Leadership on Opioids

Anyone who proposes an easy solution to the overdose epidemic is either a simpleton or a politician.  But far too many people entrusted with the power and responsibility to set priorities decry the number of overdose deaths, then stigmatize and demonize every effort to save lives.   “Suboxone can be diverted.”   “Someone might drive impaired after methadone.”  “Needle exchange programs attract drug dealers.”    Meanwhile the number of deaths from overdose make clear that current solutions are not working.  Small community newspapers have story after story about the increasing number of deaths, but the silence in Washington is deafening.    I picture a cruise ship leaving  one after another drowning passenger in it’s wake, while the ship’s captain dines at the captain’s table, pausing between bites to tell dinner guests that all is well.
Statistics and numbers don’t tell a story unless put into context, so some simple comparisons help demonstrate the magnitude of the ‘opioid problem.’  My perception is skewed after sitting with so many people affected by addiction, but we seem to have a huge blind spot for one of the leading killers of young people.  Consider the issues our country’s leaders talk about and our news reporters write about.   I think we all know the things that get our President’s undies in a bundle… but did I miss the Presidential Summit on Opioid Dependence?  This would not be the first time that our leaders missed the elephant in the living room, of course— but it may be one of the first times a President has been given a pass after missing this big an elephant for this long.  I’m old enough to remember the media soundly criticizing Reagan for failing to create a sense of urgency over AIDS.  And so I wonder… When is Obama going to express urgency about opioids?  Where is the media criticism of his lack of urgency?   Today he told reporters he ‘will leave everything on the field during his last year in office,’ just before he took off for another Christmas in Hawaii.  Will that time on the field include some concern for people killed by overdose?
I don’t get the impression that our President lies awake all night worrying about overdose deaths.  But maybe he should.  We heard a great deal from Obama about the need to bring troops home from Iraq a few years ago.  And all of the networks kept a running tally of US deaths in Iraq in the lower right corner of the screen during the evening news.   So let’s compare priorities.  Let’s add up all of the deaths of US troops during Iraq II during two administrations of Bush and the 1 and 3/4 Obama administrations.  Let’s add the deaths from the World Trade Center attacks, the recent terrorist attacks in France and California, and the mass shootings at Sandy Hook and Columbine.  How does that number compare to the impact of opioid dependence?
I don’t intend to lessen the honor of fallen military servicemen and women, or downplay the horror experienced by victims of 911 and other violent attacks.   I chose these numbers because the horror of each situation prompted speeches by our leaders, rallies by our citizens, and headlines in National news media.   The speeches and commitments of our President and the coverage by news anchors are supposed to be a reflection of what our citizens care about.
The number of deaths from overdose in 2013 alone– one year– was over four times greater than the complete count of US deaths in Iraq, plus all of the horrible events listed above.   US deaths in the Iraq war?  About 4500.  The Trade Center attacks killed almost 3000 people.   In 2013, over 30,000 US citizens died from overdose.  Surprised?  I was.  On average about 100 people in the US die from overdose every day– day after day.
As I wrote above, I remember the reporters calling out Reagan over AIDS.  Activists claimed that Reagan avoided talking about HIV because of the stigma associated with ‘homosexuals’, the people hit the hardest by the initial outbreak of HIV.   They say that the people who died were ‘second class citizens’ who didn’t have a voice, and it was easier for Reagan to pretend that the problem didn’t exist.  Many people believe that if Reagan spoke about AIDS in his speeches or directed National attention toward the outbreak of the virus, that fewer people would have died.   Maybe those people were right.
If they were, what’s Obama’s excuse?

Obsessed with Suboxone Diversion? Raise the Cap!

Last week, HHS Secretary Sylvia Burwell announced that the cap on buprenorphine patients will be raised above the current limit of 100 patients per doctor. This move, should it actually occur, will potentially save tens of thousands of young lives per year, given that over 30,000 people die from narcotic overdose each year. But instead of cheering the good news, some doctors used the occasion to rant about diversion. Those doctors get on my nerves, and I’ll explain why.

Buprenorphine, the active ingredient in Suboxone, prevents opioid withdrawal in heroin addicts while at the same time blocking the effects of heroin and narcotic pain medications. Many heroin addicts keep a dose or two of buprenorphine handy for times when the heroin supply, or money to buy heroin, runs low. Other opioid addicts use buprenorphine in attempts to detox off opioid agonists. Their efforts almost always fail, as freeing one’s self from addiction is much more complicated than getting through withdrawal. But the statistics don’t keep addicts from trying, over and over again. After all, the belief in personal power over substances is part of the addictive mindset.

