Posts Tagged ‘heroin’

Exercising my buprenorphine waiver but going back to Alaska

February 26, 2014

I wonder if this is the way

With all the things I could say

I’m away and I’m off, To the Island Metkoff.  

I’m taking vacation today

SYNOPSIS:  I’m a family doctor from Sioux City, Iowa who danced back from the brink of burnout in 2010.   Honoring a 1-year noncompete clause, I did short term medical work in Keosauqua, Iowa, Grand Island, Nebraska, Barrow, Alaska and New Zealand.  I came back to work in a part-time position with a Community Health Center, and I’m now down to 40 hours a week.  I’m taking a month to work in Petersburg, Alaska, 

For the last week I’ve warned my patients  that I’ll take a month of vacation for March.  I’ll work in the same clinic in Southeast Alaska where I worked for 2 weeks in August.

My addictionology practice has grown by leaps and bounds in the last month, and the news of my upcoming time off has been particularly hard on my opiate addicted patients.

The narcotic or opiate group of drugs includes morphine, opium, heroin, hydrocodone, hydromorphone, meperidine, fentanyl, codeine, and others.   The epidemic of addiction to these drugs has started to strangle the country, until deaths from overdoses of legal narcotics surpassed deaths from motor vehicles in 2012.  Already, the US uses more narcotic pain killers than the rest of the world put together.

Some attribute this surge in dependency to a government agency’s decision to make pain the 5th vital sign, and to sanction doctors who failed to address a patient’s pain level that exceeded 5 on a 10 point scale.  In fact the opiate use started to grow logarithmically that year.

The problem usually starts when a person has a legitimate injury, such as a broken leg, and gets a prescription for a pain reliever, then gets hooked by taking a friend’s leftover pills.  Abuse escalates in short order, many start onto heroin because it’s cheaper than the prescription stuff, they lose their job/house/spouse/car/assets/family and when they find themselves with absolutely nothing they realize they have a problem.  Then they come to see me.

If I wait till they’re in full-blown withdrawal (yawning, tearing,  diarrhea, insomnia, aching) I can prescribe buprenorphine, but only because I have a special license to do so.

The requisite education, done online, only cost me 9 hours; I got the waiver last summer  to back up one of my partners while he had medical problems.  I didn’t write my first prescription for it for 6 months.

The medication blocks them from getting high, and can stop a lot of pain.  Success demands close monitoring and frequent blood tests.

Patients don’t seek help until chaos dominates their lives.  I don’t get to retell the dramatic , ironic stories because of confidentiality.  The temptation to judgementalism runs strong in my business, but especially in addictionology, yet I know I will finish my day with more energy if I approach each patient with an attitude that acknowledges the mistakes of the past and emphasizes the need to move on.  And really, the patients do the best when they take control of their lives.

But they have a lot of emotional needs and tend to bond tightly to people who listen without judging.

Fortunately I have a partner with more experience with that drug than I have.

Exercising my buprenorphine waiver for the first times

January 29, 2014

With my patients I can make a pact

Per the modified Harrison Act


A blocker of morphine

Can help, and that is a fact.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went to have adventures and work in out-of-the-way locations.  After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took up a part-time position with a Community Health Center; I’m now down to 40 hours a week.

In 1914, the Harrison Act mandated that physicians could not prescribe narcotics to treat narcotic addiction, which, at the time, seemed a pretty good idea.  Using morphine to get someone off heroin, or vice versa, didn’t make much sense. Yet 3000 doctors went to jail for defying the Act.

Time marched on, and scientists discovered compounds that could counteract morphine and its cousins, giving rise to a new class of chemicals, narcotic antagonists.  The novel drug naloxone (trade name, Narcan) came during my time in med school, and quickly became a staple in ERs all over the country.  If someone came in OD’d on heroin, you could just inject a vial or two and save a life.

Further chemical sophistication led to drugs with mixed effects; in some ways like a narcotic blocker, and in some ways like a narcotic.  In residency, when confronted with a drug-seeking patient, I learned to offer one of these narcotic agonist-antagonists, warn the patient of withdrawal if they were addicts, and watch them storm out of the ER.

As time went on, methadone showed its utility to block narcotic’s euphoria or high and squelch craving for narcotics.  Because of the 1914 law a doc could use methadone to treat pain, but could only use it to treat addiction in a licensed methadone treatment center.

Buprenorphine, a compound available since 1980, eventually established itself as a useful agent in treating addiction.  Again any doctor with a DEA number could use it for pain, but only those with a special waiver could use it to treat addiction.  But that treatment could be based in a physician’s office.

In our quadrant of the state, only 3 doctors have that waiver, though it takes a mere 9 hours of education to qualify.  I got mine over the summer so I could fill in for one of my partners.  In the time since the only methadone program in a hundred mile radius shut down.  And for months, the only patients who showed interest would not have fit the entrance criteria.

In the last two weeks, three patients have requested entrance into the program.  I confer with my more experienced partner on each one.  He tells me his buprenorphine practice brings him tremendous satisfaction.

I have cared for one of those three patients since I arrived at my current position, and writing that first prescription came as a relief.

Confidentiality limits what I can say about the patients, but it doesn’t limit what I say about myself.  I have lots of first-hand experience with chronic pain, and today ranked as one of the worst since the summer.  I try to walk normally, and I try not to grunt or grimace when I sit down or stand up.  I focus on the patient, but I also tell my story.  Those who want to score drugs for remarketing show themselves with stridency, those who listen usually end up demonstrating a real desire to get on with their lives.

Once, a patient revealed that the pain had completely gone, obviating my tale.  That happened only once, and the story brought light to my day.