from a retired attorney with the AMA:
Pay attention to what state-level officials are doing -- not what they are saying.
#1 Every state Attorney General that is suing any prescription drug manufacturer is just sending hundreds of thousands of dollars to buddies in law firms . . .who will reciprocate at the next election. There is no basis in law for any claims against opioid manufacturers. None. These are not Over-the-Counter (OTC) products like tobacco so there is no relationship between the tobacco companies settlement and prescription drug manufacturers. In between every company and consumer of a prescription drug is a physician who completely controls patient access.
#2 While CA gets its $1B federal funding to pay for in-state opioid addiction experiments like those described in the article, your state can get identical dollars for comparable programs under Congress' 2016 21st Century Cures Act. DO anchor those in-state programs in the same rigorous science that CA is applying--to measure medical and financial outcomes over years. Look away from your elected leaders and they will send the money expanding buddies' or churches' programs that are proven not-effective for opioid addiction, e.g., AA and talk therapy.
Every Governor must be watched on money in and money out if we are to make progress like CA has made.
13
Twelve step programs CAN be effective with ANY type of addiction, but it is difficult to measure outcomes. Most efficacy studies of them are improperly designed (they start with a roomful of people at an AA meeting, and see who is around a year later....a worthless design ). Healing based on spiritual energy (which is what 12-step programs really are) are never going to be measurable using "scientific method" approaches of predictability and repeatability. That does not suggest that they can't work, just that we can't measure them easily.
3
@Rick S
Not disrespecting what AA has achieved with alcoholics over decades, including my drunk Irish parents, aunts and uncles.
What we must get with this seed money is what is called "health and economic outcomes" data that can be analyzed to find what is and what is not effective. And which interventions are most reproducible at a manageable cost across this country. More of what the Yale study is now sharing in CA and UT.
Not sure if it is still the case but in a long time ago I was told one way to prevent DT - especially when no other medications available - is a stiff drink. Perhaps same idea.
Of course, like clean needles and using condoms, this sort of controlling the input as a way to step down the addiction is controversial but between death or alive, perhaps it is a judgment call by the people who know what they are doing professionally and do not carry any chips on their shoulder.
Too bad there are people too righteous to the good of society. They want to substitute personal beliefs for science. Decades ago, there were the Twitchells
7
I should have mentioned in my earlier post that I've been a mental health and addictions treatment provider for 40 years. I've noticed over the years that everybody seems to think they are addiction experts and know how it should be treated-including addicts and alcoholics as well. Many of the comments made are from people who identify as professionals or addicts who found relief from their problem from suboxone or abstinence, but many of them come from people who appear to have little knowledge or experience with addiction. Addiction is complex. It is mainly a biological problem, but it may have psychological and social components as well--or it may not. Not every person responds equally well to the same intervention. Some respond well to buprenorphine or methadone. Some respond to an abstinence-based approach. Some need psychotherapy, family therapy, job training, other medications--or some combination of all of the above. The idea that there's one solution to everyone's addiction problem is absurd. This is not an "either/or" matter. One thing I learned in 40 years of dealing with addicts, is that we need every weapon in our clinical arsenal to help them. And yes it's true--some addicts don't want to get better or are afraid to. They will have to accept the consequences of their behavior. But many addicts DO want to change their lives for the better, and in my opinion they need and deserve every opportunity we can give them.
24
@Quiller
BRAVA or BRAVO! Thank you for putting up with the nit wits who won't or can't accept any anchors in science and medicine.
As a physician member of the Internatl Society of Biological Psychiatric reminded me decades ago in my medical work life: "Start with biology and then consider all other elements." All ISBP are dual Board-certified in IM and PSYCH.
3
In this article you can see the hope for a better world. This article really stuck out to me because you hear many stories about people in bad places in their life that want help, but don't know how to get it. This article stands out because this is it. This is the help they need. The way the doctors help is by giving the patients a dose of buprenorphine. This drug is not meant to cause any pain and this is why it is so useful for these kinds of treatments. This article stands out because of all help it will provide and how big of a game changer this really is
9
- 1980s - addiction is a crime. Mass incarcerate those predators!
- 2010 - addiction is a disease. Treat them in ER on tax payers dollars!
Hmmm...I wonder what's different between the two cases...
4
We've had quite a few articles similar to this recently. When do we get the articles about the other victims of drug abuse, the women and girls across Central America who have been raped and killed by the drug cartels, and the schoolgirls in Afghanistan, killed by the Taliban?
These women and children die at the hands of criminal gangs that get money by selling drugs to American addicts. The money these addicts spend for their fixes pays for the guns and ammunition. It's a direct link.
When do we start reading those stories?
2
for 6 months I am on suboxone.before 13 years on opiods for pain.although I still have pain. I stopped the opiods for good.i never got high on the opiods and it never helped much with my pain.Not sure if I needed suboxone but it is nice having less constipation.
6
These people arrive at the hospital looking for treatment for their symptoms, not a solution to their drug problem. I know, I've been through it. A temporary fix at best - and an enabling one at that. A slim margin wind up in a treatment program that further has a miniscule success rate because the drugs are still too easily available. One in a thousand chance perhaps.
They are a danger to themselves and others and the only way they can ever think lucidly enough to make a rational decision about their well-being and future is a minimum 6 month course of involuntary confined treatment. Yes, a brain-washing for lack of better terms - some poisoned brains need it. As long as an addict's care is in their own hands, drugs will win 99% of the time.
5
@Dave T
WOW! throw the creeps in jail because of their DNA-from-birth that hard wires their bodies to be addicted. Don't treat them like a person with another chronic lifelong disease like diabetes?
They'll have company in our wide array of mostly private for-profit prisons: 62% of inmates are mentally ill. We cannot figure out what to do with those people so they too are jailed.
Blame&Shame is alive and well in this commenter while the rest of the world and, very slowly, this country moves to a medical model of walk-in clinics for methadone maintenance or others drugs that addicts need dispensed daily before they go to work or school or home to care for families. . .just like diabetics need insulin and periodic trips to an ER as part of their lifelong care plan.
10
What an expensive waste of resources for people that really don't want to stop using. Once a junkie always a junkie.
Next will come the religious right telling us this is not God's will or some other nonsense. Instead, addicts should seek the Lord and counsel thru their priest. Oh wait, the local priest is headed to jail for child molestation. Now who should they turn to??
2
Finally. Go Oak Town.
3
I feel compelled to add my comment as a chronic pain sufferer who experienced a transformation in my ability to work, parent, volunteer, socialize, exercise-in short, to have a life thanks to the relief offered by well-controlled, monitored opioid dosing. My doctor (an interventional anesthesiologist) has been diligent in seeing me for regular appts., lowering or raising doses as circumstances warranted, coordinating w/other physicians when medical procedures have required temporary additional pain relief, etc.
I have never considered myself an "addict," but like any other health condition that is controlled by medication to which your body can & does become acclimated & in some sense dependant to achieve normal functioning, were I to lose my Dr. and/or my access to medication, it could create a serious medical challenge for me-requiring rapid response in an environment that is often, frankly, hostile to the needs of ANY patients, much less those who have followed the rules & cooperated w/their Dr's. for years. I applaud the efforts of Dr. Herring & others like him who remain focused on the best interests of the patient in attempting to rein in this needless avalanche of suffering & loss of life to a condition that CAN be managed.
16
Buprenorphine quite simply saved my life. I had tried for years to stop using heroin and pills and if it was simply a matter of willpower I would have beat it years ago, I white-knuckled it through withdrawal many times.(I even went on methadone which is a whole other issue) What I needed however was some other chemical, to replace what was off in my brain and allow me to function like a normal productive adult. Projects and goals I had struggled with for years--I was suddenly sailing through now that I was taking bunorphine on a regular basis. I was able to complete 4 years of college, then a master's degree and I am now a journalist who reports on local news! I wish I could stand up and shout to everyone that it does work!!(but it might be the end of my career) I have been taking 4mg of buprenorphine for over 10 years and I will probably have to take it for the rest of my life, a small price to pay to stay out of the insanity of illegal drug use. Yes, I had the desire to quit using and was highly motivated but I needed the tools to do so. Abstinence only works for only a few lucky folks. If your city or state has a chance for a vote or referendum to allow buprenorphine to be distributed from hospital ERs please support it, you might be surprised whose life you saved and how productive and constructive that person can be if you give them a chance to be healthy. If anyone has questions about how buprenorphine works (not brain chemistry) but how it feels I'll try to respond.
25
@saved in baltimore
Congratulations on turning your life around. You sound happy.
5
As a retired Addictions Therapist, and a long-time user of buprenorphine to control my chronic pain, I loudly applaud California's actions (especially in forcing detox centers to accept methadone and buprenorphine patients.) It's ABOUT TIME!! Abstinence-only approaches have been firmly shown to be largely ineffective, yet the most we are usually willing to do is double down on them. It's like "Oh, this treatment approach doesn't work AT ALL. Let's do twice as much of it!"
I also applaud the accuracy of this article. It's 99% true, which is RARE for anything regarding addictions, and that goes double for anything involving Buprenorphine. THANK YOU! You have probably saved a great many lives by publishing this.
I do have a small correction: Buprenorphine is NOT "a weak opioid." It is, in fact, 30 times more potent than morphine. It's main gift is that it doesn't cause the same sort of euphoria present in heroin, fentanyl, oxycodone, etc. It also has almost zero cravings, and it doesn't cause a "rush" like other drugs do when snorted or injected. Because buprenorphine is so incredibly potent, the risk of overdose is higher, and harder to treat. It's also extremely dangerous to mix it with benzodiazepines (such as valium or xanax,) as it can stop someone's breathing. This can also happen if a patient drinks alcohol with their buprenorphine dose.
Again, MANY THANKS! You have changed a lot of people's lives for the better today.
19
The drug dependence epidemic (AKA opioid epidemic) is not an emergency. It is a chronic problem resulting from decades of misguided "War on Drugs" mentality. Drug dependence is a medical problem and should be treated as such rather than the pigheaded punishment by imprisonment approach. Until we stop treating drug dependence as a crime we will continue to repeat the past. Recreational drugs should be legalized, taxed, and strictly regulated. This would have the additional benefit of putting the illegal drug industry out of business. Tax dollars should be spent on treatment and rehabilitation rather than on the "correctional system" which is far from correctional.
13
@DAK - You are absolutely right. In addition, most treatment approaches are nothing more than an extension of the 12-step "abstinence only, AND you should be ashamed of yourself if you relapse" mentality. Yes, AA and its ilk have helped many, though actually a tiny fraction of the millions they claim to have saved. We are FINALLY realizing that addiction is no more or less a disease than cardiomyopathy or diabetes (both of which are notably exacerbated by poor lifestyle choices.) We need to legalize EVERYTHING NOW.
6
The AMA declared alcoholism to be a disease in 1954. I am not sure why so many people think the disease model of addiction is some brand new idea that recently emerged from the medical community. Furthermore, 12-step programs do not shame people who don't make it on the first try. That suggests a profound lack of knowledge about the administration of 12-step programs. Finally, the co-founder of Alcoholics Anonymous, Bill Wilson, was a strong advocate of the use of pharmaceuticals to assist with addiction.
