As I’ve mentioned, I receive several e-mails each day asking questions about opioid dependence.  There are a number of confusing opinions, attitudes, and regulations that ultimately get in the way access to treatment.  And with opioid dependence, access to treatment can mean the difference between life and death.

One area of confusion relates to the use of methadone to treat opioid dependence.  Methadone is a potent, low-cost pain medication.  While a month’s prescription for Oxycontin may retail for $400, $500, or much more, a prescription for a similar amount and potency of methadone costs less than twenty dollars.

Besides treating pain, methadone is used to treat addiction to opioids through highly-regulated programs.  Laws allowing for these ‘methadone maintenance clinics’ were enacted in the early 1970’s, to counter the surge in heroin use that began in the late 1960’s .  The clinics were located mainly in inner cities, where most of the intravenous heroin addicts were located at that time.

Over the past ten years several corporations have purchased, consolidated, and refurbished methadone clinics, moving them to suburbs and rural areas to match the dramatic increase in addiction to heroin and other opioids in those areas.

Yesterday I received the following e-mail:

Hi Dr. Junig,

Please let me first say – Suboxone SAVED MY LIFE. I was down and out until 2 years ago, when I began using Suboxone. Now, having completed all the pre-req’s for medical school with nothing less than straight A’s, I find myself on track to apply to medical school.

But here’s the problem. I’m still taking Suboxone and have no desire to stop. I will quit if absolutely necessary, but I’m wondering if you’ve heard anything new regarding the legalities of health care providers taking buprenorphine.

I would love to enter a field like psychiatry or family medicine, as these are the doc’s I’ve grown fond of over the past two years. I haven’t told my doctors of my med school plans, as I fear that they will block my attempts to apply/matriculate. Do you have any insight on the subject? Do you know of any patients who have gone on to medical school?

Thank you,

MD to be

I have received a number of similar messages over the past few years.  Just today I received an e-mail from a person who wants to become a CNA.  I have been asked the same question by people wanting to work as truck drivers, nurses, and police officers, among other professions.

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.”

Like many people with opioid dependence, I did not progress to a severity of illness where I decided that I needed addiction treatment.  It would have been less burdensome for my family, of course, had I come to such a realization.  But I needed stronger ‘encouragement,’ in the form of life falling apart and having nowhere to turn, except treatment.

The nature of opioid dependence leads the addict to cling to the illusion of power, believing that if he tries one more time— just a little bit harder, or perhaps using some special technique—he will find the will power to taper off drugs on his own, and then avoid them forever.

Of course any person addicted to pain pills desperate enough to walk into a psychiatrist’s office has tried to stopping dozens of times, if not more.  That doesn’t prevent cold feet at the prospect of surrendering to the treatment of some doctor, and patients often scramble to reverse the actions set in motion by spouses, parents, and other family members.  ‘I really think I can do it this time,’ they say.  I’ll cut back by a tiny amount every few days, and THIS time I’ll REALLY stick to the schedule!’

I’ve described the gray area between appropriate treatment of chronic pain using opioid medications, versus deliberate or accidental over-prescribing of narcotics for patients who don’t need them.  In many cases, the decision whether the prescribing is justified depends on who is making the determination.

There are clearly physicians who act too aggressively at increasing dosages of narcotics, and there are clearly patients who are too careless in their use of addictive medications.  At the same time, there are a number of patients who suffer from severe pain, who are unable to find a physician who will prescribe opioid pain medication– medication that if managed properly could relieve that pain.

And then there are cases that remind me of the famous quote from Justice Potter Stewart, in a 1968 Supreme Court case involving pornography: “I know it when I see it.”  Such was the thought that came to me as I read the news story about a physician and his wife, whose prescribing of opioid pain medications has been linked to at least 68 deaths: