The forces of nature appear intent on reversing mankind’s progress toward better health.   An example is the ever-increasing resistance of bacteria to antibiotics.  A timeline of the existence of humans and bacteria shows that bacteria have been around for a very long time— much longer than mammals, and much, much longer than humans.  In fact by the dawn mankind, bacteria had been thriving, relatively uninhibited, for over 2 billion years.

Modern humans have been around for 40,000-200,000 years or so, depending on the definition of ’modern.’  Bacteria have had the upper hand during all of mans’ existence, save for the past 100 years after penicillin and other antibiotics were discovered. Only the most self-centered of species would look at a timeline and conclude that humans have won the battle with bacterial diseases.  There are always reasons for optimism, but a fair assessment of our current struggle with antibiotic resistance suggests that someday, people will look back on the current sliver of time, when humans can treat most bacterial infections, as a golden era of medicine that wasn’t appreciated as such at the time.

Viruses adapt to mankind’s health efforts too, with new variants arising from the sludge at the bottom of the food chain to infect birds, swine, or other creatures before moving on to human hosts.  The CDC and other scientists work to predict the vulnerabilities of the next super-virus, hoping to reduce the severity of the next pandemic.  As with bacteria, we are enjoying an era without smallpox, polio, or other dreaded viral diseases that used to kill otherwise-healthy people.  We take the victor’s position for granted to the point that our children don’t know why chlorine was first added to swimming pools.  Gone with the last generation are the fears associated with iron lungs, orange window-signs, and leg braces.

Even the Human Immunodeficiency Virus, an agent of certain death in the 1980’s was transformed into a chronic, treatable illness.  I was new to medicine when ‘universal precautions’ were first instituted (can our children even imagine having their teeth examined by someone not wearing latex gloves?!)  Researchers don’t celebrate, though, since medication-resistant strains of HIV were expected …

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 …

Today I read about the stereotactic brain surgery used to treat opioid dependence in China over the past ten years.   The procedure is relatively straightforward; the patient’s skull is clamped in place while small holes are drilled, guided by computerized, 3-dimensional maps of the brain.  Probes are inserted deeply through brain tissue to the nucleus accumbens, where electric current destroys varying amounts of brain tissue.   Patients are awake and talking during the procedure, so that surgeons know if the probes are too close to brain regions that control speech or other functions.

A large number of ablations for the treatment of addiction were performed in China about ten years ago.  The rapid growth in popularity of the technique, before full knowledge of the risks and long-term effects, led to a ban on the procedures by the Chinese Ministry of Health in 2004.  Still, ablations were performed as part of research studies, with over 1000 people treated by ablation since 2004.

The scientific community outside of China overwhelmingly condemns the technique, and medical journals are pressured to withhold publication of ablation studies.  Human rights advocates claim that such experiments are performed on people who are not fully aware of the risks, or who are pressured to participate in the studies to avoid harsh punishments for drug offenses.  The veracity of the results from ablation studies has also been challenged. Ablation treatment of opioid dependence is in the news lately because of a recent paper describing the five-year follow-up of opioid addicts treated by the procedure.

Neuroscientists distinguish between DBS (deep brain stimulation by electric current) vs. procedures where brain tissue is destroyed.  I’m surprised by the intensity of the distinction, given the similarity of the procedures.  In both cases long probes are passed through brain tissue, risking hemorrhage, stroke, or seizures.  For DBS, wires are left behind and connected to power-packs that release different patterns of electrical current.  In the ablation studies, small areas of tissue at the end of the probes are destroyed, and the probes removed.  If there is a …

People who read this blog are aware of the shortage of physicians who can prescribe buprenorphine to treat people addicted to pain pills, even as an epidemic of addiction to heroin and pain pills devastates the heartland of the country.  In order to prescribe buprenorphine, physicians take a short course and obtain special certification.  To obtain certification, physicians must promise to treat no more than 30 patients at one time, a number that can be increased to 100 patients after one year.

If you only have a few minutes, please take the time to go to the White House web site and add you name to a petition to allow individual doctors to treat more than 100 patients using buprenorphine.  The whole process is fast and easy, and only requires your name and email address through this link: http://wh.gov/QR6K

If you have more time, need convincing, or just like hearing a 52-y-o rage against the machine, continue reading my thoughts about limiting treatment for this one health condition.

The reason for the patient cap, according to cap proponents, is to prevent pill-mill practices where patients could obtain narcotic medications without adequate care for their underlying addiction.  That concern is reasonable, I suppose, but I often discover that proponents of the cap have other motives to keep the limits in place.  For example, one person at a ‘linked in’ group argued that individual physicians don’t provide the all-encompassing care that he provides… to the 800+ patients he ‘counsels’ at the methadone clinic where he works!  According to that counselor, all people addicted to opioids need years of counseling—largely from other people with addictions, who after a couple years of school have all the answers.

