NYT: Fighting Drug Addiction With Drugs Works, but Only if Doctors Sign On

[neversickanymore]

Fighting Drug Addiction With Drugs Works, but Only if Doctors Sign On
Austin Frakt
MARCH 2, 2016

Almost one million American physicians can write a prescription for an opioid painkiller like Vicodin and OxyContin — one pathway to opioid addiction. But, because of regulatory hurdles and other factors, fewer than 32,000 doctors are permitted to prescribe buprenorphine, a medication to treat such addiction.


That’s a statistic worth thinking about since opioid painkillers and heroin contributed to the deaths of nearly 30,000 Americans in 2014, triple the number in 2000. Perhaps many of these lives could have been saved with buprenorphine. The Obama administration intends to increase access to it — and its proposed budget would commit hundreds of millions of dollars to do so — but it won’t be easy.


Taking buprenorphine or methadone, alongside counseling, is the most effective approach to opioid addiction treatment. Because the drugs relieve patients’ cravings for heroin or narcotic painkillers, patients taking them can focus more on recovery and less on getting high. When taken properly, the drugs can help addicted patients and their families get their lives back to normal while reducing the risk of fatal overdose, crime and their societal costs. But the need for these treatments far outstrips available supply. Less than half of the 2.5 million Americans who could benefit from medication-assisted treatment for opioid addiction receive it.

Expanding the use of methadone will be difficult. Methadone is provided only in dedicated clinics, which patients must visit daily. But many communities resist clinics because they attract patients with addictions, a highly stigmatized population. Work by Christopher Jones, a pharmacist and public health researcher, showed that the number of patients treated at them has barely increased in over a decade. Most methadone clinics operate at or near capacity, and some have waiting lists.

Expanding buprenorphine use could be simpler, but is still fraught with challenges. Though used to treat opioid addiction, buprenorphine, like methadone, is an opioid-based medication, so it too can be abused if improperly used. However, it does have a lower overdose risk than methadone. Since 2000, buprenorphine can be prescribed by qualified doctors to a limited number of patients to take at home. Buprenorphine use has expanded as a result, but availability is limited by regulation. Doctors may prescribe it only after taking an eight-hour course and applying for a special license. No such hurdles are required for prescribing any opioid painkillers.

Buprenorphine use got a boost in 2006 when another change in the law permitted physicians who have held the special license for at least a year to prescribe buprenorphine to as many as 100 patients at a time, up from 30. Because the drug can be misused or diverted for illicit sale, the limit is in place to prevent the emergence of buprenorphine “pill mills” — clinics that make a buck from high rates of prescription and with insufficient patient oversight.

A study led by Dr. Bradley Stein of the RAND Corporation found that this change increased access to treatment. But the regulated supply has not kept pace with the need. Dr. Jones’s study found that even if all doctors who are approved to prescribe buprenorphine did so to the maximum number of patients permitted by law, one million patients who could benefit from it would still be unable to obtain it.

cont http://www.nytimes.com/2016/03/03/u...s-works-but-only-if-doctors-sign-on.html?_r=0

 

[MyDoorsAreOpen]

The practice where I work has been pressuring me to get my bupe license. It's not that hard to get, if you have no marks on your record as a physician. It really just involves watching a set of videos and filling out a form. You're then limited to 30 bupe patients at any given time, and the DEA will visit your practice and inventory and audit you regularly.

I'm reluctant to do it, for the simple reason that it's extremely high-stress and high-stakes work. It tends to completely take over the practice of physicians who do it, and I don't want to give up the variety of family medicine. The clientele you deal with tend to be hard-luck cases with little means, who have a much higher rate of breaking the deals their doctors make with them. This is not a judgement of the character of opiate addicts -- it's the nature of an addiction that tends to cost people everything, by the time they get to bupe therapy. Meanwhile the DEA is watching you like a hawk, and any little slip-up in documentation or protocol can cost you your career. I'd be forced to be a hardass and cut people off who really deserved a second chance. It doesn't make things any easier for me that I come off to many street-hardened people as an easy mark.

