Opioid Addiction and Patient Care by Dr. Erik Steele

Published on April 11, 2017 by

Peter was a patient of mine to whom I prescribed opioids intermittently for several years. I remember to this day how shocked I was to finally discover that he was not only pathologically hooked on opioids, but was so hooked he was stealing money to buy them on the street. Even more shocking to me; a patient I liked and respected, an upstanding member of the community, had been deceiving me.

Well intentioned as I was, I did my part contributing to Peter’s opioid use disorder (OUD), and by extension my part in contributing to Maine’s opioid use disorder epidemic. I was not aware enough that every patient I prescribed opioids to even once had a real risk of developing OUD. I was too easy to convince that every patient’s pain needed eradication, and that opioids were the best tool for doing that. I was intent on reducing the painful suffering of my patients, and too unaware of the suffering that might develop if my pills were used inappropriately. I failed to see that our efforts in healthcare to be more effective treating pain – efforts promoted on a national level by healthcare regulators and pain experts – was ‘opioid-dependent’ itself, and would come back to haunt us all.

For these and other reasons I contributed my small stream of unnecessary opioid pills to thousands of other such streams from physician offices, hospitals, and emergency departments across Maine. Together we created the flood of opioids that has now engulfed us, kills more Mainers each year than car crashes, wreaks OUD-induced havoc in homes and communities, and has made Maine a national showcase for the opioid tsunami.

Having helped make this mess, I now need to help fix it, by starting a different small stream. As I go back into family practice in Maine, I will take my 8 hour course and do other work to be able to prescribe suboxone therapy – one part of Medically Assisted Therapy (MAT) for OUD, and provide treatment for as many as I and my practice can capably manage. I will begin screening for OUD among my patients, and treating or referring those who need help. I will dramatically change my approach to the treatment of pain, avoiding use of opioids wherever possible, weaning patients off opioids wherever I can, and partnering with other healthcare providers and state government in meticulous management of opioid prescribing. That all amounts to a big, challenging pain in my practice, but I don’t think any of us who helped get Maine and its people into this opioid mess can, in good conscience, do anything less.

There is a growing help for those on the challenging front lines of MAT; health systems across Maine  have geared up substantial efforts to support their physicians, nurse practitioners, and other caregivers in this work. The Maine Medical Association, Maine Quality Counts, Maine state government, the Maine Health Access Foundation, and many other organizations across the state are contributing educational, financial, legal, organizational, and other support. Some organizations with more expertise and resources are building hubs of advanced OUD management to which smaller practices and organizations can turn for expert consultation and other assistance. We all could do more, we all could do better, but what we are doing means that physicians and others who take on the obligation of providing MAT will feel less alone and more supported than many of them have in the past.

To that can be added the help of knowing that we are helping reduce the suffering of our patients and their families; MAT providers I speak with talk of how challenging this work can be, but also of how rewarding it can be to help turn around the lives being ruined by OUD.

Others must join this effort if they have not already. Every hospital that employs physicians must support those physicians to add to the MAT stream. Every physician who prescribes opioids on a regular basis must do his or her part; at a minimum fastidiously prescribe – and not prescribe – opioids in a responsible manner, screen for OUD and refer those who need it, and follow the state prescribing regulations, etc. Ideally, every primary care practice should develop enough MAT capacity to be able to care for its patients with OUD (and every practice has them) and a few more patients in their communities who do not have access to primary care. Every practice that fails to do that leaves their population of patients who needs MAT to some other practice to provide, potentially overwhelming those practices that step forward.

The people to whom I and others must offer this treatment for OUD are, in fact, us; they are our family members, some of our physician and other caregiver colleagues, our community members, our children’s friends in school, the people who build our bridges and serve us food. They are the ones dying in Maine at the rate of one per day, and the grief their deaths bring is a cry for help to us all.

It took years for Maine to get into this mess, and it will take Maine years to get out of it. But a concerted effort improved and sustained over the long haul will turn back this tide. The scale of the effort needs to increase rapidly – we should be establishing a statewide goal that every community in Maine has adequate MAT access by the end of some finite date – perhaps the end of 2018? The clock is ticking on our efforts, and it is a terrible human clock; every second it ticks tells another story of the misery that OUD brings all it touches, and every 24 hours it tolls the death of another one of us from OUD. We cannot move quickly enough.

