At a time in everyone’s life, we come to find ourselves in a situation where the music stops, and we must go on. The unfortunate truth about life is that the unexpected will happen. Some of us learn from it, some of us change because of it and some of us find our life’s calling because of it. The latter was the case for me. After our dad picked us up from middle school, we spent that afternoon like we had every afternoon that month. We went to the oncology unit at the hospital, where my brother was admitted.
I remember him. I remember the man in the dark blue sarong the same way I remember the lines on back of my own hand. He was hunched over next to a column on a dirty platform at a railway station in Calcutta, India in the middle of the harsh summer sun. His hands were withered, his fingers and toes looked like tiny nubs, and he was completely malnourished and alone. He had opaque blue eyes, as if fog had taken place of his irises and pupils.
I studied insects in college; my favorite insects were the bees (I found them diligent and so helpful to humankind). One of my favorite classes was about medical diseases caused by insects. My professors noticed my interest in the medical side of things and connected me with a professor who did clinical research. Our work focused on a clinical trial for children with intractable epilepsy and exposed me early on to patient care and patients.
Like many medical students, my interest in medicine arose during high school anatomy courses. Unlike many medical students, I did not begin my collegiate studies at a university. I went to high school in a suburban town Northwest of Detroit called Clarkston. It was my junior year between 2008-
It all began with bagels and orange juice. I was seven, and my dad had promised we would go to lunch as soon as he finished making rounds in the hospital. My stomach grumbled, though, so Dad plopped me in the doctors’ lounge, snacks in hand, and promised he would be back in an hour. As I waited, I overheard the other doctors in the next room, answering pages. They spoke in hushed voices laden with what I was sure were remarkable secrets. But then, I could only hear one side of the conversation.
The back of my head lies flat as a pin board. In the orphanages of South Vietnam, darker babies carried the stigma of the war, bearing a physical resemblance to the ruthless soldiers from the north. I was one of those children. Because of my skin tone, the caregivers’ prejudice prevented them from picking me up to play. Left to lie on the wooden mats, my head never rounded, and now serves as a constant reminder to me of the human body’s malleability.
From humble beginnings as a curtained-
Compassion does not know city limits or county lines. Neither state nor international borders can contain such acts of altruism. For the last four years two surgeons and one nephrologist have travelled to Honduras to perform living donor kidney transplantation thereby expanding the art and science of transplant surgery and medicine in Central America.
Early on a cool, crisp autumn morning, Dr. Paul Kearney addresses his fellow surgeons and other volunteer medical professionals just before they embark on a busy day at the Lexington Surgery Center (LSC). Many of them have already been preparing the facility since before sunrise as a part of the monthly ritual known as Surgery on Sunday (SoS). Dr. Kearney chairs the board of directors for this organization, which is the brainchild of Dr. Andy Moore, who has served Lexington as a plastic surgeon….
As Americans most have been secure in our needs for food, housing, safety and health. Health care has become more of a right than a privilege and has become more accessible thru expanded Medicaid, Medicare and the more recent Affordable Care Act. In spite of these, many continue to fall thru the cracks and that number may again increase with proposed changes in public health policy and program coverages. The underprivileged will continue to require care often not covered by government....
Dr. Privett has practiced medicine in Lexington since 1973. After finishing his residency, he spent two years in the United States Army from 1971 to 1973 at Fort Bragg, North Carolina. He returned to Lexington thereafter to begin his neurology practice. He practiced clinical neurology for 15 years, from 1973 until about 1988. In 1988, he developed the Lexington Diagnostic Center shortly after MRI equipment was introduced into the United States.
As physicians, we are required to master changes on a daily basis. Very shortly, we will have to deal with changes in the Accountable Care Act. At some point, we will be required to deal with changes in our electronic health record system. Medical organizations are struggling with the demands of physicians to make changes in the Maintenance of Certification (MOC) process. Everyone wants some kind of change from us, and adaptation is the watchword.
Mentoring is an art form developed in the United States in the 1970s within large private companies and corporations and is used to support junior staff. Since the 1990s, mentoring programs have emerged in various medical professions, most frequently in the field of nursing though, rather than physician practice. Formal mentoring programs for medical students and doctors did not develop until the late 1990s (Buddeberg-
Despite the availability of other satisfying or more lucrative career opportunities for the bright and altruistic, admissions to medical schools remain desirable and competitive, thanks largely to an influx of talented and qualified female and minority applicants. Premedical and medical education has always been stressfully competitive and a financial burden. "Stress in medical school" even merits its own individual entry on Wikipedia.