Simply put, in the current system we have, it takes a special type of physician to do opioid replacement therapy, and I am not that type. If the healthcare system wants more doctors to do this kind of work, it's got a long way to go to creating an incentive, and lowering the stakes to the doctor.

At the bottom of it all, ORT suffers from the same existential conundrum as psychiatry: You're serving a clientele who, on the whole, take more from the system than they [can] give. Therefore there will always be an undercurrent of right-wing sink-or-swim hard-assery when it comes to policy making, which says that these people deserve the bare minimum if even that, because they're a net drain on society. Not that I feel this way at all (quite the contrary), but there's plenty of Americans in powerful places who'd be just fine with letting anyone who's ever abused opiates win the Darwin Award.

 

[cj]

The practice where I work has been pressuring me to get my bupe license. It's not that hard to get, if you have no marks on your record as a physician. It really just involves watching a set of videos and filling out a form. You're then limited to 30 bupe patients at any given time, and the DEA will visit your practice and inventory and audit you regularly.

I'm reluctant to do it, for the simple reason that it's extremely high-stress and high-stakes work. It tends to completely take over the practice of physicians who do it, and I don't want to give up the variety of family medicine. The clientele you deal with tend to be hard-luck cases with little means, who have a much higher rate of breaking the deals their doctors make with them. This is not a judgement of the character of opiate addicts -- it's the nature of an addiction that tends to cost people everything, by the time they get to bupe therapy. Meanwhile the DEA is watching you like a hawk, and any little slip-up in documentation or protocol can cost you your career. I'd be forced to be a hardass and cut people off who really deserved a second chance. It doesn't make things any easier for me that I come off to many street-hardened people as an easy mark.

Simply put, in the current system we have, it takes a special type of physician to do opioid replacement therapy, and I am not that type. If the healthcare system wants more doctors to do this kind of work, it's got a long way to go to creating an incentive, and lowering the stakes to the doctor.

At the bottom of it all, ORT suffers from the same existential conundrum as psychiatry: You're serving a clientele who, on the whole, take more from the system than they [can] give. Therefore there will always be an undercurrent of right-wing sink-or-swim hard-assery when it comes to policy making, which says that these people deserve the bare minimum if even that, because they're a net drain on society. Not that I feel this way at all (quite the contrary), but there's plenty of Americans in powerful places who'd be just fine with letting anyone who's ever abused opiates win the Darwin Award.

I agree that you shouldn't treat opiate addicts. You have an obvious prejudice against opiate addicts that I have noticed in quite a few of your posts. Your potential patients deserve better.

I was on sub for 5 years and I never saw any "street people" in the waiting room as they can not afford suboxone. I mostly saw 2 types of people. The first where 20 something year olds who have born the brunt of the opiate epidemic. They where often accompanied by there parents who paid for the visits. The other group of people where older folks who got started on opiates during the pain management era and where then summarily dumped by those doctors as the DEA cracked down. They usually looked like perfectly normal working people.

The reason it takes over many physician practices IMO is because its really profitable. The place I went was 250 dollars for the first appointment then 200 dollars a month after that. No insurance was accepted, oh and they only accepted cash no debit or credit cards. Even if your only serving 30 patients a month that is 6000 dollars. After 1 year of being a sub licensed doctor that patient limit goes up too 100 as well which is when the cash starts really rolling in to the tune of $240,000 a year. This place was only open to suboxone patients on Saturday mornings because naturally they didn't want the stink of the sub human to get on there family practice clients. So yeah you will have to excuse me if I don't believe that sub doctors are martyring themselves for the good of humanity.

 

[dirzted]

i agree that you shouldn't treat opiate addicts. You have an obvious prejudice against opiate addicts that i have noticed in quite a few of your posts. Your potential patients deserve better.

