First Posted 8/11/2013
We’ve all read articles about the epidemic of opioid dependence during the past ten years. We’ve heard the concern over pain medications being overly-prescribed by some physicians. Some of us older docs even remember the claims, by the Joint Commission on Hospital Accreditation and other medical watchdogs, that physicians were undertreating pain and were in need of education to increase their responsiveness to suffering patients.
We witnessed the increased use of potent opioids, a trend favored by regulators and fueled by the growth of ‘health systems’, large hospital and provider businesses that added the concept of efficiency to the doctor/patient relationship. Along with insurance networks, the systems eliminated many traditional aspects of healthcare in the US, leaving behind a system where one doctor is easily replaced by a different doctor, and doctors who take too great an interest in their patients’ welfare are seen as paternalistic.
We remember the controversy over Oxycontin, a delayed-release preparation of oxycodone that was claimed to have less addictive potential. Purdue eventually paid $600 million over claims that their sales force misrepresented the risk of diversion and overdose of Oxycontin. Never mind that the product truly was less addictive than the immediate-release drug that it was intended to replace. Purdue did not foresee that they would be held responsible when the pill was crushed, snorted, and injected, and the drug was a handy scapegoat. But more about scapegoats later.
In the late 1990’s the combination of two old drugs created ‘Suboxone’, which hit the US market in 2003. The epidemic of opioid dependence continued to grow, and overdose became the leading cause of death for young adults in many parts of the country. Suboxone and buprenorphine have prevented thousands of deaths during that time, but now are considered contributors to the problem. Even as hundreds of thousands of patients benefit from proper use of buprenorphine, the deaths related to buprenorphine and Suboxone, measured in dozens, capture headlines.
Opioid dependence has long been known as a permanent, lifelong illness that requires long-term treatment. But the long-term nature of the illness is lost on some people who have come to see effective long-term treatment— a concept not even considered a couple decades ago— as a problem rather than a solution. The features of buprenorphine treatment that increase compliance and effectiveness, such as discontinuation effects (a.k.a. withdrawal), are viewed as drawbacks. Many people eventually ‘freed’ from Suboxone die within a year of stopping the medication, and countless others return to desperate lives of active addiction. Yet more and more, the lifelong addiction faced by opioid users is blamed not on the long-term nature of the illness, but on the presence of life-preserving treatment.
Physicians who treat patients with opioid dependence using buprenorphine are not the best positioned to defend the treatment. One of the most common arguments against treating people with buprenorphine is that doctors want to keep people on the medication ‘for the money.’ How do I argue that I’m NOT in it for the money?
I read a blog post today that used what the writer considered ‘conservative estimates’ to conclude that doctors prescribing Suboxone could make as much as $150,000 per year. The estimates require that the doctor’s buprenorphine practice is completely full—not a horrible assumption given the number of people in need these days, but the reason practices are full is because few doctors want to take on the difficult aspects of treating patients with addictions, such as the high rate of no-shows that leave doctors with hours of unused time. The writer assumed that every one of the 100 patients is seen monthly, apparently for however long they take the medication—something at odds with most physician practices. The writer assumes no overhead, leaving out the cost of rent, malpractice insurance, furniture, office staff…. Do you know what an ad in the yellow pages costs?!
But even if I used his numbers, does it matter that doctors who prescribe buprenorphine have the same education (and education debt) as other physicians—i.e. at least 4 years of college, 4 years of med school, and then internship, residency, and annual CME? Medical students (including future buprenorphine prescribers) where I lecture graduate with debt literally in the hundreds of thousands of dollars. The future anesthesiologists, surgeons, radiation oncologists, dermatologists, and radiologists will average salaries 2-4 times greater than their classmates who decide to treat addiction using buprenorphine.
Does it matter that the people arguing against long term treatment with buprenorphine are generally in favor of using buprenorphine SHORT term—which is exactly the way to make money off buprenorphine? Does it matter that the doctors who make a lot of money are the same doctors whose patients do the worst—the doctors who market buprenorphine detox?
I suspect that the answer is ‘no.’ I’ve debated this issue on my forum, with visitors who stop in to argue against the use of buprenorphine. I suspect that just mentioning the word ‘money’ makes it easier for such people to see me as greedy. Envy wins over logic, at least when it comes to headlines.