A local District Attorney wrote to me last week to express his concern about the increased diversion of buprenorphine. I often sense an undercurrent of tension when I cross paths with attorneys, aware of the different attitudes that we hold that arise from our different roles in society.
The DA wrote about the dramatic increase in overdose deaths in the Midwest. Overdose scenes are often littered with a variety of substances, ranging from bags of heroin to the orange plastic vials used by pharmacies to dispense medications. If the overdose victim was on Suboxone or buprenorphine, the prescribing doctor is often contacted about the death and the ensuing investigation. Doctors notified about patient deaths have reactions beyond the grief over the loss of someone they cared about, including guilt that they couldn’t save the patient, and even fear of being blamed for doing something wrong. Every doctor has seen headlines featuring peers accused of reckless prescribing, and the addiction world is somewhat unique from other specialties in the way that patient deaths cause a sense of ‘guilt by association.’ Oncologists, for example, are not viewed with the same degree of suspicion when their patients succumb to cancer.
I felt a bit defensive about the DA’s letter. I know that buprenorphine saves lives, beyond a doubt. I also notice that the positive actions of medications are often taken for granted, while the risks are cited as scapegoats. I notice how quickly people complain about others ‘on buprenorphine’, without taking the time to ponder what would likely happen were buprenorphine not available.
Some physicians’ fears stem from dilemmas faced in treating addiction that are difficult or even impossible to resolve. For example, a DA may point out that the doctor’s patients are not behaving like ideal citizens, not realizing that the doctor is every bit as aware of the problem, yet unable to make things better. In some cases doctors do the very best they can (or that anybody could do, yet their patients struggle to maintain sobriety. Doctors may be tempted to abandon the problem patients altogether, to avoid being seen …
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.
Researchers in Pisa, Italy recently published findings from a study of heroin addicts treated with either buprenorphine or methadone. The study was a follow-up to earlier studies by the same group; one that examined the personality characteristics of heroin addicts, and a second that measured the impact of agonist treatment on psychiatric symptomatology and the quality of life of heroin addicts.
The recent third study, published in the Annals of General Psychiatry, divided heroin addicts according to personality traits, and then examined whether these personality traits predicted success with one agonist treatment over another (i.e. methadone vs. buprenorphine).
‘Agonist treatment’ is used in the Italian studies to refer to maintenance with methadone or with buprenorphine—even though buprenorphine is technically a ‘partial agonist’ rather than an ‘agonist.’ Personality characteristics were defined using an instrument called the SCL-90 (Symptom CheckList-90).
In the first study, researchers found that the 1000 or so addicts could be divided into five subgroups, according to clusters of symptoms. One subgroup was characterized by depressive symptoms. The second was characterized by somatic symptoms, i.e. focus on physical symptoms and complaints. The third group was characterized by ‘interpersonal sensitivity’ and symptoms of psychosis—such as delusions. The fourth group had significant panic or anxiety symptoms, and the final group had symptoms related to violence toward self or others, including suicidality and self-mutilation.
Ready for a little controversy? A decade or so ago, a new approach to addiction treatment was developed under the general heading of ‘harm reduction.’ Proponents of the approach realized that many addicts will never achieve total sobriety from all intoxicating substances, efforts were best focused on reducing the most harmful consequences of addiction—drunk driving, overdose deaths, and the use of the most addictive substances.
Treatment centers focused on the use of opioids, and reduced emphasis on marijuana. Other harm reduction approaches include clean needle exchanges, and some proponents have even argued for the development of ‘shooting galleries’ where addicts can use heroin in a ‘safe’ environment.
I saw a patient from up north earlier today, and we talked about the economy in his part of Wisconsin and in the Michigan Upper Peninsula. From what he had to say, things are the ‘same old same old;’ i.e. jobs are few and far-between. Seems as if it has been that way for a long time now. And it’s hard to imagine any industry doing well enough in the current economy to make a dramatic change up there.
One change that HAS become apparent over the past year is the increased availability of heroin, now easily found in small towns throughout the upper Midwest.
I’ve seen the same trend closer to my practice, where heroin use has grown from a Milwaukee phenomenon to just another high school temptation. Along with the use of heroin comes something not as often associated with high school; intravenous drug abuse, or IVDA. And a troubling comment pops up more and more during my discussions with people actively addicted to opioids: “Now that O-C’s are abuse-proof, we gotta’ use heroin.”