Archives for July, 2011


Is the Placebo Effect a Reason to Lie?

I think that it is because of my own experiences as a study participant back in medical school that I get such a kick out of volunteer studies today.  Years ago, my classmates and I were paid to undergo bronchial lavage (a procedure where a tube is passed into the lung and the alveoli rinsed with fluid—all while wide awake), to be infected with the cold virus and then receive various treatments (administered by squirting substances up the nose), and to take antidepressants or other medications to allow researchers to screen for side effects.  The greater the inconvenience, risk of injury, or physical discomfort, the bigger the payoff for test subjects.

We were often faced with the question, ‘how bad do I need the money, and how much pain can I tolerate to get it?’  Oh, the things med students will do for $100!

A new study out of Great Britain reminds me of those desperate days as a research subject, and also bears relevance to prior discussions here.  The study, published in the Journal of Science Translational Medicine, subjected volunteers to a beam of heat applied to the leg, to induce pain that was 70% of what the volunteers thought they could tolerate.  The subjects were then given an intravenous infusion of a potent, ultra-short-acting narcotic called remifentanil, all while having their brains imaged by fMRI, an imaging technique that determines electrical activity in certain brain areas by measuring regional blood flow.
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Heroin in the Heartland

A local newspaper—the Oshkosh Northwestern—carried a story last week about a major drug bust in the part of Wisconsin that I call home. According to the story, the 45 people arrested were responsible for the distribution or sale of several million dollars worth of heroin and crack cocaine. The online story features a slide show featuring the mug shots of the people arrested in the bust.

I’ve known a number of people killed by opioid dependence and I have no sympathy for those who decide to peddle desperation and death. But the article reported that of those arrested, 21 were connected to distribution, and the rest were ‘independent users and sellers.’ I realize that most people will look at the rough-looking photos with disgust. But some of the people in the photographs, I know, have stories that would arouse sympathy—particularly if the stories were accompanied by photos from the days before their doctors prescribed pain pills, when they first presented with back pain, with their hair combed and wearing outfits other than orange jumpsuits.
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A Noble Profession

Each physician who prescribes buprenorphine for opioid dependence can treat only 30 patients at a time during the first year as a certified prescriber. After a year, physicians can apply to have the limit increased to 100 patients.  I have been at the 100-patient limit for some time, in part because of the shortage of providers willing to undergo training and go through the paperwork to get certified.

At the same time, there are no limits at all on the number of patients who can be treated by doctors with high-potency opioids, and no limits or regulations on the types of conditions that can be treated using narcotics.  It is no surprise that I receive several calls per day from people who ask for help, who I am forced to turn away.

The 100-patient cap, combined with the shortage of doctors, results in one of the few areas of true health care rationing, and it is only appropriate that the rationing hit drug addicts-- those viewed as society’s least deserving.  I realize that some people see ‘inability to pay’ as a form of rationing, and I understand the point.  But inability to pay has at least a theoretical solution—if not an actual solution if enough hoops are jumped through.  For opioid dependence, the patient cap is an absolute restriction, with no grievance or appeal process for those left out.
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