Many thanks to Channel 2 WLBZ Portland for allowing me to explain some of the issues regarding the current Heroin/Opioid Epidemic - and don't think for a minute that it is only affecting Maine. In fact, it has become a worldwide issue, so maybe we should more appropriately be refer to it as a Heroin/Opioid Pandemic.
Welcome back to my Blog Site and I apologize for deviating from my planned sequential discussions of the “Ten Reasons for the Heroin Epidemic” but I really do have good reasons. I felt obligated to respond to the readers inquiring why an Emergency Medicine & Addiction Doctor became a novelist (“Why I Wrote a Mystery Thriller” – May 6, 2015) and the need to acknowledge my appreciation to my readers (“Heartfelt Thanks for 100 Reviews” - May 20, 2015). And yes, thrown in the mix was my exuberance to report on my trip to the American Society of Addiction Medicine meeting in Austin, TX to make sure folks got a look at the wonderful work being done by advocates such as Patrick Kennedy & The Kennedy Foundation, Gary Mendell and Shatterproof, and so many others (“ASAM Recap: Great People Doing Important Work” - April 29, 2015). In addition, in early May I was invited to discuss my book and to give a presentation to thirty-five medical school representatives gathering at a regional meeting in North Carolina on behalf of the Coalition for Physician Education in Substance Use Disorders (“COPE”). What an incredible group of physicians dedicated to the advancement of knowledge of addictive diseases. But more on this another day – let’s get back to the “Ten Reasons for the Heroin Epidemic”.
As you may recall, past Blogs discussed:
The disease of addiction has three components: Biological, Psychological and Sociological;
The three related terms that are essential to understand the disease of addiction: Tolerance, Dependency and Addiction; and
The ten reasons of who or what to blame for the heroin/opiate epidemic:
- Injudicious Prescribing by MD’s
- Patient Expectations
- Internet Sale of Pain Pills
- Oxycontin Reconstitution
- War in Afghanistan
- Supply & Demand - “War on Drugs”
- Physician Training & Biases
- Mental Health Treatment
- Public Officials
Today, I will discuss the first reason, injudicious prescribing practices by physicians. When I was a medical student some decades ago, we were taught to very carefully prescribe opiates, such as Morphine, Demerol, Percocet and other pain medications typically referred to as “narcotics”. Well, it came to pass that we as physicians were under-medicating patients for relief of pain. In fact, it has been shown that for severe pain, if the patient waits for the pain to recur to high levels before taking their next dose of medication that in fact it may take more medication to again relieve the pain.
Then physicians were educated to more appropriately prescribe pain medications. However, due to factors related to patient expectations, “Big Pharm” the increasing number of pain pills available and the need for additional physician education, many physicians have inadvertently been over-prescribing pain medications in dose amounts, frequency of administration and length of treatment. The pendulum has swung too far in the other direction.
Long term use of opiates in most cases of non-cancer pain has not been shown to be advisable, which is understandable due to the terms tolerance, dependency and addiction discussed in an earlier blog. However, for intractable pain, exceptions may need to be made. Fortunately, many states now have continuing medical education requirements that obligate physicians to take courses in appropriate opiate prescribing as a prerequisite to renewing their medical licenses.
So, yes we can blame the doctors for the increase in opiate/heroin addiction, but as we explore the other nine reasons, it will be clear that this is not just a physician prescribing issue – there is plenty of blame to go around. And let’s not forget that biological, psychological and sociological aspects are major contributing factors to the disease of addiction!
I hope you will stay tuned for the next episode of why we have an opiate/heroin epidemic - Patient Expectations. Until then, I hope you enjoy the following snippet from Addiction On Trial.
“Dr. Tolson understood in a very philosophical manner that Jimmy’s illness, the disease of addiction, was composed of biological, psychological, and social elements. He would give lectures on a regular basis to fellow drug counselors, local school committees, police, and to anyone who would listen.
‘Everyone in this room already has an opinion of what an addict is. Usually we use the word addict in a special way—cocaine addict, heroin addict, but rarely do we hear the words alcohol addict or nicotine addict. No one would refer to Vice President Cheney as an addict, despite the fact that we know that nicotine contributes to heart disease. And Mickey Mantle remains a hero despite needing a liver transplant because of liver cancer, complicated by cirrhosis from his years of drinking. I am hopeful that each of you can put aside any bias, any preconceived notions that you bring here today. For thirty minutes I ask that you be like that athlete who has never rowed before and put aside your current opinion of addiction. Give me your cleansed minds for just a brief time. At the end of my presentation you may accept, reject, or modify anything I say, but please start now with a clean slate. Before I begin, I want everyone to join me and tightly close your eyes. For just sixty seconds let us each listen to our own breathing and contemplate nothing.’
Not everyone followed Dr. Tolson’s request, some dumping him into the category of one of those earthy crunchy granola type liberals—precisely the type of labeling he was trying to combat, which is why he would wear a sport coat and tie to the lectures. He would wait a full sixty seconds before saying ‘Now, slowly open your eyes and without verbally responding, I want you each to ask yourself if the last sixty seconds were spent only listening to your breathing while repressing all thoughts. If you were not successful in completely voiding your mind, you now know the struggles of addiction. It is not just mind over matter. I will do my best to further explain the complexities of addiction.’”
Over the past several weeks I have received several emails from readers and others inquiring about my background and why I decided to write Addiction on Trial. I want to use this week’s blog to explain why I wrote a novel, albeit based on medical and legal truths, and to share my background. So, bear with me as I babble along!