I was on sub for 5 years and i never saw any "street people" in the waiting room as they can not afford suboxone. I mostly saw 2 types of people. The first where 20 something year olds who have born the brunt of the opiate epidemic. They where often accompanied by there parents who paid for the visits. The other group of people where older folks who got started on opiates during the pain management era and where then summarily dumped by those doctors as the dea cracked down. They usually looked like perfectly normal working people.

The reason it takes over many physician practices imo is because its really profitable. The place i went was 250 dollars for the first appointment then 200 dollars a month after that. No insurance was accepted, oh and they only accepted cash no debit or credit cards. Even if your only serving 30 patients a month that is 6000 dollars. After 1 year of being a sub licensed doctor that patient limit goes up too 100 as well which is when the cash starts really rolling in to the tune of $240,000 a year. This place was only open to suboxone patients on saturday mornings because naturally they didn't want the stink of the sub human to get on there family practice clients. So yeah you will have to excuse me if i don't believe that sub doctors are martyring themselves for the good of humanity.

this this this

 

[manboychef]

I went to a pediatrician for my subs. It was strange. Yes it was intensely expensive.

 

[MyDoorsAreOpen]

I agree that you shouldn't treat opiate addicts. You have an obvious prejudice against opiate addicts that I have noticed in quite a few of your posts. Your potential patients deserve better.

I know my limitations and I acknowledge them. Opiates make me very uncomfortable. No where did I say that opiate addicts shouldn't have medical help available to help keep them sober. I'm just not the man for the job. FWIW, I have a number of patients who've been opiate addicts, whom I have a fine working relationship with. But I take care of their other medical issues, not their ORT.

crimsonjunk, please give me an example of a BLer who openly voices a stance on opiates that isn't pro, whose voicing of this opinion you don't find offensive. I'm really trying to understand what it is about the way I write that so many outspoken BLers who've struggled with opiate addiction find such a turn-off. I ask because I've tried my best to be kind and civil, despite the fact that I don't relate, and won't pretend that I do. What I'm getting at is, is there an unwritten social rule here at BL that opiates and opiate addiction are exempt from even the politest of criticism, so as to create something of a "safe space"?

If there's something specific about how I broach the topic that's offensive to folks who've been there, please let me know, because my aim is not to offend, it's just to speak frankly from my own experience of the world. If on the other hand, my opinion on the subject is fundamentally unwelcome here, then that's another matter entirely.

 

[slimvictor]

MDAO, your opinion is extremely welcome and even valued highly here.
Please don't think otherwise.
Your "prejudice" against opiate users, if you really do have one, seems very light indeed, and I feel certain that you only want the best for everyone, regardless of what drug they use.
Most people I meet in "normal life" have a stronger, angrier bias against opiate and other drug users as well.
And here, I just learned so much about this topic, thanks in large part to your post.
So, please continue posting your opinion, and do not be afraid to criticise anything, especially politely and gently as you typically do.

 

[TheRapperGoneBad]

MDAO, your opinion is extremely welcome and even valued highly here.
Please don't think otherwise.
Your "prejudice" against opiate users, if you really do have one, seems very light indeed, and I feel certain that you only want the best for everyone, regardless of what drug they use.
Most people I meet in "normal life" have a stronger, angrier bias against opiate and other drug users as well.
And here, I just learned so much about this topic, thanks in large part to your post.
So, please continue posting your opinion, and do not be afraid to criticise anything, especially politely and gently as you typically do.

X10

Thanks slim saved me some typing.

 

[MyDoorsAreOpen]

Thanks guys. I've got my big boy pants on today, so I'm not going to be a drama queen, don't worry. I'm just a little amazed at how strongly negative a reaction I can arouse around here saying anything less than positive about having an opiate habit. And when this happens, it only serves to reinforce my perception that there is a yawning gap, worldview and life-experience wise, between people who've had an opiate habit and those who haven't, that's extremely hard to bridge.