He would be surprised to see just how well people can do on buprenorphine, a medication that selectively removes craving for opioids.  After years of treating and knowing patients on buprenorphine I realized that ‘character defects’ are largely maintained by active craving.  Yes– people with antisocial tendencies before and during active addiction have the same antisocial tendencies on buprenorphine.  But people who …

Several of my patients have warned me about the world ending in a few days, on December 21, 2012.  There are variations on the theme, but the basic idea is that the Mayans, who were accomplished mathematicians and astronomers, used an advanced calendar to measure planetary cycles… and that calendar ends at the end of this week.   Some patients tell me that the end of the Mayan calendar coincides with predictions by the French seer Nostradamus, although the definitive authority on everything, Wikipedia, holds that Nostradamus did not make such a prediction.

I’ve browsed internet sites about this topic in order to prepare this post and found that there are about as many different versions as there are web sites about the prediction.  I suspect that some versions have more adherents than others, and I have no idea which web sites are the most authoritative.  I’ve read, though, that the world will end as described in the Book of Revelation in the Bible, or that instead, humanity will be erased, leaving the Earth unscathed.  I’ve read that the Earth and Sun will line up in a way that eclipses the energy flowing from the center of the Milky Way Galaxy, causing humanity to die off and be replaced by aliens from outer space.

Like any good prediction, this one has plenty of wiggle-room.  Comparisons between our modern calendar and the Mayan calendar require assumptions about how the Mayans determined months and years, so December 21st is only one best guess for the end of times.  Some interpretations place the date a year or so ago, and others place the date a year or so in the future.  In other words, things are not quite as tidy as they were at the millennium, when people only had to figure out which time zone marked where midnight would spell disaster.

Talk about the end of the world carries a certain levity, but like anything conjured by humans has a dark side.   In 1997, 39 members of the religious group Heaven’s Gate committed suicide in order …

Lately it seems as if I’ve been hearing more calls to change US marijuana laws.  The legalization of marijuana has been a cause for some citizens for decades, and efforts to change marijuana laws have waxed and waned since I was a teenager in the 1970’s.  Some people believe that this time around, attitudes are truly changing.  A recent Quinnipiac University poll  showed that as of November 2012, a majority of US voters favor legalization of the drug for recreational use.

The current status of marijuana laws are confusing, to say the least. Marijuana is regulated at multiple jurisdictional levels, so a person in any one location is subject to state, federal, and sometimes local statutes.  These statutes are often at odds with each other, so the legality of marijuana depends largely on the employer of the agent or officer making the arrest.

There are also multiple forms of legality. In November, Colorado and Washington State legalized the possession of up to one ounce of marijuana.  Another dozen-or-so states decriminalized marijuana over the past 20 years, so that possession of the drug is punishable by citation, not prison time.  Another 20 or so states have laws allowing for the medical use of marijuana, including in some cases provisions to grow marijuana for personal use or for a small number of patients.

By federal law, marijuana continues to be illegal in virtually all settings.  The DEA classifies marijuana as ‘Schedule I’, the same status as heavy-hitters like LSD or Heroin.  Smoking marijuana can be reason enough for most employers to terminate employment.  And violation of marijuana laws, even the possession of small amounts of marijuana, can result in permanent banishment from federal financial aid programs for higher education.

I have no pressing personal opinion on this issue.  I don’t have a ‘marijuana problem’, and I never really had a problem with the drug.  I smoked it as a teen, and note that the year of my high school graduation, 1978, was the peak year for marijuana use in this country.  But I never enjoyed smoking pot …

The LA Times ran a very interesting story a few days ago about deaths from overdose of narcotic pain medications.  I strongly encourage readers of this blog to read the story, which discusses the issue from the perspectives of doctors, patients, and family members.

The story reports that a small number of Southern-California doctors wrote prescriptions that have killed a large number of patients. Over the past five years, 17% of the deaths related to prescription-drug overdose–298 people—were linked to only 0.1% of the area’s doctors.  I was not surprised by the findings in the article, as I have read stories from other parts of the US reporting similar statistics.

There is a simple reason for the skewed numbers.  Prescribing opioids for chronic pain is associated with risk of death by overdose.  More and more doctors are avoiding that risk by refusing to treat chronic pain with opioid pain medication.  That means that the few doctors who are willing to prescribe such medications are linked to a higher number of deaths from those medications.

Are the doctors who prescribe narcotic pain medications ‘bad doctors?’  Some doctors would claim that they are.  I have described the doctors in a group called PROP, or Physicians for Responsible Opioid Prescribing, who take the position that almost all opioid treatment of chronic pain is inappropriate.  I understand the point made by those physicians.  Treating chronic pain using opioids carries significant risks.  Complications, including death, are common.  But I have met a number of patients who suffer from severe pain who take issue with doctors who tell them that they are better off without opioid pain medications.  And I’ve noticed myself, from my own rare occasional injury, that it is one thing to talk about the proper treatment for someone else’s pain, and another thing when one’s self, or one’s loved one, suffers from pain.