For as long as I can remember, I’ve always wanted to become a doctor. However, I did not realize all the challenges I would have to face in order to make my dreams come true, and I also did not know who I was going to meet along the way to help me become a successful medical student. When I was reapplying to medical school, I was told gaining more clinical experience could strengthen my application. I reached out to as many physicians as I could in order to shadow them.
Who played a significant role in your journey to becoming a physician? My senior year of high school I applied to participate in a University program for rural students. During this process I had the opportunity to converse with an amazing woman, Carol, who is passionate about helping others and dedicated to her students. She has a wonderful heart and a genuine interest in my well being. She truly cared about me as a person.
Being a Physician, you can be asked to treat symptoms effecting your patient you would not expect. Your patients that are elderly believe they have a very special relationship with you, like a beloved and trusted niece or nephew. You are the wise counsel for all that matters, the Doctor knows best. Sometimes they want you to make their family stop fighting.
It was reported in a 2015, in the US, by the Pew Research Centre that 24 percent of teens go online “almost constantly,” facilitated by the widespread availability of smartphones. With all the social media platforms out there, it is estimated there will be 2.67 billion social network users by 2018 reported by article from Katina Michael (PC World). She also noted that “Social networking already accounts for 28 percent of all media time spent online, and users aged between 15 and 19 spend at least….
The American Medical Association published in JAMA (May 15, 2017) a recent article by Dr. Dabora and Dr. Turaga, two Harvard Business School professors (MD, MBA), who are joined by Dr. Shulman (MD) of the Duke University School of Medicine. The following is a summary of this article. The distribution of US pharmaceutical products is fairly simple. The physical drug product, such as a pill or vial of drug, leaves a manufacturer and is then purchased by a distributor.
Most of us have personally experienced the impact of electronic health record (EHR) and required clinical documentation, which have resulted in decreased productivity and decreased job satisfaction. Physicians and nurses have traditionally used clinical documentation to record and convey information as well as treatment plans to other members of the care team. However, clinical documentation has evolved to justify reimbursement and serves many purposes which may not contribute….
In August 2015 in Roanoke, VA, 2 television station employees were gunned down live on the air. The attention of employers and employees nationwide focused once again on violence, and more specifically, workplace related violence. Since the 1980s, violence has been recognized as a leading cause of occupational mortality and morbidity. According to the Bureau of Justice Statistics, an estimated 1.7 million workers are injured each year during workplace assaults….
When it comes to practice growth new faces of patients is a good thing, but not when those new faces are staff members. The constant revolving door of office and medical staff is killing more practices now than ever before. The success of today’s medical practice is not only measured in the accounts receivables and overhead, but the cost of office conflict. You cannot avoid conflict and disagreements within the office. That is human nature.
It is not often you get the chance to meet a celebrity in the emergency department, especially at 2 a.m., and when that opportunity arises you must seize it. When Iron Man strolls through the door notice is taken. As a child I was fascinated by superheroes. Superman, Batman, Iron Man, Wonder Woman; my appetite was insatiable. I felt a connection to these figures, wishing I was only a radioactive spider bite away from saving the world.
Monday mornings on the unit are always a little chaotic. Even though during pre-
“So if you don’t mind me asking, why did you make the switch?” I get that question quite often. I honestly never grow tired of answering it because that’s always when I launch into what rekindled my spark for being a physician. I still remember running down the hallway, balancing on one foot, ferociously pulling on knee high booties while trying desperately to tie on a shield mask simultaneously. I was both excited and anxious, ecstatic and scared, because I was about to deliver life.
When my dad went in for heart surgery, I never expected that he wouldn’t wake up. Not to say that I was worry-
I ran from my first fire. As a seasonal worker with the Forest Service, there were very few days between my fire boot fitting and the first time I trampled embers in them. I was trained to be part of a wildland fire hand crew. Hand crews serve a crude, but essential purpose. Forest fires often burn on difficult terrain. Machines cannot operate on the steep inclines or navigate the dense vegetation. Where machines are ineffective, hand crews hike in. With chainsaws and sharpened garden tools they…..
“That could never happen to me!” is a phrase most of us say about near death experiences, especially when you are in your twenties. However, the reality of the matter is that medical emergencies can happen to anyone, including you and me. I learned this lesson the hard way when I went into ventricular tachycardia for several hours on Thanksgiving Day last year. As a medical student, I am learning how to diagnose and treat all kinds of conditions and diseases, but studying medicine….