4
Opioid users need the help of psychiatrists. Most opioid users are too concerned about other people and society and the affairs of the world, they dare not resort to cigarettes to soothe their problem and finally, they resort to drugs.
Whitney Houston and many other entertainment artists became the victims of this problem because they were so concerned about others.
@Joshua Tan Kok Hauw - so, in other words, people become addicts because they have too much empathy? Sorry, no. I can see your reasoning, but the issue is far larger than that.
I am an expert in this field, having been a treatment provider for many years. SOME people may have started using for that reason (among thousands of other reasons) but using is not addiction. It becomes that in a small fraction of those users, and then suddenly we treat them as a pariah. Our best scientific knowledge at the moment of why some become addicted and others do not, is that it's hereditary. We know this is true for alcohol addiction, and there's more evidence appearing daily that it's also true for those who become addicted to other drugs.
2
@Joshua Tan Kok Hauw
Actually, the scientific literature says that opioid users need buprenorphine, not psychiatrists.
Buprenorphine is the proven treatment for addiction (with some arguments for methadone).
IV drug users who switch to buprenorphine are likely to avoid the adverse effects of addiction, such as death, infection, heart disease, and social consequences; those treated with talk therapy are not.
IV drug users who are treated with buprenorphone plus talk therapy are no more likely to have those adverse affects than those treated with buprenorphine alone.
That's what the scientific literature says.
https://www.nejm.org/medical-research/addiction
3
I applaud Dr. Herring's effort to fight this health crisis killing so many souls. Prescribing buprenorphine is a great help but just a beginning. The missing link to the cure of addiction can be found in the articles series such as the one your shared;
The Treatment Gap
Articles in this series are exploring the lack of access to effective opioid addiction treatment in America.
Take a moment and listen to this Ted Talk given by Johann Hari;
"Every thing you think you know about drug addiction is wrong"
TedGlobalLondon
It was a real educational awaking for me along with 9,668,210 other listeners. Johann does address the "gap" missing in long term freedom from addiction.
What I am left with is that will live in a fracture society and the need to belong to a family, a community, to feel of value is paramount to human existence. Freedom from addiction is a life long journey. I question if those who hold the power to commit the financial investment to long term care will ever 'step-up to the plate'.
4
Each week the NYT has some article on a public or private system addressing a societal and/or physical problem---education, health care, climate change disasters, etc. In these articles you read about men and women solving real world problems, often with limited funding and at times fighting bureaucratic or private interests. On the same page of the NYT you read numerous articles about a President and an administration consuming all of their time engaging in reality TV show dramas and defending themselves against an avalanche of legal and ethical breaches. What would make this country great again is if the residents of the Oval Office devoted all their time to real world realities instead of the fake realities of their made for TV dramas.
6
Of all the overdoses, most are not from Doctor prescribed medications; they are from street drugs like heroin & fentanyl brought to the US by Mexican gangs. Why punish the drug companies who are providing relief from the excruciating pain of cancer and accidents? Protecting our borders from narcotics brought in or catapulted is the answer.
7
@Steven Pettinga
While the actual overdose may frequently be from “street drugs”, the addiction itself likely started from prescribed (overprescribed) narcotics for pain.
6
@Steven Pettinga
First of all I'd like you to cite the evidence for what you state.
Second as over 30% of opioid overdose deaths also involve a legal benzodiazepine, obviously legally available drugs are involved in a significant number of them.
1
Andrew Herring is one of the most amazing humans on this planet. I know him and this is the truth.
3
This is one of the reasons you should ALWAYS give homeless people money when they ask (if you can) even if you believe they will buy drugs with it. Going through withdrawal on the street is deadly, and withholding the ability to buy drugs will not cause a homeless addict to say "Gosh, I guess I should check myself into the Betty Ford Clinic." A homeless addict is as likely to die from drug withdrawal as they are of drug overdose. There are few drug detox or drug treatment centers available to addicted homeless people. Smugly refusing homeless addicts a dollar will not help them - it will only increase their shame & make their hunt for drugs that much more desperate.
5
I'm sorry to say this but it's the truth.. If there was an ingredient in dog food killing off "service dogs" at the same rate as people with an opioid addiction - American pet owners would have tarred and feathered the CEO of Purina by now.
I have always said- If you want policy change in any level of government substitute "people may become sick or injured," with "dogs may become sick or injured," and you will have legislation passed the very next day.
It's who we are- and it's embarrassing and shameful..
14
What if we had a national policy that addresses this issue and actually realized a humane approach in each community? Suboxone training for all ER staff and community resources to meet needs. For forty years researchers have told us that the costs to the community would be recovered in less crime, less lost work, less health care spending , etc. When will we find the will to make it so?
1
@linny
You're in Indiana. Why don't you ask Mike Pence? Or Jerome Adams? When he was governor, Indiana was hit with an epidemic of IV drug use. Pence refused to implement a needle exchange program, the first step in dealing with IV drug use.
As a direct, predictable result, Pence turned an IV drug epidemic of about 100 users into a hepatitis C epidemic and then into an AIDS epidemic, without reducing IV drug use.
It was left to his health commissioner, Jerome Adams, to make a fool of himself by trying to justify Pence's decisions. https://en.wikipedia.org/wiki/Mike_Pence#Public_health
***
Actually I once spoke to a scientist who had documented the effectiveness of needle exchange programs. She said, they said they wanted more data, so we gave them more data. So where's the policy change?
Then I asked a lawyer to respond to that. She said, "Scientists do not rule the world."
Often in public health you run into a brick wall of public stupidity and cowardice.
If only we had more Andrew Herrings. (And give credit to Everett Koop.)
6
Finally, sensible treatment of addicts in withdrawal. My experience in treating addicts and alcoholics has been that they are most likely to respond to the idea of treatment when they are hurting. Getting them started during an ER visit makes sense and will cost less overall than a revolving door policy.
However, in order for this to work long-term, the treatment facilities need to be available, as treatment for drug addiction must be ongoing.
While Suboxone is not a cure, the fact that it does not produce a high allows an addict to become stabilized before trying to quit all drugs. I have known many who can then go on to reenter "normal" life, get more education and work in good jobs.
3
I have used nothing but 4mg suboxone/buprenorphine for over 10 years. (I was on 8mg for 2 years 12 yrs total clean)Are you sure it didn't cure me? I know as long as I take it I'm productive and constructive tax paying, voting citizen and I hate to think what would happen to my sobriety without it. And it is different than methadone, it's not the same type of opioid replacement, I know this from personal experience of using it, not from a health care professional view point. Methadone creates a craving cycle and the clinics that dispense them are a mess!!(at least they are in Baltimore) I check-in into a doctor's office once a month to get my prescription, which helps keep me from interacting with people who may still be active in their addiction and holding drugs. How long does buprenorphine/suboxone have to keep clean before I'm cured? I wish we could drop batches of it from helicopters onto the streets for the people, I've had friends die on the methadone program, and die from overdose after withdrawal from heroin, but I've seen suboxone save lives including mine.
7
@Barbara
No, you're wrong. The medical literature says that Suboxone is a cure. The goal of "quit all drugs" is a false hope that leads to relapse and death.
Those abstinence programs that monitor their results find that they have high relapse rates over 6 months, and almost complete relapse over 3 years. They relapse, use IV drugs again after losing their tolerance, and die. Buprenorphone treatment prevents relapse for years. If you don't have long followups, you won't know that.
https://www.nejm.org/medical-research/addiction
https://www.nejm.org/doi/full/10.1056/NEJMp1802741
Perspective
Jul 05, 2018
Primary Care and the Opioid-Overdose Crisis — Buprenorphine Myths and Realities
Wakeman S.E. and Barnett M.L.|N Engl J Med 2018; 379:1-4
A realistic solution for reaching the millions of Americans with opioid use disorder is to mobilize the primary care physician workforce to offer office-based addiction treatment with buprenorphine. But stigma and myths inhibit acceptance of this approach.
https://www.nejm.org/doi/full/10.1056/NEJMp1804059
Perspective
Jul 05, 2018
Moving Addiction Care to the Mainstream — Improving the Quality of Buprenorphine Treatment
Saloner B., Stoller K.B., and Alexander G.C.|N Engl J Med 2018; 379:4-6
If treatment for opioid use disorder were moved to mainstream health care, more patients might recover. Buprenorphine currently presents the greatest opportunity for expanding treatment into the general medical system.
1
Suboxone, like Methadone before it, is an addictive opioid, albeit safer for the user than the other drugs of addiction. It is not a cure-all and it does not necessarily allow a user to eventually give up drugs altogether. In order to prescribe this drug one need special training and clearance; it is a long term drug which, when used with some kind of therapy, may (or may not) lead to the end of an addiction.
As with alcoholism, an addict has to decide somehow to end their dependence. The drugs used to smooth withdrawal do not make a cure, only something in the person can do that.
3
@Elwood - True, all the available (including court prescribed) treatment in the world won't help someone who doesn't want to get well. All that does is water down the recovery program's success numbers. Those that really want to change can do it for free through 12 step programs, and nothing will help those that don't.
1
@Dave T - I appreciate your statement, but as a retired treatment provider myself, I've gotta say that your final statement is not correct. Yes, 12-step helps many (though rarely when it is court-mandated, which is common.) In my time as a Therapist, I helped MANY people get clean and sober without using the 12-step approach. It's not for everybody, and the inflated claims that are often made don't help the situation. It's just ONE choice you can make from a growing body of extremely effective treatment approaches.
@Dave T
Not what the science and medical data show.
Those hard-wired from birth to be at higher risk of addiction, alcohol or drugs, have best outcomes with lifetime maintenance drugs as other comments have detailed with embedded links to the medical data. This includes the fact that opioid addicts rarely make it to three years sober with AA-only interventions.
It is essential that these people get life long maintenance with safe meds . . .to manage their damaged DNA and brain . . .to be able to return to near normal lives and loves and contributions to their families and neighbors.
This is a giant step towards recognizing that addiction truly is a medical condition. Social workers are taught in school to always begin where the client is at. Throwing a list of phone numbers at an addict in withdrawal is putting the cart way before the horse. They are suffering and need relief and stabilization before they can even comprehend the steps they need to take to begin the process of recovery. The old models are not effective enough. This program is an excellent start at rethinking our outdated concepts about addiction and addiction medicine. Lives will be saved.
10
Dan G said something interesting.. He said we are in the early stages of the opiate epidemic. I had to stop and think for a moment. There has been so much damage already. Imagine when enough people are using in middle America that small towns just think of it as normal. This is what happened in the 90's with meth.
2
We're surpassing our ability to deal with the things we've wrought. None of it ends well.