 
  1. Mary To Beyer says:

    We will miss that insight, humility and eloquence!

  2. Mark Woodward says:

    What I would expect of Erik Steele: thoughtful, accountable, focused on solutions. Welcome back, Dr. Steele.

  3. Dr Steele, I realize that you are reporting your own experience in medical practice. But may I gently point out that we may not generalize practice standards from a sample of one? I find it entirely inappropriate to state as you do, that there is a risk of addiction for any patient who receives opioid medications even once. That position simply isn’t supported in the available medical evidence, including studies released by both FDA and CDC.

    The present “opioid epidemic” is dominated by street drugs, not drugs prescribed by doctors. The street drugs include heroin, imported fentanyl, Methadone diverted from maintenance programs, and morphine stolen from hospitals. Drugs like Oxycontin are difficult to discriminate from the street drugs.

    For deaths in which an opioid is implicated as a contributing factor, the majority of fatalities involve two or more agents — most often alcohol or benzodiazepine drugs co-prescribed for anxiety. Indeed it is arguable that deaths from Tylenol toxicity and associated sudden cardiac arrest very likely outnumber those from opioids prescribed by a doctor.

    I invite you to read and comment upon two articles in the Journal of Medicine of the National College of Physicians:

    The CDC’s Fictitious Opioid Epidemic, Part 1 (January 15, 2017) https://www.ncnp.org/journal-of-medicine/1929-doctors-fleeing-pain-management-dumping-patients.html

    and

    The CDC’s Fictitious Opioid Epidemic, Part 2 (April 15, 2017) https://www.ncnp.org/journal-of-medicine/1980-the-cdcs-fictitious-opioid-epidemic-part-2.html

    This article is re-published from its original appearance on the National Pain Report under the title “How Would Prescription Opioid Guidelines Read if Patients Wrote Them?” It has also been introduced in the April 11th online issue of PAINWeek, with the title “What if Prescribing Guidelines Were Patient Centered?”

    Also useful and deeply referenced is “Neat, Plausible, and Generally Wrong: A Response to the CDC Recommendations for Chronic Opioid Use” by Stephen A. Martin, MD, EdM; Ruth A. Potee, MD, DABAM; and Andrew Lazris, MD

    https://medium.com/@stmartin/neat-plausible-and-generally-wrong-a-response-to-the-cdc-recommendations-for-chronic-opioid-use-5c9d9d319f71

    Respectfully,
    Richard A. Lawhern, Ph.D.
    Patient Advocate

  4. Mark Ibsen says:

    Dear Dr. Steele: I invite you to read the Institute of medicine report on Pain in America 2011
    This report indicates that there are 100 million Americans in chronic pain. Significant percentage of those patients perhaps 20% are currently on opiates. Yes, your patient deceive you. Is this any different than your blood pressure patient you don’t take their pills? The female patient who live out their age? Or you yourself when you go to the dentist and claim that you floss every day?
    Addicts lie in attempts to obtain pain pills. The real evidence is that only 2 1/2 to 5% of patients on pain pills develop an addiction.
    Pain pills don’t cause addiction , anymore than beer causes alcoholism.
    Are you willing to submit all your patience to the agony of chronic pain in order to avoid this so-called mistake?
    It seems to me that your patient has opiate abuse disorder, not opiate use disorder. Addiction is cunning and baffling’s and Midlakes it and difficult to deal with. So is pain. Your job is to distinguish between the two.
    You are well-trained and you can do this.
    Please read
    A nation in pain by Judy Foreman
    Please read the IOM report on Pain in America
    Please review your Hippocratic oath to do no harm.
    Your obligation is to do your best to serve each and every individual patient by taking a history and listening deeply, creating a provisional diagnosis, then reassessing each individual patient.

    I truly do appreciate how much you care, about all of your patients. I your patient got caught and got treatment. The system worked. Keep up the great work. You haven’t failed. It just took a while to make his diagnosis.
    All the best to you and you’re very fortunate patients



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