I haven’t gone anywhere in case you’re wondering… but I recently started writing a blog on Psych Central, called ‘an epidemic of addiction.’ Please add it to your reading list! This is my favorite time of year and the time I am most likely going to be outdoors, so watch for posts to pick up a bit as things get colder outside.
I’m probably in the wrong state of mind to be blogging, so consider this more along the line of venting. I had an encounter with a local physician a couple days ago that left me shaing my head– I have a solo practice so I have forgotten just how misguided medicine can sometimes be. I was asked to speak with an orthopedist for a patient who takes buprenorphine, who was having major knee surgery. The orthopod started the discussion by saying that he is angry that the patient didn’t say at their first meeting that he takes Suboxone– like it should have been spelled out on his forehead, to make certain that he didn’t give the patient some undeserved pat on the back or some measure of kindness. I explained that people on buprenorphine find often find that they are treated differently by (ahem) those doctors out there who (AHEM) pre-judge people… And the ortho guy said ‘well, for good reason!’ As I remember the encounter I’m having visions of the song ‘KILL THE BEAST!’ from Beauty and the Beast– I’m sure this particular doc wishes we ALL would just go away…
Where was I? Oh yes– the doc then explained to me just how hard it is for him to treat people on Suboxone. He explained how the ‘therapeutic window’ is narrower– meaning that the ratio of the dose that treats to the dose that kills is larger. I tried to explain that it ISN’T– the entire window is HIGHER, but not NARROWER. You all know that, of course– on buprenorphine your tolerance goes up, and it takes a much larger dose of opioid to get pain relief, and a much, much, much larger dose of opioid to cause death. I tried to explain that this is not rocket science; I would taper the person off buprenorphine ahead of time (I usually tell people to take 4 mg of buprenorphine per day for a week before the surgery, then skip it entirely on the day of surgery), and he could simply treat the person as he would anyone who is tolerant to about 60 mg of oxycodone per day. I still cannot believe the response from him–that ‘nobody around here takes that much oxycodone’– that those are ‘big city problems’ and that there just aren’t people doing that around here.
He told me that he doesn’t like giving pain pills to ‘these people’ (he knows, by the way, that I am an opioid addict). Never mind that he is going to be doing a ‘total knee’, where the ends of the femur and tibia are sawed off and replaced with metal pieces. I explained that proper treatment is to provide a basal amount of narcotic, and then use a larger than normal PCA (patient controlled analgesia) deamand dose. I explained that fentanyl may work better according to some reports, but he said ‘I never use fentanyl.’ So I explained that he could use morphine, but that it would take at least 5 – 10 mg IV to have ANY effect on pain. He said that he would never give that much– that he would give less than usual, if anything.
At some point he mentioned that it bothered him that the patient has taken buprenorphine for 8 months– that it bothered him to ‘think that there are people out there walking around on that stuff.’ I told him that in some states, the more progressive and intelligent licensing boards are recognizing that patents on buprenorphine are not impaired, and are treating them like regular people– to which he replied ‘then why don’t we just give alcoholic pilots a 12-pack and let them fly?!’
Wow. I had a range of feelings after the discussion. The first thing I did was contact the patient and strongly recommend that he seek surgery elsewhere. The guy I am talking about is good enough at sawing bones, but is clearly an idiot when it comes to thinking through medical challenges– and my patient deserves to know that. In a perfect world, someone would recognize that doctors like this one have no business working in the field of medicine. I used to work with this doc when I was an anesthesiologist and I knew that he was bone-headed (pun intended!), but I had forgotten just how nasty and judgmental he could be. I am tempted to post his name, but I won’t — it would only bring me even more headaches than I already create for myself! But if anyone is having orthopedic surgery in Northeast WI, feel free to send me an e-mail and ask.
The main thing I’d like to say though is that I am sorry that the medical profession has those types of people among its memebers. Those of you who feel like you are suddenly being judged, when your doc finds out that you have struggled with addiction– you are probably NOT going crazy. Ignorance is alive and well, and the day when addiction is treated like other diseases is still a long ways off. And that is a real shame.