1
YES! A compassionate ER that treats opioid addiction for what it is: a disease. It's a horrible, debilitating condition that requires medical intervention. If Highland is implementing a simple procedure that increases the percentage of folks who move into treatment, then it should be viewed in the same light as a diabetic in ketogenic shock: get the patient through it, then into education, counseling and medication to prevent the condition.
Kudos to Highland. OakTown is truly changing in the right direction.
14
@PattyG - You're thinking way too far ahead. I know I'm being cynical, but there's no evidence to indicate that addicts arriving in the ER want anything more than to have their symptoms treated so they can continue their using later. They don't necessarily want help, most want a quick fix to make the pain stop - and a chance to see if there are drugs around to steal. Been there, done that.
1
When I was a medical student in Baltimore during the last 1970s I rotated through a methadone clinic. People there were doing the hard work of keeping opioid addicts off the drugs they were buying on the street.
That 40 years later we still haven't done much about the problem reflects on how little our society has cared about it.
11
You are so right! Care hasn't evolved much since then you have the choice of trying to white-knuckle it through abstinence in an NA program or become a zombie on the methadone program. I "attended" 3 different methadone clinics in Baltimore city before I was able to find a suboxone maintenance program, the difference it made in my life was astounding. Before, I was barely holding down a part-time job and occasionally able to attend classes. Once I switched, I was able to get through 4 years of college in under 3 yrs, went on to get my Master's Degree and now I'm actually a journalist! None of this would have been possible without a buprenorphine maintenance program set up by dr. Hayes at CAM chemical addictions medicine at Maryland General Hospital, he's always been at the forefront of opioid treatment in Baltimore--his program literally saved my life. He was the first person to provide Suboxone maintenance in Baltimore City. I check-in once a month and get my 4mg prescription. I may have been living before then, but now I can truly say I'm productive, give back to my community and that I'm making a difference.
2
@Steve - No. It reflects the fact that you can't help an addict that doesn't want help - and most do not want help, they want drugs. Been there, done that. Pointless hand-wringing does little to help.
2
There are too many people on the planet. We need to focus our time and energy on helping heal the earth and making sure that young people grow up healthy and stay that way. The money being spent on this problem could be spent better elsewhere.
2
The Earth is not the limiting factor. The Earth can sustain life for more humans than it currently does. The limiting factor is the chosen economic system, capitalism, which exploits, exhausts, and destroys the resources needed to sustain human life. So, you are right from a certain perspective, but to just blatantly say there are too many humans seems to be a dangerous assumption, because what is the implied action to be taken? Genocide?
Let them die, huh?
@CA Dreamer, Having spent over 30 years in recovery from this disease, I have found that the people we help and obtain a Sober & Clean life style are much more productive members of society!! Far Less Selfish, Self centered or GREEDY!!!
2
The problem with this is that it's like treating the bodily injuries of an alcoholic who keeps getting into car accidents. It's the easy part and provides absolutely nothing to address the underlying problem.
As to that lack of docs who can prescribe buprenorphine. There is an even greater shortage of docs who can treat drug addiction. Because psychiatry is such a low paying specialty, few American med school grads enter it. Buprenorphine alone is no answer to opioid addiction and that is all most docs who are certified to prescribe it do.
2
Psychiatry is "low paying"? The Psychiatrists I work with all make 6 figures or more, usually upward toward 300K a year. If that is "low income", then I guess I'm an impoverished social worker (or maybe just one who is content with having basic needs met without the superficial needs of the wealthy).
6
@PJ
You distorted what I wrote.
I said psychiatry is one of the lowest paid medical specialties along with primary care specialties such as family medicine and pediatrics. Average salaries for these are in the mid $200,000 while many surgical specialties, invasive cardiologists, radiologists and anesthesiologists average in the 400,000 to 500,000 range and there are now many surgeons making over $1 million per year. I don't know of any psychiatrists who are making that much.
Perhaps this is why we have too many surgeons and not enough psychiatrists.
@Steve - True, they are only treating symptoms. All these years and we are still trying to make people well that do not want to get well. People will do what they want to do.
2
This "crisis" could not have grown out of control were it not for the drug manufacturers and their paid agents, medical doctors who over-prescribe opioids.
It is part of our national health care crisis where profit taking supersedes patient care and public health.
Can you imagine a national health system that allows drug manufacturers to create an addiction crisis and then profit from its care and treatment?
One day, this country will work for the people and not the powerful.
13
When my friend was first given Suboxone, in 2010, she had been addicted to heroin for eight years--a daily, soul-crushing habit that she could not kick. She has not used since the day Suboxone gave her life back. "I did those things," she told me, "but this is me. I got myself back."
26
A completely healthy person gets stung by a mosquito in South America and contracts a virus. They have contracted a disease.
A completely healthy person gets hit by a drunk driver, shatters their shoulder and face, gets "stung" by a doctor with a needle full of opioids in the hospital for a week and becomes addicted.
I'm not sure if that's a disease or not but the opioids create a disorder of structure or function in their body. That is the clinical definition of "disease".
Whatever we want to label addiction -- disease or not -- it sucks for the addicted. And if treatment like this can help unfortunate people, save lives, reduce suffering and save money we should get over the judgement labeling and make lives better through treatment.
17
Please understand that there is a distinction between addiction and physical dependence. All opioid medication will eventually cause dependence. Those who are prescribed long acting opioids for pain relief and take them as prescribed under the care of a pain management specialist are physically dependent and will experience withdrawal. If they wish - or are forced - to come off of the medication, a responsible user and a trained doctor will work together to taper off the medication and will hopefully be treated with other medications to ease their chronic pain. Addicts abuse their medication and become not only physically dependent but psychologically dependent as well. When their supply is cut off, they turn to whatever means necessary to obtain their drug. It's not a matter of semantics. There truly is a difference.
2
@Mark Please do not perpetuate the lie that substances cause addiction. I have taken vicodin for pain, but was easily able to stop when my physical pain stopped. My daughter had to take opioids in the hospital; when she was released she had no desire to continue taking them. Addiction is NOT CAUSED BY DRUGS. Addiction is a symptom of multiple underlying problems that precede the use of the drugs. Until we deal with that fact, every generation will find a new drug that "causes" addiction and we will continue with this endless game of whack-a-mole that treats symptoms rather than causes.
3
Really millions have opioid prescriptions 1,000s die the rest us of lead healthy productive lives. That means that less 1 in a 1,000 opioid users die from opioids. Also many of those dying are using street drugs because of articles like this. We do have a problem with foreign countries making synthetic drugs like K2 and Fentanyl.
Not to quibble over nomenclature, but suboxone treats opiate withdrawal, not addiction. Much like Librium or Valium treats alcohol withdrawal. Ibogaine, as a substance, perhaps, treats addiction. 12 steps treat addiction. Partial antagonists offer a temporary respite from withdrawal.
3
@Taximan Thats a valid point, but I think for many the pain and difficulty of withdrawal makes overcoming the addiction nearly impossible. As described in the article, these drugs when taken according to their subscription can enable an addict to live a normal life. Perhaps some time later when their lives are more stable they can try for full addiction treatment.
3
@Taximan
I would put a bit differently: suboxone allows for the physiological (and to some extent psychological) stability that allows one to engage in other aspects of treatment for addiction: behavioral therapy, mutual=help groups, etc. Also, because Suboxone contains naloxone, it blocks the effects of opioids if used with Suboxone, thereby acting as a deterrent to further use.
7
I remember how sincere and empathetic Candidate Trump sounded when speaking about the opioid crisis up in New Hampshire. But now in hindsight I can, of course, see the con.
6
@Richard Mclaughlin - A huge problem inherited from President Obama. Nobody could reasonably expect this to be solved overnight - or in two years. Your expectations are unrealistic.
1
Some people that's only SOME PEOPLE are able to "put it down" but most simply cannot because the brain is in disorder thanks for the prescriptions.
However treating withdrawal is far far better than just calling the police have him beaten and put in jail for what exactly?? How come booze gets a free ride when it costs the country far far more than opioid addiction?
7
A big yes to Highland. Treatment works better than prison. Costs less, too. Dr. Herring is doing the true work of the righteous. Thank you!
10
“As Dr. Herring’s shift began one Tuesday, a 30-year-old woman in a white baseball cap entered the E.R. She said she had been using heroin for the past three years, but had been taking opioids since a doctor prescribed her the painkiller Norco after a softball injury when she was 12. She had overdosed twice and had never stopped using for more than two months at a time. Most recently, she told the doctor, she had been snorting fentanyl from a dealer who gave it to her for free in exchange for meth provided by her friend.”
The responsibility for this cruel, devastating epidemic lies with drug manufacturers and physicians. Why did a pediatrician give Norco to a 12-year-old? Probably not necessary. But drug company likely bought the doctor a nice dinner, paid for a conference in a resort town in Mexico or the Caribbean and more. It’s shameful.
10
I think this sounds pretty encouraging but please don't forget about people addicted to Meth either. Methamphetamine use/addiction is still a big problem too. I know someone who is trying to kick their use of meth and I have seen them have the same problems mentioned in this article about the Opioid withdrawal. They seem to have to throw up a lot, the symptoms of withdrawal can be so uncomfortable that they are tempted to use again. Please don't forget problems associated with Meth and alcohol too.
7
@Carrie Smith - you are correct - other drugs cause addiction as well, and it's not necessary for them to have the profound physical symptoms that are present in opioid or alcohol addiction for them to qualify as addiction. Still and all, that takes NOTHING away from the power and beauty of this article. Also, the real excitement of this news is that attitudes are changing. Today, it's about opioid addiction, but soon enough, with the new care and respect being shown these poor souls, other addictions will receive the care they need.
@Carrie Smith - interesting. I used to have quite the meth habit (snorting, smoking, shooting) and never experienced any withdrawal symptoms. I know lots and lots of meth addicts and have never heard or observed anyone having these problems.
Are you sure she was just using meth? Its quite common now (at least here in Seattle) to mix heroin with meth.
When I quit using meth, I noticed no physical effects other than I could go to sleep at night and had an appetite. I woke up one day and realized that I was now having grand-mals like mom and grandpa and I could no longer go and go and go without falling on my face (literally). So, I just quit rather than have a seizure. I found it harder to give up Coke and don't even think about getting me to give up coffee!
Every article like this one about opioid addiction has the awful, unintended consequence of making medicine unavailable for those who live (and die) with chronic, unbearable pain. Instead of helping folks who are addicted (and outside the medical system), this coverage makes physicians reluctant to prescribe legitimate narcotics to patients in need. Shame on you.
6
@Rolf
"outside the medical system"--exactly, that's the problem. there is no easy access (as there is at Highland) that facilitates entry into the medical system so those dependent on opioids can get the treatment they need. As to prescribing pain medication, that's what started all of this: opioids such as hydrocodone and oxycodone were prescribed for chronic pain, sometimes recklessly prescribed, and it is widely accepted that they are not appropriate for chronic pain. Much of this lies at the feet of Purdue Pharma and other drug companies.
1
The underlying cause of drug addiction, as with all addictions, is insufficient willpower, lack of self-control, low self-esteem, the absence of spirituality, and no self-respect. I do not believe addiction is a disease, if it a disease, then it is a mental illness, and should be treated as such.