I am a physician who is the youngest son of a physician. My father came to the United States at a very young age, worked his way through college and medical school and chose to practice medicine in two offices attached to our home in Everett, Massachusetts. My mother was the bookkeeper, secretary, cook, laundry service and most importantly, my Mom. When the home phone rang (which was also the office phone) we all answered it the same, “Doctor Kassels office; may I help you.” Not infrequently, patients would come to the front door on holidays and weekends with “specimens”. These were the same patients that would make holiday gifts for my brother and me. I can still hear my Dad, “Put that bag with the bottle in it on the counter in my little office and then wash your hands – and wash them thoroughly – did you hear me Stevie?” I heard my Dad then and I still hear him now.
Why did I write Addiction on Trial: Tragedy in Downeast Maine? Simple answer: I wanted to.
Through my years of practice in Emergency Medicine and Addiction Medicine I have had the privilege to treat patients from all walks of life. From a medical perspective, it is very clear that we have differences but we are more similar than not – we all need hearts to pump in order to sustain our organs and to perfuse our brains. When we are sick, we all benefit from compassion and care. Society should not differentiate between diseases! But who wants to read another scientific book about addiction? Not me! That's why I wrote Addiction on Trial as a mystery thriller to both entertain and educate through the depiction of the realistic struggles of addiction. I hope you enjoy reading Addiction on Trial as much as I enjoyed writing it.
"The Scourge of Heroin Addiction"
Op-ed published by the Boston Globe April 1, 2014 http://b.globe.com/1kAzt54
Governor Deval Patrick has appropriately declared the opioid addiction epidemic as a public health emergency. The governor's directives will save lives and help to put some brakes on this run away scourge to society. But questions remain and more issues need to be addressed.
For example, why is medication management for the treatment of heroin/opioid addiction scorned by so many? In a recent Boston Globe article, "Heroin Epidemic Exposes Deficiencies In Care System" (http://b.globe.com/1iNFmzo), Ms. Jacobs, Director of Substance Abuse Services for the Commonwealth of Massachusetts, acknowledged, "medications are not used as much as they could be for opiate addictions because of stigmas attached to them, she said." We watch endless commercials about how to treat illnesses such as urinary incontinence or erectile dysfunction but public service announcements addressing the heroin/opioid epidemic and the proven benefits of outpatient cost effective medication management have been relatively sparse. The governor's directives, which include public health advisories to educate the public about opioid addiction treatment options, will hopefully demystify common misperceptions, such as crime increases when there is a treatment center in one's community. In fact, there is a 50% to 80% reduction in crime by heroin addicts when in treatment. (http://bit.ly/OVVRfh ; http://1.usa.gov/1dtb42B)
We read about the blame for the heroin epidemic, but rarely do we address a complex underlying issue – that we as Americans want instant results and we want total pain relief after an injury or procedure. Injudicious prescribing of pain medications undeniably contributes to the problem, and holding doctors accountable is essential; but this is not the only reason we have an unabated heroin epidemic. Other factors include: the war in Afghanistan, which directly led to a surge in heroin production; the reconstitution of oxycontin pills, so they could not as easily be used to "shoot up" or "snort", resulting in more persons turning to heroin as a drug of choice; the increased availability of opiates through the internet; inadequate mental health treatment services resulting in some patients "self-medicating"; and the lack of addiction treatment facilities due to a common community approach of NIMBY (Not In My Back Yard) along with the stigma associated with seeking treatment for the disease of addiction. Despite the arrest of kingpins and drug pushers, big and small, we still have a supply and demand problem. The supply of heroin has increased and cost is down to as little as $4/bag. As fast as we take drug pushers off the streets, they are replaced by others - there is too much money involved. Governor Patrick is right to focus on the demand side of the issue.
If outpatient treatment is not more widely accepted and available, inappropriate hospitalizations and incarcerations of patients will continue. It is time for our locally elected officials to openly support establishing treatment centers in their communities? We all know heroin addicts, albeit we may not know who they are. They could be any one of a number of patients I have treated: your plumber; the mailman; your kid's college professor; the IRS agent who audited your tax return; the person selling flowers at the corner; the principal of an elementary school (http://bit.ly/1m6XMbL); someone who works in a mayor's office (http://bo.st/1hbtN20); or a neighbor; or a family member.
A recent study has shown that less than 20% of individuals needing addiction treatment actually received treatment (http://1.usa.gov/1hYRzvX).. Another study found that only 1 in 10 people with addiction involving alcohol or drugs other than nicotine receive any form of treatment and that "most medical professionals who should be providing addiction treatment are not sufficiently trained to diagnose or treat the disease, and most of those providing addiction care are not medical professionals and are not equipped with the knowledge" (http://bit.ly/1o2l3Ax). Are we willing to accept as status quo the present system of unnecessarily hospitalizing or incarcerating patients? We are wasting tax dollars: it costs up to $50,000 or more per year to incarcerate (http://bit.ly/1iBKSlg ; http://nyti.ms/NW5dGQ) and approximately $5,000 per year for outpatient treatment (http://bit.ly/1rCh3G6). “There are things besides beds that are effective in this system,” Jacobs said. “More people should see this treatment as a viable option.” (http://b.globe.com/1iNFmzo)
There should be just as many public service announcements about addiction as there are Viagra and Cialis commercials. In addition, expansion of addiction treatment services in jails would help to mitigate much of the revolving door phenomenon. Furthermore, we should demand that our medical schools and hospitals improve addiction training of our physicians. While there is plenty of blame to go around, let's focus on the solutions. The scourge of addiction is in all of our yards. The solution is to decrease the demand with bold public initiatives and a change in attitude. It is both the humanitarian and fiscally responsible thing to do.
Steven Kassels, MD has been Board Certified in Addiction Medicine and Emergency Medicine. He currently serves as Medical Director of Community Substance Abuse Centers and has authored the book, “Addiction on Trial: Tragedy in Downeast Maine”.