When a patient recently came into the St. Paul, Minn., office of Dr. Mark Willenbring, the doctor already knew his history. Diagnosed in his 20s with a chronically painful disorder, James (not his real name) had done well on opioid painkiller Oxycontin for almost a decade.
Then, however, his pain spun out of control. He developed a craving for higher and higher doses and began misusing his medication. At that time, Willenbring started him on methadone, a synthetic opioid that offered another few years of effective pain relief.
“He went from one hour a day up and active to 16 hours up and active,” Willenbring says. “He started coaching his kids’ sports teams. He got a job.” Unfortunately, James also suffered from depression and anxiety. When he developed a phobia related to work, he dropped out of treatment and returned to his pattern of self-medicating with Oxycontin.
Now he was back. Because Willenbring specializes in addiction—he’s the former director of treatment and recovery research for the National Institute on Alcoholism and Alcohol Abuse and currently runs an addiction treatment program called Alltyr—he knew what to do. He began prescribing Suboxone, another synthetic opioid, along with treatment for James’s psychiatric problems.
“He’s better,” Willenbring says. “He’s not well and I’m also modifying his depression treatment and doing psychotherapy because he’s got issues with his family and spouse and you have to treat the whole person.” Still, he is no longer taking unprescribed drugs and Willenbring sees a good prognosis.
But what if James had been caught misusing pain medication by a less educated or enlightened doctor or pharmacist? What should doctors do if they discover a patient is “doctor shopping” or has developed an addiction?
In a country where overdose deaths have overtaken car crashes as the leading cause of accidental death, with nearly 50 people dying from opioid-containing overdoses every day and 2.1 million people addicted to such drugs, these questions are increasingly urgent.
Sadly, the typical response is to refuse to prescribe more pain drugs—and, if the patient is lucky, to provide a referral to treatment. Alternatively, people caught misusing opioids or obtaining illicit prescriptions by prescription drug monitoring programs or pharmacists who serve as gun-toting narcotics control agents can be arrested and prosecuted.Compared to no treatment, maintenance reduces mortality by around two-thirds. Since dead addicts can’t recover, failing to provide access to these medications for those who can benefit from them is literally killing people.Willenbring’s example suggests a better way. It’s not like we don’t know what the best currently available treatment for opioid addiction is: The CDC, the World Health Organization, the Institute of Medicine and many other leading expert bodies have examined the data repeatedly. Studies show that long-term maintenance on either methadone, Suboxone or even heroin—without time limits—is best.
The most important statistic is this: Compared to no treatment or abstinence-only treatment, maintenance reduces mortality by around two-thirds. Since dead addicts can’t recover, failing to provide access to these medications for those who can benefit from them is literally killing people.
However, only 39,000 Americans are currently on Suboxone treatment and nearly 312,000 are in methadone programs. In other words, more than 80% of opioid addicts aren’t being reached.
For a model of how to do better, we can look to our own past and to the more recent success of the “British system,” which dominated opioid treatment in the UK from the 1920s through the 1960s.
First, the American experience. After nonmedical use of opiates became illegal in the US with the Harrison Narcotics Act of 1914, initially many doctors simply prescribed for addicts and considered this as medical care. Unfortunately, in 1919 and again in 1923, the Supreme Court ruled the practice was illegal.
Drug policy became increasingly focused on criminalization, and large-scale maintenance did not re-appear in the US until the introduction of methadone in the 1970s. Then, it became the most regulated drug in the pharmacopeia, with prescribing for addiction limited to specialized clinics and restrictive zoning laws typically limiting those clinics to poor neighborhoods.
In the UK, however, maintenance prescribing was officially accepted in the early 20th century, with the 1926 Rolleston Report. It defined addiction as a disease and, therefore, a condition that can be treated with medications. For almost four decades, the UK’s opioid problem was limited to a few hundred addicts, who got their drugs mainly from general practitioners.
Those numbers began to increase in the 1950s due to changes in drug culture. When flagrant “pill mills” appeared—prescribing high doses with little regard for safety—this approach came under pressure. And so, in 1968 and 1969, the UK shifted to a system that, like ours, basically ghettoizes opioid addiction. It confined maintenance treatment to doctors with special licenses, although it did continue to allow prescription of heroin and other injectable drugs.Doctors who would overlook a patient’s lies about, say, diet and exercise instead become personally affronted [about painkiller misuse]. It’s hardly surprising. Being fooled in this way can have severe legal consequences for the doctor.Then, however, came a US-influenced flirtation with even more restrictive measures like time limits on prescribing in the 1980s. That led to an increase in overdose deaths. In reaction to this and, even more, to the threat of AIDS, the UK expanded maintenance through its clinics and licensed doctors. Together with needle exchange and other harm reduction measures, this prevented HIV from becoming an epidemic in IV drug users, as happened in the US, which did not respond as fast.
In the UK, HIV infection rates never went above 1% in addicts, while in some cities in the US, levels reached 50% or higher and then led to a heterosexually transmitted epidemic in minority communities. (Unfortunately, the UK now is once again battling politicians who want to limit prescribing, but its medical establishment, based on the data, continues to resist).
And here, today, we’re still stuck with overly restrictive limits on prescribing and the segregation of addiction care from the rest of medicine. While the FDA did not repeat the mistake it made with methadone and limit Suboxone prescribing to specialty clinics, doctors are still only allowed to prescribe to 100 or fewer patients and they must receive special training before they do so. Methadone, when used for addiction, not pain, is still only available in clinics.
“The major health organizations, for the most part, have not stepped up to the plate in response to the crisis in opioid overprescribing and the increase in overdose deaths,” Willenbring says. “They haven’t offered high-quality easily accessible insurance-based Suboxone treatment.”
Some states are starting to try to do better. Vermont, for example, has set up a “hub and spoke” system, intended to ensure that anyone with opioid addiction can be referred to a doctor or program near home who can prescribe. State policy is now aimed at deferring prosecution for addicted people who agree to seek treatment.
But while this has resulted in increased demand for treatment—with hundreds of people on waiting lists—it has been hard to increase the maintenance supply. Despite the availability of state money to pay the nurses and counselors of general practitioners willing to prescribe, only one in five such doctors have agreed to do so.
David Pattison, who has been treating addiction for eight years, says many doctors have been burned by patients who faked needing drugs for pain. They’re leery when the same patients come back for addiction treatment.
“It really feels bad to get tricked like that,” Pattison says. “They don’t want to have anything to do with those people who have been violating their trust.”
This is where stigma continues to curtail care; where doctors who would overlook a patient’s lies about, say, diet and exercise instead become personally affronted. It’s hardly surprising: Being fooled in this way can also have severe legal consequences for the doctor.
If we want to improve addiction treatment, then, we’ve got to get the criminal justice system out of the relationship between doctors and patients—or, at least, minimize its involvement. A doctor who finds out she’s been “tricked” should be able to prescribe maintenance on the spot: She shouldn’t be legally at risk for having been taken in or legally barred from helping once she realizes what’s going on.
We also need better medical education on addiction, presenting it as an actual medical disorder—not as the only disease for which the official treatment is referral to other patients to guide them in prayer and confession.
A few years ago, I saw Dr. Nora Volkow, the director of the National Institute on Drug Abuse, at a conference. I asked her whether anyone was studying or attempting to spread the practice of such prescribing, when a doctor or pharmacist catches a doctor shopper or prescription forger or simply realizes a patient has become addicted. She started to mention a program that involved a drug court and I stopped her.
I said that I meant a program that didn’t involve criminalization. She said, “Well, that’s what we would do if we saw addiction as a disease.”
13 January 2015