2
@Southern Boy Addiction is a mental illness & it should be treated as such. Sadly, it is treated as a character failing instead. My daughter had pancreatitis last year, and was given high doses of opioids to cope with the pain. Once she left the hospital, she did not touch the bottle of opioids she was given to take home. The pills eventually expired & I disposed of them. Addiction is a symptom of a deeper problem, not the result of using a particular drug. Until we treat the underlying cause of addiction, addicts will continue to suffer, and every generation will find a new drug that "causes" addiction.
1
@Southern Boy
So mental illnesses aren't diseases? And I guess you don't think that people who have diabetes due to obesity or lung and cardiac disease due to smoking don't have real diseases either.
Actually, there are studies that have shown that addiction is caused by physiological changes in the brain. For certain opioids, it can take as little as 3 days for people to become addicted. And it’s true that they’re very overprescribed. I have read that the largest contributors to this problem are the dentists who prescribe narcotics for dental procedures such as wisdom tooth removal. When I had my wisdom teeth out, I was prescribed a bottle of Norco, which remains unopened in my cabinet to this day. But the fact is, many people (but certainly not a majority) who have the same procedure that do end up that do take the prescribed narcotics do end up dependent and eventually have to resort to buying heroin on the street to get their fix. So it’s not as simple as you suggest, being a matter of will, or having a mental illness. It’s a disease that should have the same level of commitment to treating (by physicians and insurance providers) as cancer or heart disease.
1
Finally. I just hope other ERs catch on. Most doctors haven’t a clue about withdrawal. It’s a huge and perhaps the most important issue in solving this crisis. It’s certainly both a blind spot and gaping hole in the U.S. approach.
10
from a recently retired AMA attorney:
Time to get the American Medical Association (AMA), the American Academy of Family Physicians (AAFP, the American Academy of Pediatrics (AAP), and American College of Emergency Physicians (ACEP) to publish a joint letter addressed to the CEOs and Board Chairs of the largest health insurers in this country:
"Dear CEO/Board Chair:
We have determined that your health plan provisions denying coverage for a drug addict's substitute drugs and medically necessary supervision in a suitable clinical setting needs to be updated--immediately. The simple path forward is to substitute "drug addict" everywhere the word "diabetic" or "person with diabetes" appears in plan documents. Thereby, making persons with chronic drug abuse disease equal to those insureds with diabetes and its maintenance drugs.
We understand that one lawyer working full-time for three weeks was able to revise Medicare and Medicaid and private health plan documents to add "hemoglobin" to "hematocrit" when FDA approved the first fingerstick blood test for hemoglobin--making the new policy read: "a hemoglobin or hematocrit test" shall be covered. Therefore, we will be checking one month from now to determine when we can inform our physician members about each company's effective date for this new coverage policy."
Find the Execs and elected practicing physician Presidents of each group online and get behind all taking a stand en masse. It really is that simple.
19
Kratom, a naturally occurring plant in SE Asia that is 100 percent natural, will ease opiate withdrawal symptoms to the point of being negligible. It has already helped thousands of addicts in the United States wean themselves off of deadly opiates and other chronic pain patients (like myself) manage pain related to ongoing health conditions without having to rely on pain meds that carry a high risk of addiction. It’s cheap and easy to obtain by mail or locally if a shop in your city carries it.
And of course, Big Pharma is now trying to preserve their pain pill cash cow by leaning on their stooges in the FDA and Congress to have Kratom classified as a Schedule 1 drug despite zero credible evidence to support this and a long history in Asia as a plant-based pain remedy and mild stimulant (similar to coffee). Rolling Stone magazine just published a great article where the FDA’s sham evidence against Kratom is shown to riddled with outfight lies, half-truths and sloppiness (not to mention a complete lack of ANY scientific research proving Kratom is harmful).
Funny how Kratom never attracted much attention for years until it became known as a safe alternative to opiate painkillers and another poisonous Big Pharma product (Suboxone). Just another example of how in our plutocracy the government agencies that are supposed to be protect us (funded by our tax dollars) look after corporate interests instead. See also recent 60 Minutes piece on DEA’s failure to stem opiate crisis.
12
Kratom contains opioids. It is not an alternative to opioid addiction and has not been shown to treat any medical condition. Just as the opium poppy is natural, it does not mean it is safe to use.
As to the rest of your thoughts, who can argue that medicine and government are subject to the profiteers in big business.
@Concerned
First .... BAN production of Opioids by all legit pharma companies for 13 months .....
We already have billions of pills sitting in drug company warehouses ... we are not running out.
5
@barneyrubble Ban whatever drug you want - addicts will find something to numb their pain. And those who suffer physical pain & truly need the opioids will suffer cruelly & needlessly. It's not about the drugs - it's about the reason people abuse the drugs.
THis article clearly documents what can be effectively done -empirically based, indicated treatment -to help a person who is experiencing a series of symptoms, which individually or together are not “diseases” but rather processes, of an addicted person’s body stabilizing itself when medical staff and policy makers relate to a person in need,and not to a dehumanized stereotype, by marginalizing, excluding, rejection, etc. The various named people, as well as those unnamed ones, who enabled the creation and maintaining of a program and resource offering relief of pain, whatever its source, manifesting menschlichkeit and not pain-producing policies, and unhelpful mantras, are to be commended.A caveat to consider during these challenging, divisive, socio-political WE-THEY times in which selected, targeted “the others,” including substance users, are being violated, daily:
7
Purdue knew their product was a killer. They got rich from it.
Reuters) - New York state on Tuesday sued Purdue Pharma LP, accusing the OxyContin maker of widespread fraud and deception in the marketing of opioids, and contributing to a nationwide epidemic that has killed thousands.
6
Didn't Trump vow to solve this crisis?
He's done nothing.
10
@Citizen I've heard rumors that Trump is a liar.
2
@Citizen - It's not so easy trying to solve all the problems he inherited from Obama.
1
This is all well and good, but the horse has largely left the barn by the time an addict in withdrawal shows up in the ER. At this point it's going to take a huge amount of public resources to clean up an addict and many relapse and this doesn't take into account the misery and cost to the addict and society that the addiction has caused before they get to the ER. The push from government regulators and the big pharma response to over treat pain has lead to pts leaving the doctors office or hospital with bags of narcotics so that they won't get a bad score for under treated pain. It's time for Americans to come to grips with something most of the world knows already. the fact is, some stuff hurts and you need to tough it out. Pts have been having surgery and other painful procedures for decades and only after the gov and big drug companies got together did this tidal wave hit. Getting rid of the mandate to over treat pain (especially non-cancer pain) and giving people a more realistic outlook would be a better idea than trying to dry addicts out after the fact.
4
Thank you for an excellent article. However, I would like the Times, and its readers, to remember that it's not only "doctors" who can prescribe buprenorphine and not only "doctors" who can be "mission driven." This prescriptive ability also extends to advanced practice nurses with special training and certification, as well as to physician assistants with those same criteria. Being mission driven also applies to many within health care and social services, just as being opinion driven also applies to many physicians and others within those disciplines. I wholeheartedly agree that the progressive attitudes toward substance use disorder in the Bay Area (I am an Oakland native) are likely to have influenced the ability of the health care providers at Highland Hospital to help patients by appropriately providing buprenorphine.
I am an advanced practice nurse who has worked for years in several settings in which patients receive buprenorphine.
14
Anyone wishing to inform him/herself of the Sackler familiy’s (Purdue Pharma) diabolical machinations in starting and promoting the opioid crisis in their incessant quest for profit, i.e., capitalism’s life blood should read this article.
https://www.newyorker.com/magazine/2017/10/30/the-family-that-built-an-e...
8
@stewarjt Thanks for the link. I've bookmarked it for later reading.
Providing buprenorphine sounds like a humane and more effective response to addiction than finger pointing, but that's not who Americans are. We parse who is deserving and who is not, with the wealthy being the most deserving. Not all hospitals will be able to afford buprenorphine or be willing to help staff get the required training for licensing. Small rural emergency rooms, often overwhelmed with heroin addicted patients, many without insurance, cope by cutting staff as their reimbursement drops. The irony of our healthcare system is that as more people need better care, fewer people and resources are available to provide it.
17
This whole notion that addiction is a disease reeks of corporate parasitism.
Without meaning to minimize the suffering that addicts endure, there is no rational basis for the idea that opioid addiction is a medical disease.
Some people are actually capable of putting the junk down. Lou Reed was one of them, incidentally.
9
@ubique People have been hung up the word "disease" in regard to addiction for years. The origin of calling it a disease goes back to the time when addiction was considered a sin or a moral failure. By using the word "disease," the intent was to recognize addiction as a biological problem that could be treated medically. The choice of the word "disease" may have been unfortunate as people associate it more with illnesses like cancer or heart disease, but the medical definition of "disease" is actually much broader. The point is to recognize that addiction is a treatable medical condition (the term I prefer). A broken leg is not a disease, but it's definitely a medical condition. BTW, I'm not suggesting that corporate greed doesn't exist in the addictions treatment field (in what part of our society doesn't it exist?), but it has nothing to do with calling addiction a disease. Getting hung up on the terminology is merely an excuse to ignore the problem. Whatever you want to call addiction--disease, medical condition, disability, illness, etc., what's important is acknowledging its existence and doing something about it.
27
@ubique In our work, we use the term "indication" but that could mean anything, from a broken leg as Quiller notes, or a mental disorder, or an infectious disease, or a neoplastic one. So these are all "diseases" or "indications" - something that could be treated medically. In the case of opiod addiction, it can indeed be treated with a pill/strip. I think buprenorphine or suboxone (not the same since it is a compound with another opiod receptor antagonist) is a life safer. And it can treat pain, so a near truly non-addictive opiod formulation does exist (i.e., it won't be addictive for the vast majority of people, even those who are addicts, but addicts can misuse it to further their addiction - get sober, get high, and so on).
DXM I think is more addictive (meaning not a lot) than buprenorphine and it is sold over the counter. Loperamide is an opiod agonist and at high doses can produce a high but it is also sold over the counter. Alcohol is far more addictive than buprenorphine.
6
@ubique
Yes, "some" people can put the junk down and simply walk away. "Some" people can do that with cigarettes, booze, etc. "Some" people never get fat; and "some" people who do are able to lose the excess fat once and maintain a normal weight for the rest of their lives. Others, however, can't. It's part of being human.
I haven't read every post here (no time right now), but, as a physician, I don't see how this ER treatment doesn't violate he Harrison Act, which forbids treating opioid withdrawal with narcotics.
I've seen a number of junkies over the years, in withdrawal, waiting to get into, or with appointments to enter, treatment programs, and have prescribed a variety of non-opioid medicines to try to get them through a few days, so that they can start treatment, but I have never heard of anyone prescribing narcotics for them, as this would make the physician a federal criminal, and be detrimental to his continued practice.
I wish that the article had addressed this important legal point, so that the rest of us might have some idea of how something similar might be done in our own communities.