 

[cj]

I didn't intend to start drama I was just making an observation. I have written and erased a response five or six times as I cant find the right words to say what I want to say. But I have nothing personal against you. I suspect I feel the same way about communicating with doctors as you feel about communicating with opiate addicts. I just detected a bit of disdain in your post that I have felt from a number of doctors when the topic of my heroin addiction came up.

Anyway I enjoy reading your posts on other subjects and I respect your intellect. So yeah have a nice day.

 

[manboychef]

It is hard to broach the subject with a doctor because of the negative stigma involved. If you have been an addict to opiates chances are you have either been talked down to in a condescending way by a doctor, or treated like your problems are not as worthwhile of their time as a patient without a habit.

Here is food for thought. I went to the hospital with phlebitis, everything was nice at first till I told the doctor I was an IV drug user, and chances are it was caused by that. Immediately his demeanor changed and he began talking to me like I was literally subhuman. I was working, paying my bills, and I had insurance. What makes me so different from any person walking through the doors? I just happened to have a problem that I couldn't fix on my own. Every addict at some time or another experiences this bias. Are we not all human after all? Do we not all have problems? I believe what crimsonjunk means to say is it is time to cast off these prejudices no matter how light they are and just treat everyone as equals. No person truly knows what someone can become. I never thought I would be able to quit opiates, but I have and I help others to quit as well.

I guess at the end of the day, opiates are a problem that should not be stigmatized, but rather studied to learn more viable ways to help people. No person wants to be talked down to, especially for a problem they generally feel terrible about already. I know I was miserable using and I certainly needed no one to put me down.

 

[cj]

It is hard to broach the subject with a doctor because of the negative stigma involved. If you have been an addict to opiates chances are you have either been talked down to in a condescending way by a doctor, or treated like your problems are not as worthwhile of their time as a patient without a habit.

Here is food for thought. I went to the hospital with phlebitis, everything was nice at first till I told the doctor I was an IV drug user, and chances are it was caused by that. Immediately his demeanor changed and he began talking to me like I was literally subhuman. I was working, paying my bills, and I had insurance. What makes me so different from any person walking through the doors? I just happened to have a problem that I couldn't fix on my own. Every addict at some time or another experiences this bias. Are we not all human after all? Do we not all have problems? I believe what crimsonjunk means to say is it is time to cast off these prejudices no matter how light they are and just treat everyone as equals. No person truly knows what someone can become. I never thought I would be able to quit opiates, but I have and I help others to quit as well.

I guess at the end of the day, opiates are a problem that should not be stigmatized, but rather studied to learn more viable ways to help people. No person wants to be talked down to, especially for a problem they generally feel terrible about already. I know I was miserable using and I certainly needed no one to put me down.

You said it much better than I ever could have

 

[ro4eva]

Thanks guys. I've got my big boy pants on today, so I'm not going to be a drama queen, don't worry. I'm just a little amazed at how strongly negative a reaction I can arouse around here saying anything less than positive about having an opiate habit. And when this happens, it only serves to reinforce my perception that there is a yawning gap, worldview and life-experience wise, between people who've had an opiate habit and those who haven't, that's extremely hard to bridge.

As someone who has been on MMT for the past few years, I think that most of us are, for lack of a better term, weary of medical professionals who do not express an optimistic attitude about Opioid Analgesics in general. And I believe it stems from past negative experiences of unjust treatment, unreal expectations and/or rejection from interactions with doctors and/or nurses regarding the hopeless prospect of being prescribed a narcotic. And I for one can honestly attest to the fact that these experiences have left me in a limbo where I've repeatedly tried to completely avoid conversing with my most recent family physician about this drug family and my history with it.

One recent example is the fact that I've been suffering from a kidney stone, and I've completely avoided talking about the need for very severe pain relief (because I'm even more concerned about the potential consequences of her finding out about my past, as well as being rejected of course). And so I've simply stuck with... other means to kill my pain. It's honestly not worth the potential headache for me to even try to procure a prescription for a narcotic painkiller. The whole idea of even trying really makes me feel uncomfortable nowadays (even though I know that I have the right to be appropriately treated for such terrible pain).

