“I have my life back,” she told me through tears.
I was sitting across from a woman who had just finished sharing her story of addiction and newfound freedom. Several years ago, she had a complicated delivery of her child and stayed in the hospital for several days after her cesarean section. She remembered severe pain for which she was prescribed an opioid analgesic. She told me that the hospital staff had handed her the pills with humorous winks and innuendos.
“Get them while the gettin’ is good!” they even teased.
She went home with a prescription for hydrocodone. The provider wrote it for thirty days and included several refills. The patient refilled them and diligently took them as prescribed. At first, she told me, it was about getting better. Then, it became about staying “good.” Finally, it was an all-out battle to avoid feeling terrible. She stared down at her feet as she told me how long it took for her to realize she was addicted. It took her too long — too long to realize it and too long to seek treatment.
This year, I had the privilege of rotating through an addiction clinic, Addiction Allies. During the rotation, I heard many stories similar to this one. It surprised me just how many of the accounts contained a medical professional joking about opioid use or presenting a drug as the solution to pain. The medical community’s understanding of how opioids can be used is changing, slowly. Current physicians and researchers are realizing that safe and effective pain management does not come from a long-term opioid regimen. Dr. Christopher von Elten, the founder and medical director of Addiction Allies, told me the significant problem in health care regarding addiction is “a true understanding of and empathy for the complexity surrounding the disease.”
If you are a current or future physician, the opioid epidemic will be a part of our future no matter what specialty we choose because we will be treating our patients’ pain. I’ve been able to watch current physicians relentlessly fight this battle, yet somehow we are still losing. We can feel beaten down by the patients who rate their pain as a 10/10 despite appearing completely comfortable. While it may be easier to write a quick prescription for opioids, we know every patient does not necessarily need it. Whether to spend the time to explain or recommend other options is our decision to make. It is our duty to know what other options exist, and in my experience, this is what we need the most help with in practice. Some of these resources include pain clinics, behavioral therapy and clinics for methadone and buprenorphine clinics.
Based on my experience at Addiction Allies, I found that buprenorphine clinics are exceptionally valuable resources. Buprenorphine is a μ-opioid receptor partial agonist that is used to treat opioid-use disorder by binding to the opioid receptors to prevent the sense of euphoria or “high” from opioids and symptoms of opioid withdrawal. It can be combined with naloxone, a non-selective and competitive opioid receptor antagonist, to provide further benefits for those struggling with opioid addiction. The combination of the two medications comes in different forms: two sublingual forms, Zubsolv and Suboxone, and a buccal film, Bunavail.
Naloxone has poor oral bioavailability; thus, is not readily absorbed unless the medication is misused. For example, if a patient inhales or injects the combination medication, the naloxone is present to send the patient into immediate withdrawal. In this sense, naloxone is the basic safety mechanism in the combination medication. Dr. von Elten explained that buprenorphine’s mechanism makes it “safer and easier to use than full agonist medication therapies allowing people to be less restricted in moving their lives forward.” For this reason, he has been successful in treating people with opioid use disorders.
Over the course of my rotation, I was able to meet over one hundred patients taking buprenorphine. All of them had stories of how it changed their lives for the better. The drug controls their cravings and minimizes their pain giving them a chance to break the cycle. It affords them the freedom of getting their lives back in order without withdrawal symptoms or the urge to get high.
The clinic I rotated through mandated at least one cognitive behavioral therapy (CBT) session per month to achieve optimal treatment outcomes. These CBT sessions focus on providing the patients with tools to regain control of their decisions and relationships. With the support of the team, these patients gained employment, had healthy babies and purchased homes. Their addiction no longer defined or incapacitated them. It no longer drove them to make poor financial, social or relational decisions. These patients now have a chance.
Knowing all of this begs an important question: Why is this medication not being prescribed in the average family medicine clinic?
Before being allowed to prescribe buprenorphrine, doctors are required to attend an eight-hour course on addiction treatment and apply for a special Drug Enforcement Administration (DEA) number. Once approved, providers can only treat thirty patients for the first year. With each subsequent year, the patient load increases to a maximum of one hundred.
Whenever I meet patients in desperate need of addiction therapy, I remember Dr. von Elten’s encouragement for me to treat this disease “like any other medical issue, with compassion and knowledge.” My compassion has grown out of interactions with those in recovery. Moreover, primary care providers (PCP) can apply and become certified to prescribe buprenorphine within their own clinics. Dr. von Elten recommends that “PCPs … familiarize themselves with the problem and recommend treatments and local referral sources … and even consider becoming treatment providers within their own groups.”
I now understand that while pain is still the enemy, addiction is a disease requiring the same attention and due diligence as anything we treat. Treating pain is more involved than simply writing a prescription with refills: It is too delicate for prescription flippancy. Let’s treat pain, by all means, but let’s also be physicians that give patients their lives back!