11
@Eric It is actually legal to do this: the Harrison Act opposed *maintaining* a person with addiction, not treating withdrawal. And there are two exceptions to it: it is legal to use buprenorphine and methadone to maintain addiction, though both are over-regulated
13
You could contact “Dr. Gail D’Onofrio, the lead author of the Yale study,( who) has been fielding calls every week from E.R. doctors interested in her hospital’s model.” To get help for your area . Also you might consider contacting The Shatterproof Organization and learning about the stigma and shame addicts feel which can cause suicide or relapse among recovering addicts as I was extremely saddened by your use of the word “junkie” to describe these human beings suffering from the disease of opioid addiction .
5
@Eric
from a retired attorney for the AMA:
Relax. Physicians are not engaging in criminal behavior if they know and comply with 2018 law, as these physicians are doing in this CA experiment using dollars from a 2016 law that provides federal funding for medical-model delivery system experiments or trials for improving outcomes with lifelong drug addicts. As a practical matter, the Controlled Substances Act (1970) and many laws since have largely replaced the Harrison Act dating to 1914 as it relates to physician activity.
I confess I had to look up the Harrison Act, its core provisions and Congressional intent, so I cannot imagine who dropped that law in your busy brain! There are scores of old state and federal laws on the books--never repealed--that are never considered or enforced today.
Roll up your sleeves and join the effort in your Hudson Valley community--following the Yale model and "legal" parameters for clinicians? There is no zip code that is not affected and CDC says things will get worse before they get better so engaging now just makes sense.
8
"[Physicians] need training and a special license from the federal Drug Enforcement Administration to prescribe it for addiction"
One of the biggest barriers to starting people on "Bupe" is administrative. Although anyone with a DEA number can prescribe an opioid, only people with a special license can write for Bupe.
Once again, red tape ties the hands of care givers and restricts innovations that could help people.
The other important aspect to consider is that patients have to be compliant with follow up for addiction treatment, so the health care system cannot do this on their own.
9
Really? Is there enough treatment space for all addicts? I don’t think so.
1
What if the DEA determined that only licensed people with special training could release enkephalins?
Treating Opioid addiction as a mental health disease without being judgmental could save lives and may bring a turn around in this health crisis. Besides this ER treatment described in this article, it would help if emergency care is provided as an out reach program consisting of a cadre of doctors and nurses making house calls or serving the homeless in shelters or in streets where the homeless addicts roam around.
The US government spends a billion dollars a day on medicaid alone and taking care of opioid addiction where it occurs rather than in hospitals, clinics and E.R would go a long way in providing optimal care so that people like homeless man described in the article does not have to be waiting to get to an E.R.
If we care about our fellow citizens who are fallen on hard times we need to get them the care they need in the very spot they may be found with roaming doctors and mobile clinics.
17
@Girish Kotwal
Spot on! beautiful and correct.
1
Opioids and the treatment for users is very controversial. The article brought up some believe society should help users recovery and others others believe there is no use to help. Buprenorphine is a new drug being used in hospitals to ease the user off of the drug they are using. I found this article interesting because this hospital, Highland Hospital, is making an effort to help drug users. Although they have not proved if this is a waste or not yet, they are trying to help. Instead of just giving away pamphlets for recovery homes, they are actually making an effort to help people to recover. Even more interesting, this started from a college study and is spreading to other hospitals and people. Some people may think this is a waste of money and effort, however, the article conveyed this is worth a try.
9
@Sommerlyn Jones It is not that new (it was approved for medical use in the US in 1981). If you talk to recovered opiod addicts who did it with the help of suboxone, they generally will claim it is a lifesafer. It's just that we don't hear too much about these success stories for a variety of reasons.
1
My hospital would not allow Suboxone on the psych unit even if the patient had been on it successfully for months.
We got helpful outside counseling re proper use and the director of the psych unit was encouraged to step down.
We have a long way to go to educate people in the psych community.
Thank you Dr Kehoe!
28
Opioid is a very strong drug which is a use of the good or the bad depending on the person using it. This is a good thing this ER treats opioid addiction on demand or many people would be suffering on the spot. I believe this would be a very great idea if this would happen in almost every ER to help them out with their addictions. Of course that there will be some background checks to see if they are not just seeking free buprenorphine.
The crazy thing is that this will help people out who are stressing about their addictions and will hopefully help them overcome their addictions. It helps people stay away from the more powerful more dangerous drugs and they use the buprenorphine and use it as a way of seeing it like a vitamin to keep them not thinking about their drugs. We should really be open to a lot of things especially this and this treatment is also not for opioid addicts which I had just found out it could also be for people who are in pain like for their knee or any damaged nerves. This should spread to every ER to help achieve very low addictions to the growing years as well.This article caught my attention because this is so rare that an ER treats an opioid addict on demand and I was curious to read this and I had learned a lot from this article and was very well informed. I've always have had an interest in medical and I really like reading these kinds of this about what new things are happening that could be very life changing and how some new things aren't bad.
4
Thank you for bringing up this side of the problem. I have peripheral neuropathy in my feet, ankles and calves that has severely damaged the nerves in those extremities. I live with severe pain 24/7 and there is no cure.
In order to be able to function somewhat normally I have been prescribed opioids for the last 15 years or so and I use them responsibly, I don’t sell them and I never take more than prescribed.
Politicians looking to make points have already made it more difficult for people like me...injecting themselves between physicians and their patients with no thought as to the positions they are putting people like me in. Already some people who have had to stop prescriptions because of politically inspired regulations have committed suicide...rather than live in excruciating pain every day.
How is it fair to cause suffering to people who have done no wrong in order to prevent suffering of irresponsible people who are abusing these drugs?
52
@steve Dumfordia
from a retired medical attorney:
Ask your physician about ER tramadol, a synthetic narcotic not included in the regulatory grip that opioids being abused are in? Medicare added ER tramadol Part D coverage up to FDA's recommended limit of 300mg/day on Jan. 1 2018.
If, like me, you find that one dose of 100mg ER does not manage your pain and one 200mg ER dose causes severe nightmares, work with your prescribing physician to try 100mg/12 hour intervals or 8 hour intervals. For me, it took 100mg/8 hour dosing intervals to get to consistent pain relief without big gaps and zero side effects.
IF/when your insurer denies coverage, as mine did, write a one-page plain-English letter to the insurer asking that this denial be reversed. In two short paragraphs using bullets describe all of your pain-related diagnoses and which treatments you have tried for each: opioid drugs+dose now effective, but hard to get and/or physical therapy and/or surgeries. This is what I did to reverse the denial of coverage by UHC/OPTUM for my funky-but-effective (and expensive) 3 x 100 mg ER tramadol per day.
As long as most patients do not appeal claims denied, health insurers will continue to increase their profit margins. Data from my law practice over 30+ years show that roughly 88% of first-level denials appealed are reversed with this one-page appeal letter. Try tramadol ER soon because the attack on street-abused opioids hasn't yet begun . . .you need an alternative now.
1
@steve Dumfordia
Oh, the things I've said or done when I took one extra 5 mg Hydrocodone just to be sure I didn't start hurting before I got back home. Ew-w-w-w-w-w-w
@steve Dumfordia
Blame and shame mantras are wrong. Alcoholics and drug abusers are sick. Just like people with other lifelong diseases like diabetes. Do we blame and shame diabetics or provide maintenance drugs and periodic trips thru the E.R. when their disease is out of control?
IF we could avoid judging drug addicts, we could make some progress in providing care to them and to you. The saddest part of this CA report is from the Physician's Assistant in rural ultra-conservative CA--likely 100% white except for hispanics working farm fields. The stigma in that place is so bad that addicts are not seeking this special clinic's services. Is staying a street-drug addict somehow safer in this place? No.
All of us have to get over blame&shame before we can move fully to the medical-model of care described in Oakland/CA ERs and the hub-and-spoke daily free clinics described by one Aussie in his comments about his home country.
4
In Denmark opioid assisted medication is available at pharmacies for no cost; also Naloxone is provided at no cost for anyone that needs it. They also provide safe injection sites—where there have been zero overdoses since the program began; and they have five clinics where doctors administer heroin to patients that have not found other therapies helpful. Also no overdoses at those facilities. Other countries where there few overdoses follow this model or something close to it.
If the United States wanted to deal with the crisis the would adopt models that work. But my suspicion is that people have fear-mongered and moralized for so long that we can only arrest people and maybe in exceptional cases have things like the ER. The hysteria about drugs is so over-the-top it is unbelievable. Obvious if people have problems you treat it through a health approach not the insanity that has gone on for decades. The fact that harm reduction and a health approach is still an 50/50 view shows how extreme and off-the-rails this country is when it comes to drugs.
49
@Joe Smith, As always, follow the money. Keeping it prohibited and illegal keeps the legal system propped up and millions of jobs, including law enforcement. The re-hab 'business' is also very lucrative.
3
I wish the NYT would do a story on the state of methadone clinics. The ones in NYC are degrading. Working people are treated the same as those who don’t work. They make the patients go to the clinic six days a week because they don’t trust them to not sell the methadone. Anyone on methadone can’t skip a day without feeling terrible. So selling isn’t all that appealing. Regardless. It’s a second class situation where patients are treated like they’re in a prison. If you’re prescribed a pain killer like oxycodone you’re not made to go to a doctor six days a week to get it. I stopped going because I couldn’t leave work for a follow up visit with the doctor to discuss results of blood tests and so on the eve of Thanksgiving they cut me off at the window. No doctor for several days. No medicine. Needless to say I couldn’t leave town for the holiday. Talk about a degrading situation that could care less for the patient. A professional, working patient who felt normal with a dose and could go to work everyday.
15
Methadone prescribing and dispensing, because it’s so dangerous, is tightly regulated and monitored by both the federal and respective state governments. Methadone has an exceptionally long half-life and high interaction profile (with other medications/ recreational chemicals). Methadone’s bioavailability can vary quite a bit from person to person, in a given situation — and is unpredictable.
It is exceptionally easy to die from Methadone.
What you perceived as volitional withholding of medication or an arbitrary punitive action may have been efforts on the Methadone clinic’s part to comply with federal/ state regulations — or efforts to “do no harm”.
12
@Heidi Lundeen This would be a valid arguement if it weren’t for the fact that methadone for pain is widely used, and patients often get 30 day supply at a time. Our rules for buprenorphine and methadone are antiquated. Regulations need to be peeled away so these medications can be more widely available to those who need them.
@Boga
Why do you choose the label "degrading" when you're getting better care for your addiction than 99.9% of Americans? I'm stunned and saddened by your choice to react in this way.
May be this is the first time this "professional, working patient" able to "go to work everyday" after his methadone clinic dose has had to queue-up with addicts that don't look or talk like you do? People who are equally passionate about getting to better and returning to work?
