Healthcare is Confusing Part II: The Opioid Epidemic

I live in Northeastern Pennsylvania, an area that has been affected by drug addiction and rampant alcoholicism for as long as I can remember. I personally know more people who have died from drug overdoses than any other type of death. And almost all of these people were under the age of 35 when they died. I lost one of my best friends to a heroin overdose in 2008 when she was only 19 years old and a freshman at Penn State University. I lost a close family member to an overdose in 2011 who left four children and two grandchildren (along with many others who loved her creative and beautiful spark). My response to all of this is: Heroin (and prescription opioids) really suck.

There is no clear answer on what will end this “epidemic”. People are quick to make judgement on what should be done based on their personal worldview, which can be dangerous when forming any opinion. Recently, DAs have been charging people who have provided drugs that caused a person to overdose with homicide and manslaughter. I’ve been hearing the rallying cry crescendo over the past few months- “DEATH TO DRUG DEALERS!”. In my opinion, although this may dissuade a few people to stop selling drugs, it isn’t the answer. And holding someone responsible (the person who sold the drugs) for the person who overdosed decision is an area that has the potential to create a dangerous precedent. We don’t hold gun owners responsible for people who kill themselves, right? We don’t jail Nabisco executives for those who died from diabetes or other sugar-causing illness, right? Now don’t get me twisted, I don’t think that we should be okay with people selling illegal drugs (or selling legal drugs illegally), but holding them responsible for this epidemic isn’t going to stop it, because it’s not looking at the real problem, the dangerousness of addiction, the availability of opioids, and both the lack of availability for drug and alcohol treatments and effective models to help people live sober lives after they’ve been addicted to drugs.

So what does the opioid epidemic actually look like? Someone only needs to visit the twin cities of Northeastern Pennsylvania, Scranton and Wilkes-Barre, to see an example of an area affected by addiction. People used to line up at a walk in Ready-Care clinic at 7am in downtown Scranton in order to be the first to get their script for Suboxone, a medicine akin to Methadone, which acts as the bridge between addiction (originally created for treating heroin addiction) and sobriety. The problem with Suboxone is that Suboxone has a high-risk potential for abuse, like all opioids. And, like all opioids in impoverished, rust belt cities, it is easy to get.

A few years ago, one of my friends was struggling with addiction to Suboxone and other opioids. Instead of the constant worry about getting in trouble for buying these drugs illegally, she wanted to get her own prescription for Suboxone. She also wanted to eventually get off of Suboxone, so having her own prescription would hopefully help her start the journey to living life without opioids. I ended up giving her a ride to a different walk-in clinic (about a mile from the one that people used to line up in front of), that appeared innocent and legitimate enough from the outside, but was actually just another pill-mill for those who wanted Suboxone. While in the waiting room, I spoke to a few other patients who were there for their “check up” with the doctor. I was told by one young man who was waiting for his routine check up to get his prescription filled, that all I needed to get a script of Suboxone for myself was to schedule an appointment (if I didn’t have insurance, that would be okay too, because the clinic had really good payment plans) and make sure I had some type of opioid/opiate in my system because they would give you a drug test. As long as your drug test came back showing that you had an opioid or opiate in your bloodstream to prove that you were addicted to an opioid/opiate, then they would start you on Suboxone. Easy as pie.

I was in shock. That’s all I needed to do? Just take a Vicodin or Percocet or whatever and bam!- I would have a script for a month for my own Suboxone. This really troubled me. My friend who I brought to the clinic was proof of how easy it was to get a script of Suboxone. That’s all she did- took a drug test that showed she had opioids/opiates in her system and she was all set. No more worrying about buying drugs illegally because now she could buy them legally. No type of psychotherapy or AA/NA attendance was required and her appointment with the doctor lasted less than 10 minutes. It was clear that this Ready-Care only cared about keeping their waiting room packed with drug seekers than actually trying to help these patients dying in addiction.

Now that was a few years ago, and I do know that the clinic where people used to wait in line outside was raided by the FBI and two doctors were charged with Medicaid fraud, conspiracy, theft by deception and insurance fraud for submitting false claims. They also directed unqualified people on their staff to write prescriptions for controlled substances. I guess this is a start for holding prescribers accountable, but I’m not sure how much that will dissuade other doctors from over prescribing opioids and opiates. And as far as I know, the other clinic where I took my friend is still operating as a pill-mill.

The Center for Disease Control lists the number one group of people most at risk for heroin addiction are those already addicted to prescription pain relievers. We know that people who become addicted to their pain pills turn to heroin when they no longer can get their medication. To personalize this a little- think about all the people who used to wait outside the walk-in clinic I mentioned above that got raided. Once that raid happened, and those doctors were charged with fraud, the people who were dependent on getting their pain pills or Suboxone there had to find a new way to get their drugs- and when the medical institutions won’t provide them, there are drug dealers with heroin that will do the trick.

