Posts Tagged ‘morphine’

The root that Mayo missed: whittling down the med list

May 18, 2015

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.

Mission creep: a census grows and genomics comes now comes retail

April 10, 2013

Does a thousand seem likes it’s cheap?

Beware the assumptions you keep.

Don’t think that it’s strange,

There will always be change,

And ever the mission will creep. 

Synopsis:  I’m a family doctor in Sioux City, Iowa.  In 2010, I left my position of 22 years to dance back from the brink of burnout.  While my one-year non-compete clause ticked off, I travelled and worked from Alaska to New Zealand, and now I’m back working part-time (54 hours a week) at a Community Health Center.

Last night I took the handoff for a hospital census of 4, a record low since I started with this clinic.  Even though I arrived for rounds before 7:00AM, that number had grown by 3.  I whizzed through two admissions, three patients with kidney failure, one each with alcohol withdrawal and complex pneumonia, five diabetics, a newborn, and two coronary patients.  (Do the math, you’ll figure out that a patient rarely enters the hospital with one problem.)

The longer a person lives, the richer their life story; and in the course of half an hour I had the treat of listening to a wonderful family history unfolding over the course of three generations.  I left them hope that the specialist would be able to cure the problem. 

But I squandered 15 minutes trying to educate a nurse, who overhearing me speak Spanish, made disparaging remarks about immigrants. 

Still I finished at the one hospital before ten.  At the second hospital, still in the throes of transition from paper charts to a new Electronic Medical Record (EMR) system, I only had to round on the pediatric floor, and I held onto hope of getting to the office early. 

I discovered an EMR quirk: one now needs 9 keystrokes, not 1, to edit a dictation.

I got to the office early, but not nearly as early as I’d hoped.

After half an hour of buffing documentation and messages, I attended what had been billed as a provider meeting.

The man who brought the lunch didn’t pitch a drug but a lab test.  Using material on a cotton swab from the inside of the mouth, for a mere thousand dollars, his company can provide us with genomic information about how fast or slow a person might metabolize a range of medications. 

For example, a single standard 30mg dose of codeine provides good pain relief for 80% of the population.   But 20% of population lacks the enzyme to convert codeine to morphine; for those people, codeine might suppress a cough but won’t relieve pain.  The super enzyme found in 1 in 3 Somalis converts 100% of the codeine to morphine on the first pass through the liver, enough to kill half of those who try it.    

Our clinic prescribes almost no codeine.  For whom will the test bring a thousand dollars with of benefit when it comes to choosing an antidepressant, antipsychotic, or ADHD medication?  We requested more information.

I didn’t ask the larger question: how long will it be till an entire genomic sequencing becomes available for that price? 

Mission creep remains a permanent fixture on the constantly shifting medical landscape.  Whether a doctor deals with a growing census, or a company sells technologic improvements, we all know that the world, at the end of the day, will not be the world we had at the beginning.



The difference between a horse and a mule

August 23, 2012

It’s unnecessary to that much force

To run to the ground a great horse.

So don’t be a fool,

You can stop, like a mule

If your motives come from the source.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 48 hours a week.

Even doctors have to have doctors.

I confirmed my appointment with a subspecialist today at 12:45, and I turned to Bethany.  “He works through his lunch hour,” I said.  “Should I bring him a sandwich or something?”

“I don’t know,” she said, “Are you sure he doesn’t take a late lunch?”

“Yeah, his nurse said he was working through his lunch hour.”

“You can if you want.  But is he working for someone else?”

“No,” I said, “He owns his practice.”

“Well, when you were an owner, you did the same thing.”

Of course she was right.  “That’s the difference between a horse and a mule,” I said.

A horse has a passion to run, I explained, and riding a good horse hard ranks among the great experiences of life.  A mule has none of the fire of a horse, and the best gallop of the best mule deserves the word lackluster; the words plod and mule go well together.  Yet most riders can get a horse to run so far and so fast that the horse dies, hence our term, “ran it into the ground.”  An overloaded mule cannot be induced to move at all.

Give a horse morphine and the horse will run, give the horse an adequate amount of morphine and he’ll run himself to death even without a rider.

I approach analogies between humans and animals with caution.  But making any person, and particularly a doctor, their own boss looks a lot like giving morphine to a horse.  They don’t take enough vacation, they work very long, very productive hours, and they tend to burn out.

I wish going onto salary had made me more like a mule.  As it is, my drive to work destructively long hours has nothing to do with the money but with the action of the job and my commitment to my colleagues.  I do not want to give up the drama and irony of the hospital work, nor the intellectual challenge of having to rub elbows with docs who know more than I do.  Nor do I want to stop being part of the team, going the extra mile to lighten the load of the doctor who comes after me.

The problem comes not from the outpatient hours, but from the people who get desperately ill after hours and on weekends, and from our booming expansion.  My first two weekend calls last year had a total hospital census in the single digits, but our practice now averages seven hospital admissions per twenty-four hours and our hospital census has gone as high as forty-two. 

Yet this last weekend deserves a delicious rating.  I started early, finished rounds in good time, lunched and napped and supped, getting into bed before eleven each night.  I’m running on the same relaxed euphoria that I did a year ago.

The real question is how hard I’ll let myself get worked.