As a chronic pain patient who has used opioid pain relievers safely and responsibly for over a decade, I feel I must speak for the millions like myself who absolutely would not be able to lead a productive life without them. I say this because our society is so knee-jerk in its responses to problems (except, of course, the lack of taxation on the wealthy). NO ONE who requires opioid analgesia will deny that the U.S. has a drug problem. What we disagree with is that there is no valid need for opioid pain relievers by any but the terminally ill. There are many, many painful and debilitating illnesses for which medical science can offer us nothing other than chemicals that have been used to treat pain for thousands of years. Speaking as a baby in this particular bathtub, please watch out when you empty the tub of its bathwater.
67
@Indrid Cold
talk to your prescribing physician about ER tramadol--covered by Medicare Part D starting Jan. 1 2018. It is a synthetic narcotic not caught in the regulatory grip of oxycodone and opioids that can be abused.
IF or when your insurer denies coverage without regard to the stated reason for the denial, write a one-page plain-English letter that sets out your personal pain diagnoses and all treatments used, including drugs and physical therapy and surgeries. Then point out that switching from drugs that could be abused to one that cannot be abused is effectively managing your pain. That makes this drug "medically necessary" for you.
Most patients never appeal first-level insurance denials so it's easy money for insurers. However, one-page letters like this result in about 88% reversals of denials. Get us to "Yes." Your expensive ER synthetic narcotic will be better and affordable if you can make this change safely. Good luck.
25
@n.c.fl
Thank you for your helpful, respectful, and judgement-free response to Ingrid Cloud. I'm in the same boat as Ingrid. Unfortunately, tramadol doesn't work for me; I've tried it several times alone & in combination with behavior modification, physical therapy, & other medications. I take the lowest dosage to combat my pain. I do everything I can to mitigate my pain; TENS, massage, yoga, rest. I don't want to be on these meds but in order to be 35-40% pain-free & able to feed, clothe, & pay my bills, I have to be on them. Some of us need opiods to work & contribute to society. It's tragic that this issue has created two groups of people that diametrically oppose each other. There's a third group of patients that have a medical need for these medications & are being left out of the national discussion, which means that we're being driven to suicide because our pain is real but the medication that treats it has been politicized. Politicizing medications instead of publicizing helpful pain management programs or incarcerating the big pharma creators of this mess creates real roadblocks to our doctor's ability to prescribe, which leads to less or zero pain relief. Which has lead to suicide for those who won't use illegal drugs for pain relief. This issue needs more people like Dr. Herring, the state of California, & those leading this initiative. It also needs states to help others like Ingrid & me without vilifying patients or medications. Vilify the creators of this mess
2
@Sashinka
I am a medically-trained retired attorney who takes 90mg Arcoxia for severe arthritis with breakfast and 100mg ER tramadol every 8 hours for seriously damaged spine over the last 50 years. I was suicidal in the interval between Vioxx being withdrawn worldwide and my small-town FP's suggestion that I get Arcoxia from London to replace my Vioxx. Completely controls/blocks my severe arthritis pain in both hands and spine.
Have you tried Celebrex for arthritis? If it hasn't worked, as it did not for me, stay tuned. My last big project for this year is getting Arcoxia, Merck's arthritis drug that does work for me, cleared for prescribing in this country under "expedited approval" by the FDA. Using FDA's 2016 opioids fight priorities list: "support better pain management options, including alternative treatments."
One U Utah pain management physician who strongly supports Arcoxia approval by the FDA has published an estimate that as many as 7M people with disabling arthritis pain could benefit from getting this into our drug alternatives. I have 420 days of Arcoxia before my supply is gone (get a year's doses at one shipment), but I intend to get this organized and done by year-end. fda.gov is best place to look.
Hang in there and do try Celebrex for OA if you have not done so already.
1
Ms. Goodnough,
The SFO area has been at the center of the addiction crisis for generations. The cost, both human and monetary has always been high. High not only among the users and their families but also among the care providers and their families. In spite of everything the Healthcare Community has done the crisis has only gotten worse. It is thought that 75,000 not 50,000 Americans died last year from overdoses.
It is a failure of government at every level that this many Americans die of drugs every year. Sequestering the users is practically impossible in a free society. Jailing the major sellers is becoming equally difficult. In fact there is a move afoot in Congress to reduce the Federal sentencing guidelines for dealing drugs. Since only major dealers end up in the Federal system how on earth will this “help” the drug overdose epidemic?
It’s easy to say what hasn’t worked (nothing to date) and it’s difficult to see how a government that can’t or won’t keep it’s citizens from using the sidewalks as a bathroom is going to do anything to keep them from misusing drugs.
The SFO area has always led the nation in illegal drug use perhaps its ultimate collapse will encourage others to actually treat this problem as seriously as it warrants.
We need something like a Manhattan Project to deal with this crisis as it’s that serious.
7
Recommend researching how Methadone maintenance treatment came about in 1970s Harlem. This was a Manhattan Project of sorts for opiate addicted persons.
7
@Richard
The problem is that people either treat drug addiction as something to be punished (i.e. mass incarceration) or a means for profit (e.g. pharmaceutical companies, drug dealers). Hospitals try to help patients, but too many forces in our society work against our efforts.
I wish more people would take steps to help with the problem (e.g. volunteer, donate, etc) instead of instead of blaming the government and hoping someone else does something about it.
3
Kudos for the providers and hospitals willing to do what needs to be done- try to find solutions that work for their patients. The Opiate scourge is far and wide, reaching rich and poor and is color blind. We're in the early stages and there's no silver bullet. Let's hope more providers are willing to be open minded and treat these patients well. We'll all pay the price when people die, overdose and commit crime to feed their addictions. We of course also pay the price for treatment, but I think most would agree it's a better route.
10
The only thing is you still have to come off of suboxone eventually. One is not drug free when on suboxone and I have been told that the suboxone withdrawal is rather wicked. It may be a better option than methadone but ideally people need to get off of opiates completely and then get on the vivitrol shot. this works for opiates and alcohol (opiates and alcohol are very similar and work on the same receptors) and what the vivitrol shot does is blocks all receptors so if you drink or take opiates while on the shot, you will not get high. So it is an insurance policy so to speak. Now making this accessible to all...that's the trick.
8
@KLJ Why should you come off of a drug that's working if you are not having side effects & the data shows that staying on cuts the death rate 50%? Meanwhile, there's no data showing that Vivitrol cuts mortality. We need to stop treating opioid maintenance as any different from taking insulin or antidepressants or antihypertensives. If the drug is working & not doing harm, stopping makes no sense.
8
Canada allows chronic use of maintenance suboxone or methadone. That shot is costly and seems to have no advantage to orally ingested medication. Where does it say on stone tablets that addicts cannot take maintenance medication permanently. It is right wingers that fight such thing. The previous Harper govt. fought safe injection sites to our Supreme court and lost. Ontario's reactionary Ford govt. is blocking previously approved supervised injection sites TO STUDY THEM in the face of increasing street fentanyl deaths. In BC anyone can access nalaxone kits.
2
Great work, Dr. Herring and Highland! This work couldn’t have been realized without the courage and conviction of Dr. Herring AND his entire department and hospital system. Dr. Herring is on the right track and gives us food for thought in how we can change our approach and our medical delivery. Inspiring work!
35
So many good comments here.....scientific and compassionate....but I look at the dollar signs for treatment and wonder what might be accomplished (prevented) by spending some of those funds educating K-6. I don't think we can educate or dissuade the population early enough.
9
Addiction has nothing to do with school funding. Addiction is not just a lack of knowledge either. Let’s just find ways for people to get out if addiction: methadone treatment and suboxone. The schools can focus on education, not being addiction specialists.
13
@Julie
The big $$$ signs are in private prisons everywhere. That is where we house drug abusers . . .and 62% are also "mentally ill."
The fight for dollars for change to a "medical model" of chronic disease with corresponding chronic maintenance meds will come from private prisons, privately-owned ambulance services, and law enforcement. Expect this battle to get ugly and remember to show up at your state and local meetings with public officials to address this priority.
3
Methadone maintenance treatment has been verified to be less expensive than the costs associated with the fallout of that many untreated opiate addicted persons — crime, STDs, hepatitis, HIV/ AIDS. This is how Methadone maintenance came about. Richard Nixon’s admin started Methadone maintenance clinics due to frustration with the inefficacy of anything else to treat opiate addiction in 1970s Harlem.
Methadone maintenance treatment, statistically and scientifically, makes financial and medical sense.
3
Now that white people are addicted to drugs in large numbers, the government is treating drug addiction like a disease. When crack addiction was a huge problem in the black community, the government response was harsher sentencing laws. There is a double standard. And I’m a white man.
114
This notion has been repeated ad nauseam. So would you suggest repeating the same mistakes? Complaining helps no one.
3
@Mark,
As another white guy (older one), you are correct when you point out that this and in many other areas, it ain't a problem until it hits whites . . .
2
No doubt. Methadone and suboxone clinics should operate more like a doctors office visit. Making working people go there six days a week is absurd. The staff needs to stop treating people like criminals. The double standard is crazy.
2
This the problem...Suboxone is the Silver Bullet to opiate addiction...Yet the law is so tight-fisted with this easy cure...Pure insanity...They should give Suboxone away like candy...But no! Let thousands of Americans suffer...
29
Exactly, these strips should be readily available but I want to point out that giving prescription s out in San Francisco where to fill these even with insurance, you have to get approval for the films and met deductibles, out of pocket a 30 day supply is almost $500.00. See how drug manufacturers profit off the back of this problem? On the bright side It’s nice to see local entities take this problem and use pragmatic solutions.
4
@Unintended Insider
Suboxone is not a silver bullet. Some addicts use it as a bridge between the days they inject heroin. Others take suboxone and sleep all day, every day--maybe a better alternative than over-dosing, but no silver bullet. Others get violently ill on Suboxone.
1
@Unintended Insider. Not sure where you read this, but it is far from a "silver bullet". You can get addicted to and high from it and it has been implicated in OD deaths.
2
Reality check we are own worse enemy our borders allow free access for drugs to be imported thru use of imports . Only one solution make all are own products an stop all imports. Put people to work especailly the people been ruined by these drugs. Back in 60s we had employers who cont find workers to work in factorys an they hired felons to work programs. Work programs gave broken down criminals purpose to lead better life an saved government billions. Amazing how fast we forget lessons of past made in usa solved alot problems. Today we we fight problems adding fuel to fire creating more problems then we need.
2
Do something about the drug dealers here--pharmaceutical companies and doctors who with the right incentives from the latter, have been prescribing these drugs right and left. Why not criminalize them? Incarcerate them? The dealers and the white suburban users. The American state has incarcerated hundreds of thousands of petty street dealers and users in the black community. Why not a war on drugs on white users and dealers too? Double standards?
3
@tdb
Many states have and are prosecuting providers, "pill mills" and unscrupulous pain clinics. I would refer you to recent convictions in Maryland (using their drug king-pin statute), Nevada, Florida, New York and so on.
