Originally Posted 3/14/2013
A local District Attorney wrote to me last week to express his concern about the increased diversion of buprenorphine. I often sense an undercurrent of tension when I cross paths with attorneys, aware of the different attitudes that we hold that arise from our different roles in society.
The DA wrote about the dramatic increase in overdose deaths in the Midwest. Overdose scenes are often littered with a variety of substances, ranging from bags of heroin to the orange plastic vials used by pharmacies to dispense medications. If the overdose victim was on Suboxone or buprenorphine, the prescribing doctor is often contacted about the death and the ensuing investigation. Doctors notified about patient deaths have reactions beyond the grief over the loss of someone they cared about, including guilt that they couldn’t save the patient, and even fear of being blamed for doing something wrong. Every doctor has seen headlines featuring peers accused of reckless prescribing, and the addiction world is somewhat unique from other specialties in the way that patient deaths cause a sense of ‘guilt by association.’ Oncologists, for example, are not viewed with the same degree of suspicion when their patients succumb to cancer.
I felt a bit defensive about the DA’s letter. I know that buprenorphine saves lives, beyond a doubt. I also notice that the positive actions of medications are often taken for granted, while the risks are cited as scapegoats. I notice how quickly people complain about others ‘on buprenorphine’, without taking the time to ponder what would likely happen were buprenorphine not available.
Some physicians’ fears stem from dilemmas faced in treating addiction that are difficult or even impossible to resolve. For example, a DA may point out that the doctor’s patients are not behaving like ideal citizens, not realizing that the doctor is every bit as aware of the problem, yet unable to make things better. In some cases doctors do the very best they can (or that anybody could do), yet their patients struggle to maintain sobriety. Doctors may be tempted to abandon the problem patients altogether, to avoid being seen as impotent or worse—as ‘part of the problem.’
I know, right now, that three of my patients are struggling with buprenorphine treatment. Maybe I’m naive and the true number is higher, but I’ll focus on the people who I know, for certain, to be struggling.
The patients I refer to as ‘struggling’ are taking buprenorphine or Suboxone, but taking it imperfectly. For years they were conditioned by heroin, as the misery of withdrawal was relieved by the poke of a dull needle and the injection of foul liquid, hundreds and thousands of times over. They are now ‘freed’ by buprenorphine from the need to relieve physical misery, but the urge to penetrate their skin with needles continues. Buprenorphine binds opioid receptors so tightly that heroin or oxycodone, when injected, cause no high or change in sensorium, yet users are still drawn to inject, a status referred to as ‘hooked on the needle’, where the painful piercing by a dull needle fills an otherwise-intolerable emptiness.
Their actions appear insane to people who have never ‘shot up’. Why would someone risk endocarditis—or worse– through shared needles, when the injection causes no pleasure, and in fact causes pain? The bizarreness of the situation doesn’t, unfortunately, make it less common. The situation exists.
I tell my patients that the one thing that results in immediate discharge from my practice is sharing or selling medication that I prescribed. Even in the midst of insanity there must be some absolutes, and from my perspective, an absolute boundary exists where one person’s behavior harms someone else. A patient who sells a portion of his/her Suboxone to score heroin, or for any reason, has crossed a line.
But what about the person just short of that boundary—the person who is still ‘hooked on the needle’ who is trying, most of the time, to stay off needles and smack but at 3 AM, in a room with other users—a room where he hit the needle hundreds of times before—hits the needle again?
There are plenty of reasons to terminate treatment for such a person. He shouldn’t have done it, shouldn’t have been there, shouldn’t have been with those people… and many doctors would stop treatment at such a point, even knowing that doing so contributes to another overdose death.
We don’t treat other difficult patients the same way. Our noncompliant teenage diabetics are given second, third… endless chances to get their insulin right. People with post-op hemorrhages are rushed back to the OR for more treatment—not tossed to the curb, labeled ‘difficult patients.’
And I know from experience that some people hooked on the needle, in the position I described, can be saved. For my struggling patient, maybe tonight wasn’t his night. But tomorrow, the balance between cues, cockiness, and desperation might allow him to say ‘no’. And with the right sequence of events, and maybe the right words of encouragement, he might put enough days together to make ‘no’ a regular thing.
Or he might not. Maybe saying ‘yes’ one more time will end any lingering hope that he will pull it together and give life on life’s terms a try. For this guy on Suboxone, there is still too much disease in the mind and body for any prediction beyond a guess. And if, at any time, he happens across something larger and purer than he’s ever experienced before, the respiratory depressant effects of whatever he uses may cost him his life.
It is at this scene where I suspect the DA and I would have different opinions. I’d expect many DA’s, viewing pictures of a cold body with a needle in the arm and a half-full bottle of Suboxone on the bathroom shelf, would say the guy had his chance and lost the right to take medication a long time ago. I respect the DA’s position, and wouldn’t expect it any other way. The DA’s doing what he is supposed to do.
But at the same time, I hope the DA understands MY thoughts, reviewing the same pictures. I’d think that had my patient made it past tonight, he might have strung a few better nights together. And by the odds, I’d know that had I kicked him out of treatment for screwing up the first time, he would have died weeks ago.
Of course I don’t enjoy prescribing a medication for someone who doesn’t take it correctly, despite my strongest warnings and admonishments. But had I simply kicked him out of treatment and THEN read his obituary, I’d wonder if I’d done everything that I’M supposed to do.