Buprenorphine is viewed as just one more drug of abuse when viewed through the superficial lens of news reporters. Even some buprenorphine prescribers fail to understand the important differences between buprenorphine and opioid agonists. But the differences are important. While over 30,000 people die from overdose of opioid agonists each year, less than 40 people die each year with buprenorphine in their bloodstream. Of those deaths, most were caused by opioid agonists, and would have been prevented by more buprenorphine in the bloodstream.

I admit to a great deal of irritation when I hear doctors who should know better spreading ignorance and stigma about buprenorphine—an ideal medication for the current epidemic of overdose deaths. To you doctors: Really? 40 deaths per year—deaths not even caused by the drug— are the horrible cost to society that you are complaining about? The same number of people die from lightning strikes! Maybe, while you are at it, you should complain about tall trees on golf courses!

Forty deaths. FORTY!

I think of fields of medicine where doctors take the lead to guide society to do the right thing. Getting insurers to treat AIDS was the right thing. But when overdose is the biggest killer of young adults, my colleagues spread fear about buprenorphine?!

Buprenorphine diversion is a complicated issue. Contrary to the media-propagated image of addicts getting ‘high’, opioid addicts always, eventually, become desperate and miserable. Some miserable addicts learn about buprenorphine, a medication that almost instantly blocks the desire to use heroin or other opioids. When buprenorphine was approved for treating addiction, a cap was placed on the number of patients treated by each physician. Reasons for the cap range from a desire to prevent ‘treatment mills’ to political compromises. But whatever the reason, treatment caps and other restrictions prevent doctors from prescribing buprenorphine. In the absence of legitimate prescribers, addicts purchase buprenorphine at a street price determined by supply and demand.

Some patients sell their prescribed buprenorphine medications. Such sales are against the law, just as selling Oxycontin or Vicodin is a crime. But in a world where heroin can be purchased more cheaply than Suboxone, and where pain pills kill tens of thousands of people each year, I’m sorry if I don’t get hysterical about the ‘buprenorphine problem’. If there was any evidence or suspicion that buprenorphine serves as a gateway into opioid dependence (there isn’t), I’d think differently. But use of buprenorphine, at this point anyway, is confined to miserable heroin addicts looking for a way out of active addiction, who can’t find legitimate prescribers of the medication.

So to the people who wrote on government websites over the last week that ‘it makes no sense to treat one addictive drug with another’: You don’t have a clue. Buprenorphine has unique properties that treat the essence of addiction—the compulsion to use ‘more’. And addiction is a chronic illness that deserves treatment as much as any other chronic illness.

And to the doctors who prescribe buprenorphine products and get their undies in a bundle about greater access to buprenorphine: With all due respect, you must be doing something wrong. I have 100 patients right now who tell me, at each visit, that I saved their lives. I credit the medication, since the unique properties of buprenorphine are far more important than anything I have to say! But I know that something saved their lives, because their former friends are dead, and they are alive– working jobs, raising families, and occasionally reaching out to lucky friends who survived long enough to hear them talk about the wonders of buprenorphine.

To those same doctors: How can you not be excited by a medication that has saved so many of your patients? If you don’t have such patients, I suggest you give some thought to what you’re doing wrong! In this field, with this medication, saving lives isn’t that difficult. After 20 years in medicine (including 10 years as an anesthesiologist), I’ve never had the opportunity to benefit human life as much as with these patients, with this medication.

I hate to mess up a passionate article with talk about neurochemistry, but a couple facts deserve clarification. Diverted buprenorphine is not a ‘pleasure’ drug. I’ve heard stubbornly-ignorant doctors compare buprenorphine to heroin, as if their stubborn beliefs alone can turn an opioid partial-agonist into an opioid agonist. Surely they know that if someone with a tolerance from regular use of heroin takes buprenorphine, the drug will precipitate severe withdrawal?! And if the same person injects buprenorphine, the withdrawal will be even more severe! On the other hand, if someone addicted to heroin goes without heroin for over 24 hours and then injects buprenorphine, the buprenorphine will reduce the withdrawal. But since the maximum effect of buprenorphine is far below the maximum effect of heroin, there is no way for the person to get ‘high’ from buprenorphine. This is all simple neurochemistry! When a person injects buprenorphine, opioid withdrawal will be relieved more quickly. But that’s a far cry from thinking that buprenorphine causes a ‘high’ similar to the effects of heroin.