The problem is not with ethical pain management clinics and programs who follow appropriate guidelines and standards of care. Many providers are trying to prescribe opioids in a responsible manner. The problems are with pill mills and clinics, often owned by non-health care individuals whose business plans include hiring providers to prescribe ever-increasing dosages of opioids to individuals who have no medical need for opioids. The patients become dependent and/or addicted to higher doses and will pay anything to get their opioids. Most of these entities are cash-based because their providers are not eligible for insurance panels. Patients often sell their excess opioids to pay cash for their visits and opioids resulting in excess opioids on the street.
Common signs of a problem clinic are: long lines for care, drug dealing in the parking lots, multiple pharmacies refusing to fill their providers' prescriptions, owners (not healthcare providers) driving luxury vehicles and flaunting luxury items, poor patient care, multiple overdoses and deaths associated with their providers' DEA registrations, and so on.
3
The fentanyl killing people in Canada and the USA is coming from China. It has nothing to do with medical doctors. Because it and carfentanyl are so concentrated they can travel via post in a one ounce letter or 30 g. without detection. Indeed apparently people can order it on the dark web.
Wasted lives. Too bad there wasn’t something more to it.
1
Awesome. Finally, now that enough white people are dying, this issue can be handled in a manner which will nearly guarantee that anyone who ever has a bout with addiction gets branded with a medical disorder for life.
If you think that calling addiction a “disease” is smart, just wait until you have to pay your insurance bills. Not that I’m opposed to doctors following the Hippocratic Oath, but this is a bit much.
6
This isn’t a bit much, and probably isn’t even enough although it is a step in the right direction. Communities like mine have been decimated by this addiction, and withdrawal is so painful that addicts often aren’t really looking for their next high, they’re looking for
1
We should do everything we can to help these people.
22
Prescribing opioids to a high-school soccer player?!? Put ice on it.
16
In Australia the national government provides methadone, buprenorphine and buprenorphine-naloxone 100% subsidy - so it costs nothing to buy wholesale. this means there's no involvement of insurers!
New South Wales to be specific, we have recently changed the guidelines for treating opioid dependence. Now any medical practitioner (doctor of any specialty) can induct up to 20 patients on buprenorphine (subutex) or buprenorphine-naloxone (suboxone). this means more people who go to their general practitioner or physician can get prescribed that day (and many boctors bulk bill medicare so their care is free). many patients are dosed in community pharmacy setting and that costs up to ~40 a week for dispensing depending on the mix of supervised and takeaways.
for methadone, people are mostly induced and managed in free public clinics by addiction medicine specialists. we also have 11 private clinics who treat complex patients. people start in clinics and once stabilized can be referred to either an accredited opioid treatment prescriber (who can take 200 patients bupe meth) or one of the not accredited medical practitioners (mentioned above) who can take 10 methadone patients.
overall the main thrust of what im saying in public/private/community model works well in australia. we never turn away people seeking treatment. they may have to wait at to get into public clinics but there's always other options available at a low cost.
good luck with the hub and spoke model!!
20
This approach will save lives, improve society at large — and save money overall.
4
Finally, real treatment for a real disease, instead of a scolding. As an ER physician, I applaud this humane approach to this often fatal condition.
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As a Psych doc, I agree. This is also a more cost-effective and scientific approach, never mind being more humane.
9
The problem cannot be fixed by EDs writing Suboxone. ED Suboxone treatment without a comprehensive detox/rehab program is a smokescreen. As an ED MD with 15 years experience I'm sympathetic, but realistic. This withdrawal isn't life threatening, just miserable. One ED dose will become multiple visits in an already over crowded setting and no one to prescribe or care for the victims.
The solution starts with joint community/hospital/primary care commitment to long term treatment.
5
@David G
Did you miss the part about suboxone tabs for 48 hours treatment with a referral and follow-up appt with the ER hospital's affiliated addiction recovery program? You might see yourself as limited to your shift in the ER but the doctor at Highland ER was also affiliated with that outpatient addiction treatment center if I understood the article correctly.
What we really need is single payer, Medicare for Everyone so doctors can focus less on insurance company policy and more on their talents as physicians.
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Didn't miss it. They have a support network that is misleading to generalize to 99% of ED settings. EDs are a tiny piece of the solution, utterly inadequate as a stand-alone. Single payor is another topic, incidentally one I support (and EM docs have close to the highest rate of physician group support).
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@David G Please don't forget about Meth addiction either it is still a bad problem as well. I know someone who is trying to break their meth addiction and they seem to have that same problem mentioned early in this article about throwing up aot and stuff while they go through withdrawals, I'm afraid it only encourages them to use again just to relieve the symptoms of withdrawal. Please find ways to help them too
3
Unless buprenorphine is in short supply, you'd just assume that every hospital in the county would be ready to use it for every opiod addict.
8
Yay for the ER doctors who are using buprenorphine to help opiate addicts.
France was able to cut heroin overdoses by 79% in four years and to cut the number of addicts by allowing physicians across the land to distribute and prescribe buprenorphine, a medication that reduces cravings for opiates without being addictive itself.
The United States could do the same, if only it would change obstreperous regulations, such as that doctors must take a special eight-hour class to allow them to prescribe buprenorphine. The classes cost money and are not readily available; many doctors do not even know of the existence of the classes. The regulations also limit how many buprenorphine patients a doctor can have.
How crazy is it that the government decries the so-called opioid epidemic, while making it difficult for doctors to help their addicted patients???
https://www.theatlantic.com/health/archive/2018/04/how-france-reduced-he...
22
In seven years treating individuals struggling with severe opioid use disorders (ages, genders, races, socioeconomic backgrounds vary plentifully), every single person has said getting off suboxone is far more difficult than detoxing from heroin, fentanyl, or oxycontin. When we extol the virtues of this medication that undoubtedly helps so many people, we need to also discuss the challenges with longer-term use. Don’t get me wrong: I like harm reduction. But let’s please cover the full story.
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@Jack
Chronic diseases like substance abuse require lifetime treatments, including methadone walk-in clinics where people enrolled by their physician can get their daily dose before going to work or school or church or all of those places we not-addicted take for granted.
2
Would you suggest that a diabetic detox from insulin ?
Why are you trying to get people off Suboxone ?
3
@Jack
Methadone clients in the 70s said the same thing to me about withdrawing from methadone. But the point made by @DJS is the relevant one. Why discontinue a medication (speaking now of Suboxone) that stabilizes someone, blocks attempts to use opioids--thereby acting as a deterrent, and allows for engagement in behavioral therapy, work and as normal a life as possible?
2
This article really should focus much more on the medical facilities and insurance companies creating prescribing/financing these addictive meds in the first place. Much more detail on this issue is essential as a first step to solving the problems. How do patients get prescribed dangerous drugs of which they have no understanding, how are they medically checked on a regular basis to monitor their health, how do they recognize the dangerous side effects and whom do they talk to. It seems medical facilities get patients started on very dangerous meds but then are nowhere to be found when help is needed.
6
It’s good to see that at least one hospital is showing compassion and common sense in dealing with people dependent or addicted to opioids. It should be noted that this clinic is giving people suboxone instead of heroin or some other opioid that has euphoric properties.
The current hard line approach towards opioid use is already causing severe problems including suicide for many people with chronic pain or severe pain. The current thinking is that addiction is a disease and not a moral failing or lack of will power.
For the good of our country and the lives of people who have pain issues we need to treat the opioid issue in a sensible manner and not as a political sound bite.
19
For those of us who grew up the Rockefeller Laws response to Allan Ginsberg's Howl for help about the opioid epidemic in the 1950s, (heroin), ("I saw the best minds of my generation destroyed by madness, starving hysterical naked, dragging themselves through the negro streets at dawn looking for an angry fix..."), I wonder why the need to help addicts is happening now when so many lives were destroyed punishing people for using and getting hooked on drugs. Is it because it's the white kids now? I think in addition to helping people nowadays in a good way, you people in government ought to think about restitution for all the lives you destroyed just because the afflicted ones weren't white.
31
Even now only rich whites are offered treatment. African Americans and Hispanics are jailed or killed by cops. Shame. Shame!
11
Or maybe just getting the non-white folks, who suffered from addiction and committed no violent crimes, out of correctional facilities first. Addiction treatment would be so much less expensive than incarceration, too.
1
GOP legislators belatedly begin to understand that some of their own might be directly affected; until then, as with 1000 other issues crucial to well-being of Americans, GOP cares not in the least.
1
I wish this were every hospital and ER.
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@SS It should be
The drug companies and doctors should be sued for making and selling these drugs.
11
@CookiesIncarcerated. Dealers of other drugs have been incarcerated not simply sued and fined.
4
@tdb How's that war on drugs going? Punishing the suppliers has never worked - not for alcohol in the 1930's, nor for other drugs since.
Please add the Arnot Ogden Medical Center in Elmira, NY, to your list of hospital ERs that give the Suboxone treatment. The work was done by Dr. Frank Edwards and Dr. Rob Wicelinski to get our program started and these programs are a first step to combating the opioid crisis.
48
That’s nice. The NYT should visit the Mayo Clinic in Rochester, MN and inquire about how they taper (the don’t) their chronic pain patients (such as yours truly, with an untreatble, incurable condition diagnosed by their own expert) for whom they’ve refused to continue to prescribe opioid pain medicines. I can also provide you with the details. They are not pleasant.
25
Opioid addiction is big business. Before our current problems the British East India Company and later the English Crown of the 18th and 19th century accumulated fabulous wealth growing opium in India and forcefully (think Opium Wars and seizure of Hong Kong) selling it to China. As many as 12 million Chinese addicts were created in a time when the entire population of China was 150 million. All the wealth created English country estates and fortunes that exist to this day. It took the absolute power and murderous impulses of Mao Zedong to treat China's mass addictions and to execute the sellers. We have now driving much of our American drug addiction the powerful greed that our unrestrained capitalism has fed. The idea of the legal system solving the problem would be almost vastly inadequate. If we need an illustration just look to Nixon's War on Drugs that has been a massive failure for 50 years. It did, however, spawn an industry. Also, keep in mind the mass lead poisoning of America by the the Ethyl Lead Corporation for 50 after the causes and effects of lead poisoning were well known. If we began successfully imprisoning drug company and distributor executives, physicians and pharmacists we might make a dent in the problem. Fines won't fix it. As it is addiction is thought of as a personal weakness for which societal sympathy is in short supply, as it is for companions poverty, and mental health disorders. Addicts have few patrons.
13
Was waiting for someone to present the historical perspective.
I don’t see any bankers responsible for the 2008 mortgage meltdown in jail either. Apparently once you are wealthy or connected enough past a certain point, nobody applies the laws to you.
2
We are spending hundreds of billions upon addiction treatment annually. Just give everybody healthcare already.
69
If everyone had healthcare there would be no addiction, no suffering and no funeral costs.
3
How ridiculous! People still get old and develop fatal illnesses under socialized medicine. And of course, humankind and all life is born to die.
@Fred. Give me a break. People with health care get addicted all the time. European countries with free health care have a hordes of addicts. You still have to have a brain and make the right choices, health care or not.