Does that make any sense? Aha...

Anyways, combine what I've written about with rhetoric which is interpreted as pessimistic towards Opioids, and I for one can definitely see someone with a long history of Opioid use to eventually take offense towards repeated disdain for this drug family (from anyone of course, not just medical professionals).

I understand where they're coming from, so to speak, and I imagine that most current and former habitual consumers of mu-opioid agonists will to varying degrees also. But then again, maybe I'm unique (highly unlikely).

 

[MyDoorsAreOpen]

CJ and ro4eva, thank you guys for taking the time to explain where you're coming from on this. I apologize if I've painted opiate addicts with a broad brush, because the fact is, I've known plenty of them, both here on BL and in my office, who are fine individuals.

Just for the sake of putting all my cards on the table, I celebrated by graduation from medical residency by going on a two week long poppy seed tea bender, with plenty of kava kava and marijuana on the side. It was great while it lasted. But the way this drug dug its tentacles into my mind scared me very much. I realized it was time to stop when I heard my children playing loudly one of my last days on the stuff, and was reflexively annoyed that they were ruining my buzz. That was a big "holy shit" moment for me. I fiended for that shit like a junior high school crush, for weeks afterward. I caught myself unconsciously scouting out places where I could find good clumpy seed in large quantities. I can only imagine if I'd had little else going for me in life, and few other sources of joy, and chronic pain either physical or psychological ...
I've got no high horse to ride on, trust me.

I just know addiction medicine to be very emotionally draining work that involves balancing strong competing demands and very high stakes. It's like obstetrics in this way -- you're either cut out for that type of challenge or you're not.

It's paranoia-inducing practicing medicine in an climate where I'm discouraged from scripting any opioids at all. It's been drilled into me in my training that I'm being watched, and that my profession is the source of the problem. That's heavy. I think that if I felt I deserved narcotic painkillers for some pain I had, I would try my luck illegally outside of the system, rather than going through it.

At the same time, I'm aware of the fact that narcotics are essentially unavailable (legally) across vast swaths of the world, and there are many places where even those with the severest and most crippling of pain go without them. With no agenda other than understanding and compassion, I have a mind to travel to some of these places and talk to patients, healthcare providers, and just common folk about how they go about dealing with pain. There's something almost philosophical about this for me.

 

[manboychef]

CJ and ro4eva, thank you guys for taking the time to explain where you're coming from on this. I apologize if I've painted opiate addicts with a broad brush, because the fact is, I've known plenty of them, both here on BL and in my office, who are fine individuals.

Just for the sake of putting all my cards on the table, I celebrated by graduation from medical residency by going on a two week long poppy seed tea bender, with plenty of kava kava and marijuana on the side. It was great while it lasted. But the way this drug dug its tentacles into my mind scared me very much. I realized it was time to stop when I heard my children playing loudly one of my last days on the stuff, and was reflexively annoyed that they were ruining my buzz. That was a big "holy shit" moment for me. I fiended for that shit like a junior high school crush, for weeks afterward. I caught myself unconsciously scouting out places where I could find good clumpy seed in large quantities. I can only imagine if I'd had little else going for me in life, and few other sources of joy, and chronic pain either physical or psychological ...
I've got no high horse to ride on, trust me.

I just know addiction medicine to be very emotionally draining work that involves balancing strong competing demands and very high stakes. It's like obstetrics in this way -- you're either cut out for that type of challenge or you're not.

It's paranoia-inducing practicing medicine in an climate where I'm discouraged from scripting any opioids at all. It's been drilled into me in my training that I'm being watched, and that my profession is the source of the problem. That's heavy. I think that if I felt I deserved narcotic painkillers for some pain I had, I would try my luck illegally outside of the system, rather than going through it.

