Societal attitudes Articles

Why the Suboxone Doctor Shortage?

Monday, January 6th, 2014

needleWith all the recent attention over the epidemic of opioid dependence, why do some parts of the country report a shortage of physicians who are DATA-2000 certified, i.e. able to prescribe Suboxone and other buprenorphine products? The shortage of buprenorphine-certified doctors parallels shortages of mental health practitioners in general, including psychiatrists and addictionologists. Larger cities and areas near the east and west coasts are less likely to have shortages of doctors than are smaller and more-rural parts of the country, particularly across the Midwest.

The shortage is caused by a number of factors.  All doctors train in medical schools, which are primarily located in larger cities.  So by the end of training. most doctors have spent several years living in larger cities, establishing friends and business partners and sending their children to area school districts.  As with members of any profession, doctors are more likely to choose positions in areas they know than to move to unknown areas, unless the area holds special attractions like morning sunrises over the ocean or mountain views.  Even doctors who grew up in rural areas find it hard to move back, after living in more urban areas during the 12 years of college, medical school, and residency.

Beyond the regionalization pressures, doctors are discouraged from becoming certified to treat opioid dependence using buprenorphine.  The coursework is limited by medical school standards, and the cost for buprenorphine training and registration is relatively minor.  But to become buprenorphine-certified, doctors must sign an agreement that allows random inspections by the DEA without cause.  Other doctors enjoy privacy rights similar to other businessmen, where search of the premises and review of records would require probable cause and issuance of a warrant by a judge.  But in order to treat with Suboxone or buprenorphine, doctors must waive that right of privacy and allow inspections with no notice, even if such inspections require closing the clinic doors for the day. The requirement to allow random inspections has an effect on individual doctors, especially since the 100-patient limit (30 patients the first year) guarantees that buprenorphine-prescribing will not support a …


A Deeper Look at Suboxone Diversion

Sunday, November 24th, 2013

In ‘Addiction Treatment with a Dark Side’, Deborah Sontag of the New York Times shared her observations of the clinical use of buprenorphine for treating opioid dependence, warts and all.  Readers of the Talk Zone know my bias—that buprenorphine/Suboxone is one of the only effective treatments for opioid dependence, and many patients are best-served by long-term, perhaps life-long treatment with buprenorphine.   But I read the article the article with interest because I know that Ms. Sontag ‘did her homework’, including visiting a number of practices, speaking with a number of patients, and reviewing hundreds of studies about buprenorphine and Suboxone over the course of many months.

From my perspective, the article overstates the diversion problem.  In my last post I asked if the fear of diversion should be a factor in whether buprenorphine-based medications become the leading edge of addiction treatment.    I stated my opinion—that if overdose deaths don’t pull acetaminophen from pharmacy shelves and diversion doesn’t keep hydrocodone off the market, then diversion of buprenorphine deserves little discussion relative to the value of buprenorphine treatment for addiction.

With the wave of stories describing buprenorphine as ‘controversial’, every discussion of the medication seems to revolve around diversion.   Do the numbers support the association? Deaths from Suboxone—deaths where buprenorphine was one of the drugs that caused death—amounted to several hundred over the past ten years, compared to 38,000 drug overdose deaths in 2010 alone.  The magnitude of the difference is so staggering that it deserves repetition; 400 deaths in ten years, vs. 38,000 deaths in one year.  The total number of deaths linked to buprenorphine over the past ten years is about equal to the number of people who die from acetaminophen– EACH year.

Diversion of buprenorphine is a complex issue.   Words like ‘diversion’ and ‘overdose’ are loaded with so much emotion that one word seems to tell the whole story.   A Google search of Suboxone brings up news reports such as ‘Suboxone found at overdose scene’, or ‘man arrested with cocaine, heroin, and three Suboxone tablets.’  The stories create an ugly image, with buprenorphine/naloxone as one more drug of abuse, found at ‘an increasing rate’, according to other headlines. But a superficial look …


Now the Tough Part

Sunday, May 12th, 2013

injectionThe 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 …


Guilt by Association?

Thursday, March 14th, 2013

heroincrpdA 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 …


Brain Surgery for Opioid Dependence

Tuesday, January 1st, 2013

brain surgery for opioid dependenceToday 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 …


Be Heard– Raise the Cap!

Wednesday, December 26th, 2012

buprenorphine prescriptionsPeople 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 …


The End of Times: Aren’t We Special?!

Monday, December 17th, 2012

the end of timesSeveral 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 …


Marijuana: Useful Treatment or Pandora’s Box?

Saturday, December 8th, 2012

marijuana and addictionLately 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 …


What Should Doctors Risk for their Patients?

Thursday, November 15th, 2012

risky prescriptionThe 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 …


Enough Pain Regulations?

Wednesday, October 3rd, 2012

pain regulationsI’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, …


 

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