Regarding those with an addiction ... along with lots of money and patience to help those poor souls inflicted (for whatever reason) with addiction, we all need to be compassionate. There is not one family in my circle of friends who does not have at least one member suffering from drugs or alcohol problems, including my own. Choices? Yes, I suppose so, but also the choice of an alcoholic pregnant mother, like my own, who chose to drink and smoke while she carried each of six children. Let's move on from casting blame to education & cures. It can be done. Please.
18
A 30 year old that has been addicted to opioids since she was 12 due to an injury is certainly a problem. Who was responsible for her when she was a child? I don't get it.
Medical professionals are doing what the best job they can dealing with these people. Methadone was one of the meds tried for my chronic pain, the side effects were far worst then the small amount of relief I received. My pain management team and I decided to discontinue it. I was ignorant of the need to follow the tapering of it. On the final few days/dosages I did not do according to the protocol. For 24 hours it was horrific until I was able to talk to my doc. He scolded me, told me what to do, which I followed exactly as he told me. Took another week, but when it was done, the experience had me wonder how could anyone go through this more than once? I hope there comes a day that there is a way to stop this addiction before it gets to the point of these people. Especially those that start with an injury as a kid.
15
@HJ I have a life long condition and have had painful surgeries since childhood. By 13 I was research effective pain management and handling my own pain medication. If I had suddenly started taking too much though my parents would have noticed because they had to go get my prescriptions. Either the parents were negligent to an almost criminal level or the story may not be entirely accurate, especially considering it was told by someone in an altered state. I've also never heard of a doctor giving a child narcotic pain meds for a sports injury. My mom had to beg for pain medication for me after back surgery that was serious enough to land me in the ICU and had a year recovery time and even after that the pharmacists refused to dispense it because he thought a few weeks was enough for me to be healed up. My nephew didn't even get any after he broke his clavical and my cousin recently broke hid wrist and was told to take tylenol.
8
@HJ
from a retired medical attorney:
Addiction often is hard-wired in our DNA, from birth. That is how very young children can get into trouble.
That's why my sisters, my cousins, and I pledged to not have children or to adopt. Six alcoholic parents produced ten children. Under the pledge, there are now two children (brother not in) and two adopted kids. It wasn't rocket science to figure this out in the 1960s and remains one of many hard choices informed young people need to face.
1
Let's not forget Purdue Pharma, nowhere to be found in the ER. A confidential Justice Department report found the company was aware early on that OxyContin was being crushed and snorted for its powerful narcotic, but continued to promote it as less addictive.
49
@kat perkins Oh how I remember when this started and then got out of control. Drug reps were handing out samples to physicians with incentives to prescribe the drug. There were stacks of the stuff in the sample closets of many physicians.
Drug reps were also given lots of perks~money~for the amount the docs they took care wrote for. Physicians relay on the drug reps to educate them on the drugs, they are physicians not pharmacists.
6
As someone who was a heroin addict for years here in Australia buprenorphine otherwise known as it's trade name suboxone was an absolute game changer in me battling my addiction to heroin. Here in Australia the government pays for your treatment and it is freely available and easy to access. It's a no brainer for the medical professionals and addiction specialists who deal with patients so severely addicted to heroin and opiates. Australia's proximity to the Golden Triangle saw heroin use rise dramatically during the 90s and early 2000s, Australia was in the midst of a heroin scourge with thousands of people dying yearly due to the cheap availability of heroin from Asia. We still lose individuals to overdoses but not like back then when the human death toll was on par with national road toll. We are blessed here in Australia to have government funded health care or as conservatives like to say socialized medicine and in doing so it has saved thousands of individuals succumbing to their addiction and saved thousands of families the trauma of losing a loved one.
123
@Alex - It's good to hear what's working in other countries.
Is there much discussion in Australia about how drug users, purchasers of heroin and cocaine, through the money they exchange for drugs, are a direct contributor to the crimes perpetrated by groups like the Taliban (biggest heroin producer) and the Central American drug cartels (cocaine)? It's the drug users' money, after all, that finances their activities, their purchases of weapons and ammunition, their bribing of police and politicians, and by consequence, the rapes and murders of girls and women around the world.
Is this talked about? Here in the USA it's total silence.
@Alex I am so glad to hear that you are doing well and have had access to treatment. I think we are still a long way away from widespread access here unfortunately. Our government and much of the public prefers to attack pain patients rather than spend money on treatment for people with addiction. Are people in Australia generally able to get treatment for pain?
7
What is your exactly trying to say? That individuals that are mentally and physically addicted to illicit drugs are somehow responsible for the rape of girls in developing countries? llicit drug users already carry a heavy burden with the lying, cheating, stealing and scamming they do to support their addiction I know this first hand and it's a burden I will carry the rest of my life. I feel your argument is a bit of a stretch to say the least and that sort of attitude will not solve the growing epidemic that is drug addiction without state or national government help and funding.
3
Dr. Herring is a hero plain and simple. While the politicians in DC debate, delay and ignore the problem, he is in the trenches problem solving, helping people. Thank you Doc.
106
@kat perkins: Exactly. ... solving problems and helping people. Thanks!
10
Kudos to this ER...I also appreciate the patients' willingness to be quoted and photographed. Once faces are put alongside the facts, the story instantly becomes more humanized, showing people who may think poorly of those with substance use problems that these are beautiful, appealing individuals, people who could be your friends or family members. This piece, with photos and quotes, will go far to destigmatize this frightening epidemic-- and, I hope convince other hospitals to replicate the program.
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@Ellen
these faces are called "the identified life" and studies going back decades show that people are willing to spend $100K to save each such life. Versus the $150 limit they choose without an identified life!
1
A telling point in this article is that most health-care practitioners need approval from the US Drug Enforcement Agency before they may prescribe these meds to help overcome addiction.
A consequence of reducing addiction will be, bluntly, layoffs for drug-enforcement police. It simply doesn’t make sense to give those police unbridled authority over access to meds to help reduce addiction: they have conflicts of interest. At the same time, there is definitely a sordid history of pill mills fed by outfits like Purdue Labs, so some oversight of access to opioids is necessary.
But the oversight needs to come from organizations with health-care charters and expertise. Leaving it to the police means things cannot change.
In the meantime these pilot programs are most welcome.
13
Portugal has experienced, and continues to experience, significant success in treating addiction as a health care issue. The Portuguese parliament has decriminalized drugs (which does not mean that possessing or dealing with them is unlawful). The US needs to have a close look at how well the Portuguese handle substance abuse related health issues.
48
@Edgar Excellent comment. The sad truth is that the U.S. isn't in the habit of studying the health care issues of other countries.
1
I’m having a medical emergency too. The GOP wants to take away my healthcare because I have a pre-existing condition. Who’s helping me and millions of others?
93
The Democrats are trying. You’re welcome.
25
Not the Republicans. Vote for Democrats in 2018 and 2020.
3
Thank you for writing this story about Dr. Herring's efforts to help people recover from painful opioid addiction. His efforts are exemplary and noble.
I work as a clinical social worker in Emergency Room settings, and am often given the task of connecting people addicted to opioids to detox and long term treatment.
Getting them medications for withdrawals is a big first step, but is usually not enough. For example, withdrawals handled with any medications are still dangerous for patients sent home to detox, as opposed to being on a secure medical or social unit, because of their heightened risk for overdose if they relapse.
Insurance companies like Blue Cross Blue Shield, United Health, and many others routinely deny authorization for inpatient detox, saying "people withdrawing from opioids don't meet medical criteria", meaning that unlike alcohol detox, patients are not in danger of dying because of withdrawals. While withdrawals from alcohol is more dangerous due to critical vital signs, lab findings, and delirium tremens, the insurance companies' argument conveniently ignores the fact that over 50,000 people died last year alone from opioid overdoses. These overdoses often occur in the context of withdrawals, and insurance companies are accountable for denying them treatment for withdrawals in secure environments where the individual gets support to help them avoid relapse.
This needs to change.
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@PJ After the fact wont help we need to stop flow drugs into are beautifull country . These drugs ruin people lives forever .I live with person whos been ruined she will never be better with treatment. No one wants her in there home even her family. System put her on list of doom promising her place to live which will never happen. Only one solution stop all drugs coming into are country ,no imports end of problem.
@PJ
I worked at Highland Hospital in Oakland for many years and have always found its providers to be caring and providing cutting-edge care. I commended the excellent care provided by the medical staff and nurses to patients despite limited resources. This is an excellent opportunity to counsel patients about options for recovery and to provide them with medication that may improve their chances of success.
I am now working in SLC, Utah tapering patients off of opioids and providing Suboxone for chronic pain patients, as well as patients with SUD. Suboxone has been life-saving for both populations. I hope that EDs in Utah seek more information regarding this program, so that more patients are provided with early access to Suboxone.
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@PJ- THanks. You raise an excellent point. I just spent a year fighting my insurance company (Harvard Pilgrim Health Care) for denial of my daughter's stay at a residential rehab. After two denials, based on "lack of medical necessity" I went further, appealing through the Mass Office of Pt Protection, which sent the case out to an independent reviewer, who overturned the denial. The lesson here: keep fighting. If enough people do, they will have to alter the denial criteria.
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Lather, rinse, repeat. Zero consequences for bad choices.
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@Hi Pylori
Greetings, although I understand where your opinion makes sense to you and others, it is inaccurate--there are terrible consequences for addicts. All the time. They know it.
A relative of mine went through alcoholism treatment eighteen times before becoming permanently sober. This was back in the day...and he died a happy man years later.
It is a serious health issue, related to brain functioning and deep emotional pain. Compassionate understanding would help everyone. We are way too judgmental these days. This does not mean tough love isn't needed. But do it without judgment.
Some will not survive.
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@Hi Pylori
Whose bad choices?
Pharma companies for pushing their opiates onto the market to the max with no regard for consequences?
Doctors who were targeted and rewarded hugely by the number of prescriptions they could write to the drug company motivating them?
Yes..there were few consequences for those who made the bad choices for millions of Americans who became addicted for pain medication often over prescribed as well as minimally supervised.
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@Hi Pylori
People who repeatedly make bad choices that threaten their lives will die unless they are unusually lucky.
One morality says to let this happen.
Another morality says we should save them from themselves, like we try stop people who are contemplating suicide.
A third morality says that addiction is essentially being possessed by a foreign power; even if people invited this power into their lives, it does not leave just because they want it to. Getting unpossessed is a real struggle and staying unpossessed is also difficult.
The Bible is no help because people have found each of these moralities there; people find what they want to find, so it is their choice.
Holding people responsible for their choices is a choice with its own consequences. For example, it is a gateway to sadism. The best choice is to do it with moderation, understanding, and love.
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I am so impressed with so many doctors that I talk to these days or read about. The medical system in this country is in terrible shape because of insurance--we need a single-payer plan so docs can be docs. But stories like this tell me, that this set of doctors who are on the front lines with people in the worst trouble I can think of from drugs and other social ills...are still very very dedicated to healing.
I love that. Thank you so much, we need your deep professionalism and compassion.
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