At the same time, I'm aware of the fact that narcotics are essentially unavailable (legally) across vast swaths of the world, and there are many places where even those with the severest and most crippling of pain go without them. With no agenda other than understanding and compassion, I have a mind to travel to some of these places and talk to patients, healthcare providers, and just common folk about how they go about dealing with pain. There's something almost philosophical about this for me.

I can completely appreciate your viewpoint on this subject. It is hard work dealing with opiate addicts. One of the problems with opiate addicts that stems from the stigmatization of this addiction is that they are routinely dishonest either directly or by omission when it comes to the subject. I can understand that this would make it very hard for a medical professional to have trust in someone that is seeking medication, especially coupled with the watchdog attitude that they are put into as of late. The penultimate truth is this though: An addict will find a way to use no matter what. Compassion has gone by the wayside in this climate because the addict is going to find it somehow (and the fact it isn't regulated or consistent makes OD's very common), and the doctor can lose his livelihood especially after such a large investment in it.

This problem can easily be remedied by creating an honest forum about the problem in which addicts feel safe being on a middle ground with their doctor. I have a wonderfully GP that really helped me beat my opiate addiction. It is extremely helpful that I can be honest with him about everything. He knows my strengths and weaknesses and doesn't fault me for either. This made it easier for me to come to him when I started having problems with my benzo prescriptions. We sat down together and talked about it and come up with a reasonable taper plan. The honesty goes both ways. He can ask me a question about addiction and dependence and I will give him an honest answer. This level playing field has made my recovery so much easier.

I think a lot of doctors have had a few negative experience with manipulation from addicts that sours their view on those that truly need their compassion and care. To ease ones pain is an extremely high calling for anyone regardless of your views on addicts in general. It is just too bad that doctors have to fear reprisal and job loss for doing so.

 

[ro4eva]

It's paranoia-inducing practicing medicine in an climate where I'm discouraged from scripting any opioids at all. It's been drilled into me in my training that I'm being watched, and that my profession is the source of the problem. That's heavy. I think that if I felt I deserved narcotic painkillers for some pain I had, I would try my luck illegally outside of the system, rather than going through it.

I hear ya - a buddy of mine is practicing dentistry, and on several occasions he told me that his biggest concern regarding his profession is that there's always someone looking over his shoulder, ready to pounce by way of an audit if he writes "too many" prescriptions for controlled substances, especially narcotic analgesics.

He also happens to be a huge pothead, which I consider as an anecdotal example of a highly educated, punctual individual who has never turned into a 'Stoner Sloth' despite his love of the ganja. And he's received unanimous praise from long term clients (including myself - his skill level is truly second to none IMO).

Anyway, the fact that law enforcement can shut him down because he prescribes "too many" controlled substances really ticks me off. And I told him that if I was in his shoes, that I would be extremely offended by these parasites who are masquerading as cops and considered "experts" on drug addiction by the mainstream media.

These are the same incompetent dolts who can't tell whether Cannabis carries less risks to a consumer's acute and long term health than Diacetylmorphine (Heroin). And over the past ~45 years of cluelessly trying to arrest their way out of the demand for 'street drugs,' they have achieved absolutely nothing in terms of tangible progress.

I am looking forward to seeing their disastrous racket permanently shut down by a government who hasn't completely whored itself to millions upon millions of dollars in donations from corporate lobbyists in the form of Super PACs and God knows what else behind closed doors.

I'm sorry to hear that you are also burdened by this global scourge of an opportunity to scapegoat a minority group of mostly-helpless individuals who are preyed upon and treated like they owe society a debt because they consume certain taboo plants, powders, etc.

We absolutely must continue working tirelessly in order to successfully pass an amendment at the federal level to get money out of politics before ever standing a chance of ending this fundamentally contradicted war. A war on people who, for reasons partly related to genetic diversity as well as varying personal tastes and preferences, prefer drugs other than Alcohol and/or Nicotine in order to "take the edge off." At present, a couple dozen states have signed on but AFAIK we require at least 38, so there is still a ways to go (but we are making progress, that's for sure).