creative long after the 80’s were done, however.

I remember seeing the clip of Monica Lewinsky hugging President Clinton, and wondering if she chose her hat after listening to his “Raspberry Beret.” I was in recovery from addiction myself by the time New Year’s Eve, 1999 rolled around, so it was one of best New Year’s I’ve ever had. I remembered it, for one thing, and remember listening to the song that night, of course, while we were bracing for the Y2K apocalypse that never came.

Prince had been treated from chronic hip and leg pain, and probably developed addiction as a complication of that treatment. In that regard, he is just like so many of my patients. They never intended to become addicted. Prince, as a Jehovah’s Witness, would theoretically be at lower risk for addiction than many people, since he didn’t drink alcohol or use illicit drugs. But like so many other people, he appears to have developed addiction during the treatment of pain.

Saddest of all the information I read in news reports is that Prince had an appointment with an addiction medicine doctor the day after his death, to get help with his opioid addiction. By now, it’s well-known that Dr. Kornfield, an addictionologist in California, sent his son with a Suboxone film intended for Prince, but by the time the son arrived, Prince was dead. Prince supposedly had an appointment with a Minnesota addiction medicine doctor the next morning.

One day later, he could have had the help he needed. This underlines the seriousness of the opioid use disorder.

If you have this disease, learn from Prince. Anyone can develop the disease of addiction, even a musical genius. So get help now. Tomorrow may be too late.