After treating hundreds of patients over the years and talking at length about every aspect of their drug use, including their use of buprenorphine products intravenously before they found prescribers of the medication, I have always heard the same thing: that buprenorphine relieved their opioid withdrawal.

When I ask why in the world they injected buprenorphine, I hear the same reason– because the drug is expensive, and lasts five times longer if they inject it. That answer, by the way, is consistent with the 25% bioavailability of submucosal buprenorphine.

How depressing that patients with addictions are treated like idiots… when they have a better understanding of neurochemistry than some doctors!

Raising the Suboxone Patient Cap

HHS Secretary Sylvia Burwell announced yesterday that the cap on buprenorphine patients would be raised in the near future.  Details were not released, but she emphasized that measures would be taken to increase availability of this life-saving treatment, while at the same time taking caution to prevent misuse of the medication.   Anyone who works with buprenorphine understands the importance of her announcement.  I only hope that her actions are swift, and not overloaded with regulations that reduce practical implementation of whatever increases are allowed.
I have been at the cap for years, unable to accept new patients for buprenorphine treatment.  My office receives 3-4 calls each day on average from people addicted to heroin, begging for help.  Patients on buprenorphine (the active substance in Suboxone) are much less likely to die from overdose than are patients not taking buprenorphine– even in the absence of perfect compliance.  Some doctors, in my opinion, over-emphasize the ‘diversion’ of buprenorphine medications.  At least in my part of the country, ‘diversion’ of buprenorphine amounts to heroin addicts trying to stop heroin, taking ‘street buprenorphine’ because of the absence of legitimate treatment spots.    Of the few new patients I’ve been able to take this year, almost all have histories of using buprenorphine products on their own, without prescriptions.  They are very happy to finally have a reliable source of the medication– and to have the medication covered by their health insurance!
Let’s hope the increase in the cap happens sooner rather than later.  After all, lives are literally hanging in the balance.

What’s Up with Buprenorphine?

I think about a joke my dad used to tell over and over.  A guy is upset because his kid has never talked in his entire life.  He has taken his kid to all the specialists, but nobody has an answer.  Then at his 18th birthday party the kid blurts out “we’re having ham AGAIN?!’    His family breaks out in tears of joy, and eventually his dad asks him why he hasn’t talked for so long. The kid pauses, and then says “up to now, everything was OK.”
A dumb joke… but then again I just saw a PBS show about the life of Joan Rivers, and I was struck by how so many comedians make a living by saying things that are simply disgusting, and passing them off as ‘comedy’.  Joan’s disciples all have the same type of humor… what’s the name of that red-headed woman who did a brief stint on Seinfeld?  Just say something shockingly rude to a crowd who paid to see you, and they laugh.
Got off track.  My point was that I’m sorry for being gone so long, and I wish the reason was because there was nothing to complain about.  Unfortunately, there are still plenty of things to complain about…. the cap on doctors prescribing buprenorphine products, the large number of overdose deaths, the spread of hepatitis C and other blood-borne illnesses, the ignorance of the media and among some DA’s and law enforcement agencies…
Frankly, I took a break from writing because I was tired of being so angry all the time.  But over the past few months, I’ve received daily messages from people suffering from addiction and looking for answers.  I appreciate those of you who continue to stop by the web site and the Forum, and I’ll try to get over my anger and get some new content out here.
I have at least a few things that I’d like to address at this point– but please feel free to help me out by sharing a question, an interesting situation, or anything else that you find interesting.. and I’ll use it as a starting point for a post.  Send me an email, or leave a comment… and I’ll be back!
BTW, hope everyone had a nice summer!

The Overdose Report

I set up a new site today that collects newsfeeds related to the epidemic of opioid dependence and posts links to the articles.  Some of the news stories strike a sensational tone, as opposed to the somber nature of the content— and my intention was not to create a website fashioned after an episode of ‘Cops’.   But there is an epidemic going on, and many of the articles refer to efforts to stem the tide through legislation at the state level throughout the country.  Feel free to check it out…  and I hope it doesn’t come across as insensitive because of the title.
Overdose Report