The skewed numbers also demonstrate the problem with online doctor rating systems that report on the complication rate for one doctor vs. another.   Across the spectrum of patients in need of surgery, for example, are healthier patients …

I’ve described the ongoing debate over the use of opioids to treat chronic pain.  To catch new readers up to speed, the country is in the midst of an epidemic of deaths due to overdose on pain medications or heroin.  The epidemic is evident to anyone who spends even a few minutes searching the internet using the keywords ‘overdose deaths.’   Another increasing phenomenon is the prosecution of physicians whose patients have died from overdose.  Physicians have been found guilty of manslaughter, even when people used the prescribed medication inappropriately, far outside of prescribed guidelines.  It is no surprise that in response, many doctors have stopped treating pain with opioids altogether.

I’ve described one group of physicians, Physicians for Responsible Opioid Prescribing or PROP, who have taken a position seen as extreme by some other physician groups, particularly groups involved in advocating for pain relief.  The latest efforts by PROP have resulted in a direct conflict with pain advocacy groups.  Readers of this blog who are interested in the issue can have a direct impact on the outcome of the situation.

Medications approved by the FDA have been shown through scientific study to be effective and safe enough to justify their use.  At present, opioid pain medications are indicated for moderate or severe pain.  There are no other restrictions on the use of pain medications from the FDA, but use of all medications, including opioids, must be within the ‘standard of care,’ a general pattern of practice in a given area that is sometimes difficult to pinpoint.

PROP has asked the FDA to change the indications to state that opioid pain medications are to be used only for severe pain.  They also asked that opioids be recommended for use for a maximum of 90 days, and never in doses greater than the equivalent of 100 mg of morphine.  They base their request on studies that have shown that some patients develop a condition of increased pain, when maintained on opioids for a prolonged period of time.  They are also concerned about the large numbers of deaths from opioids, …

This morning, as I read the latest stories about opioid overdose deaths, I was struck by a common thread in most of the tragic stories.  One report after another had phrases like ‘she was in and out of treatment for years’ or ‘he died tragically one month after leaving treatment.’

I often wonder, if we treated opioid dependence as if we were treating any other fatal illness, would the death rate be lower?  What practice measures would result from such an approach?

First, we would remove the veil of low-expectation that keeps us from realizing the ineffectiveness of ‘residential treatment.’  Once the low expectations are gone, huge questions would come to light.  Why does something so ineffective continue to be seen as the gold standard for treating a potentially fatal illness?

We know that opioid dependence is a chronic condition, marked by relapse.  What should be our measure of ‘success,’ when treating opioid dependence?  Is the treatment in a given individual a success, if that person dies within a year?  Within 5 years?  Does cost matter?  Should we expect better results for $50,000 then we would for, say, $2,000?

Expectations for good results with addiction treatment have been lowered over the years by the absence of other options, the assumption, conscious or unconscious, that addiction is more of a choice than a disease, and by an indifference to the loss of people who often turn friends, family, and society against them.  Instead of seeing a loved one destroyed by illness, people see those with addictions as foolish people, hurting themselves.  By the time death by overdose occurs, those close to an addicted person see death as inevitable; even as a blessed relief in some cases.

For decades, the public perception of residential treatment has benefitted from the fact that nothing better was available.  ‘Send him to treatment’ has become a phrase uttered without thinking; a suggestion that implies a great deal, yet offers almost nothing.  Perceptions of such treatments have also benefitted from abdicating responsibility for their failures.  When patient after patient does poorly, those providing such …

I subscribe to Google news alerts for the phrase ‘overdose deaths.’  Google Alerts are a great way to follow any topic; subscribers receive headlines from newspapers and web sites for certain keywords from around the world. One thing that has become clear from my subscription is that there is no shortage of stories about deaths from opioids! Every day I see one article after the next, as news reporters notice the loss of more and more of their communities’ young people.

Along with the reports of overdoses are stories about doctors who are increasingly being prosecuted for the deaths of their patients. In an earlier post I described the case of Dr. Schneider and his wife, a nurse, who were tied to a number of overdose deaths in Kansas. That case stood out by the sheer number of deaths; the State charged the couple with the deaths of 56 patients. Cases involving fewer patients have become relatively common. The latest case that I’ve read about is a doctor in Iowa, who is accused of causing or contributing to the deaths of 8 people.

I try to present both sides of the argument when I write about this topic. I have been faced with the difficult decision over whether or not to prescribe narcotics many times, and I understand a doctor’s dilemma. The doctor sees a person who is in pain, and knows that there is a pill that will reduce that pain. But the doctor also knows, or SHOULD know, that initiating a prescription for narcotic pain medication always has unintended consequences, no matter how good the intentions of both doctor and patient.

In the Iowa case, the dilemma over narcotic-prescribing is very clear. The prosecution states that the doctor prescribed pain medication to drug addicts.  On the surface, that sounds bad, right? One gets the mental picture of dirty, lazy people, dissolving tablets in a spoon, over a candle, and then injecting the mixture. But reality is much more complicated. Patients with histories of opioid dependence do not always have track marks. And even …