Our community had one of “those” providers — a midlevel who was the local pain person. If you had pain, go to her. She would write you for anything you could want and more. It’s unclear if she was unscrupulous or just inept. But last year, the DEA finally figured out what she was doing and yanked her license. There was nothing in the news. Nothing on the internet. We all knew it just by word of mouth from other providers and her patients. The tragedy for many of these patients was that not only did their primary care providers abandon them but even the local pain specialists abandoned them. No one would write for the doses of narcotics these people were on with the strategy to wean them down. No one would put them on Suboxone because no one wants to get their waiver. So they called me.
There are only a few of us in this community who have Suboxone waivers. We are a rural area that is not large enough to support a methadone clinic, so the only other medically assisted therapy that would keep these patients out of withdrawal would be Suboxone (buprenorphine/naltrexone). While shots of naltrexone alone are somewhat helpful to patients who need a deterrent from going back to opiates, those who are on high doses are facing a terribly rough road if they are not eased down with a substitute therapy. That is where buprenorphine comes in. It locks onto the opiate receptors and takes them out of withdrawal. It blunts their cravings.
These patients are often scared, to the point of being frantic. If the DEA wanted to create the perfect condition to create heroin addicts, they did a great job. Take a patient base on high dose oral prescription opioids and pull the plug on them with no plan and no providers willing to step in. Often these patients have coexisting mood disorders, depression, anxiety or bipolar disorders that have been left untreated.
Thankfully, I have been able to help several of these people wean down from unthinkable doses of opiates. One gentleman didn’t want to change over to Suboxone but just wanted me to take him down on his dose until he could get off the prescriptions. He started at over 500 mg of oxycontin and oxycodone a day and is now down to 10 mg three times a day.
Several other patients were brought in to the office in moderate withdrawal and started on Suboxone. We start these patients in the office by protocol. If patients have a lot of active opiate in their system and are not in withdrawal then giving them, Suboxone can precipitate withdrawal.
That being said, Suboxone is used by addicts in the community to keep from getting sick, and it has an extraordinarily good safety profile. The buprenorphine has a very high affinity for opiate receptors but reaches a plateau in its effect. Patients who are completely naive to it may have some euphoria with a first dose, but after that, they are not feeling “high” with steady dosing. It takes them from a state of withdrawal to feeling normal. Watching this transformation over the period of an hour in the office is an amazing thing to watch. These patients go from gray, fidgety, sniffling, nauseated wrecks to someone who looks fine in the span of an hour.
The tragedy here is that most primary care providers will not take the course and take the test (which any drug addict could pass) in order to write for this medication. Why? Because it is a difficult patient base to treat. These patients often lie, divert, relapse and misbehave in all sorts of ways that make the physician want to sit them down with Howard and Marion Cunningham (Happy Days reference) for some solid parental oversight. They need discipline, love, and guidance. And they need providers to not fall for their “my dog ate my films” stories.
Most providers seem paralyzed at the prospect of treating a patient that they can not trust. That being said, the patients I have who have been clean now for years, have gotten their children back, maintained a job, a home, and a car, and aren’t in jail or dead, and have been the most amazing patients I have ever known. They often have come from life situations that are ripe with stories of being beaten, abused and — at best — neglected. It takes a lot to come back from that. It takes a patient who sees that there might be a reason to hope that there is a way out of the hole. It takes a medical community who is willing to give them rungs to climb up.
Kathleen A. Hallinan is an internal medicine physician.
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