The Center for Disease Control lists the number one step for preventing heroin abuse by reducing prescription opioid abuse. The CDC calls on doctors to implement better prescription practices. Now this seems pretty logical, right? If doctors know how to better understand pain and treat pain in ways that don’t involve medication, or at least limited use of medicine, then of course the number of people abusing opioids and opiates will drop. However, I have observed that this is a real point of contention for doctors.

Back in May I held a panel discussion about opioid abuse in NEPA, with the focus on speaking about solutions. I had the Scranton Police Chief Graziano, Democratic State Senator for the 22nd District, Senator John Blake, and two direct practitioners who work with opioid and heroin abuse in our area- Doug Albertson and Ricardo Horn. The panel was very well attended, and I was so happy to get so many different people in a room together to talk about one of the biggest issues in Northeastern PA. However, when the discussion started to move towards prescription practices, an attendee decided to take over the panel and made sure that those in attendance knew his opinion on the matter. He walked right up to the podium, took the microphone away from the professional moderator, and went on a rant for about 10 minutes. What he had to say really opened my eyes to the need for better prescription practices. He was a surgeon who works for a small hospital in rural Pennsylvania. His tirade included blaming the audience, and not physicians, for people abusing opioids (that didn’t go over too well- any “you people”, literal finger-pointed statements don’t tend to bring positive discourse). He went on and on about how doctors aren’t the problem, and that it’s the people who don’t throw out their unused medications who are the real contributors to the opioid epidemic. He went on to say that when patients want opioid prescriptions, he will give it to them, because he can’t risk having a patient fill out a patient satisfaction survey negatively. tBut again, he reiterated, that it wasn’t doctor’s faults for overprescribing pain meds.

I very rarely get mad. I’m a pretty calm person, and my anger has always manifested in sadness or self-destructive behaviors towards myself. But I can say truthfully that when that doctor took over my panel that I worked months on organizing, that I spent countless hours researching the epidemic in order to write the best discussion questions that I could, well, I was really mad. After his initial tirade, he continued to stand at the front of the room next to the panelists until I had to walk up and ask him to sit back down. After I calmed down a few days later, I was able to look back on the experience and saw how this doctor is a perfect example of what is wrong in our medical milieu when it comes to prescription practices. He refused to see himself, and fellow doctors, as adding to the problem in any aspect. He diligently defended himself, although there was no reason to do so- he was never under attack, in front of about 100 people. My theory now is that he needed to absolve himself by taking over my event. And I think this is where the real problem lies. No one likes to be wrong, especially when it comes to a serious issue like opioid addiction. No one wants to take any type of responsibility for being a potential factor that is adding to the problem. This doctor refused to see the part he and fellow doctors played in over-prescribing opioids, and that sucks. I really had to question the ethics of this doctor as well- he was more concerned with getting a positive patient satisfaction survey back than the safety of his patient.

The blame game doesn’t work. The doctor blamed everyone but himself for adding to the opioid epidemic, and I see a lot of doctors and physicians unwilling to look at how it might be beneficial if they changed their prescribing practices. Nothing changes if nothing changes, and that’s a scary fact when we’re talking about people’s lives. There is no easy answer to fixing the opioid crisis, however we must start to be honest about what works and what doesn’t work. This applies to all things healthcare (and I guess, all things in everything). We aren’t going to make any progress in reducing the amount of people addicted to opioids/heroin until we examine to why it’s so easy to get addicted in the first place.

I think a good place to start to try and figure out how to combat the opioid crisis is what the CDC recommends- looking at how we prescribe pain pills. One thing that I found very surprising and alarming is the minimal education students receive in med school about addiction. The Association for American Medical Colleges and the Liaison Committee on Medical Education (the accrediting body for Med Schools) have no clear requirement of hours for studying addiction. This is also true for other health provider trainings and education. I recently spoke to a physician assistant student who is in her last year whether she had any training on addiction or working with people with addiction. She told me that she thinks there might have been one lecture on the subject, but she couldn’t remember it. This is a big freaking problem.

We need our doctors and medical providers to understand addiction on a micro level, on a direct-practice level. They need to treat addiction and be aware of the potential for addiction risk in their patients. Medical schools need to increase and mandate hours of learning focused on addiction in their curriculum. Although opioids are obviously a money maker for Big Pharma, my hope is that one day we can treat addiction and pain in a holistic approach. Studies on mindfulness have recently shown how practices like mindful breathing and meditation can be effective for treating pain and in helping guide people towards a life without pain meds and addiction. Teaching patients about the risks of the medicine the doctors are prescribing can also be helpful so patients know what they might be getting themselves into. I hold a hope that one day healthcare in all of its aspects will embrace a holistic approach and look at how integrating the mind, body, and soul into treating pain is more effective than writing scripts after scripts for opioids.

When will any of this happen? When will we see any change? When will the line graph finally show a decline in overdoses and addiction? The answer is, I don’t know. But I think the only thing we can do is hold our prescribers accountable. How we do this is isn’t clear yet. But at least the conversation is starting, and that’s a good place to start.