If you are the physician, recognizing the symptoms of Caregiver Burnout Syndrome is essential. According to A.A.R.P. it is estimated less than 50% of doctors ask caregivers if they are experiencing any burnout symptoms or high stress. Symptoms are characterized by physical and emotional exhaustion, depression, anxiety, bouts of anger, withdrawal, impaired thinking and performance, and most often a feeling of being overwhelmed and guilt.
In the immediate world of what most of us would consider "politics," there are only a select few that we actually see run for a public office. Behind the scenes in Kentucky, there are perhaps only a few thousand volunteers, office workers, and support staff who are also considered 'part of the political process' and often have very important roles in the realm of governance and development of policy. But, this is only a small percentage of our Commonwealth's overall population; and as physicians, we are....
What advice could a retired US General give a doctor, to improve healthcare? I recently read Growing Physician Leaders, by Lieutenant General Mark Hertling, US Army (Ret.). General Hertling, a recent retiree from the US Army, was at one time the commander for US Army Europe and the Seventh Army where he had over 40,000 soldiers under his command. As an Army general charged with the safekeeping of thousands of lives his post-
Tamika rushes into the clinic. She’s late. 32 minutes late, to be precise. As she arrives she meets the eyes of the Medical Receptionist, who glances at her disapprovingly. Darting into the back, she pulls off her gloves and hurriedly hangs her coat in her locker. Her manager, Kate, is suddenly there. “You’re late” she declares. “I know. The bus broke down,” she replies. “Sorry.” Her boss turns and walks out. Tamika quickly stashes her lunch in the lounge refrigerator and clips on the badge that identifies her name and title....
It is not uncommon for me to be asked “Why do you do this and do you enjoy it?” At the onset of my career in medicine, the idea of being President of the American Medical Association or Chair of Council of the World Medical Association was never a consideration. In fact in those early years, I had very little knowledge about these organizations or what they could accomplish. It was not until the AIDS epidemic and the impact it had on patients and my practice did I recognize that part of my responsibility as a....
There has been a flurry of activity in the last decade regarding neuroscience and leadership. From a brain standpoint, much of leadership is based upon the cerebral functions underlying social cognition. Social cognition has evolved to contextualize the matters and outcomes under consideration, the effects of any decisions made on others, and to guide considerations of what others might or might not think. These cognitive functions are expected to lead to sound reasoning and rational judgment.
Rising healthcare costs and demands from the public for increased coverage have led to an ever increasing presence of government in the traditional patient-
This quarterly edition of KentuckyDoc features LMS physicians and their hobbies. Two LMS members, William Wheeler M.D. and David Bensema, M.D., have chosen woodworking as a hobby. As with most physicians who choose hobbies, Bill and David came to their hobbies by different routes. When Bill Wheeler began thinking about retirement, while continuing his practice as an obstetrician/gynecologist, he decided to choose woodworking as a hobby.
What is horseback riding? Are there different types? Horseback riding is exactly what it sounds like – riding a horse. There are a many different types. The two basic horseback riding styles are English and Western, the saddle is the biggest difference between the two. I started out as a hunter jumper. Eventing, like the Kentucky Three Day Event at the Kentucky Horse Park could be termed an "equestrian triathlon." It involves working with a horse both on the flat and over fences.
For many physicians, the question is not “if,” but, “when” you will experience burnout. A recent systematic review and meta-
A link between exercise and mental and physical well-
The Pain Treatment Center of the Bluegrass is the largest freestanding facility in Kentucky dedicated to the treatment of pain. It hosts 11 physicians of varying specialties and sub-
Not a day passes without some story in the media about the devastating opioid epidemic in this country. Often the item concerns the latest government statistics that show an ominous worsening of some indicator of the crisis – such as a CDC report that estimates that there were more than 42,000 drug overdose deaths in the U.S. in 2016 alone, a figure that was projected to reach 72,000 deaths in 2017, representing a deadly drug overdose about every six minutes.
I had the opportunity to interview Steven Stack, M.D. regarding opioid issues confronting emergency department physicians. Steve is well known to many of us, as he is a very recent president of the American Medical Association and currently is employed as an ED physician at St. Joseph Hospital East. Steve’s opinion of the opioid crisis currently is that it is sad, tragic, and an enormous problem. From the patient perspective, the patients that Steve sees are very hopeless and….
America’s first epidemic of opioid addiction occurred in the 1840s. Mothers dosed themselves and their children with opium tinctures and opioid containing medicines. Soldiers in the U.S. Civil War treated their injuries and diarrhea with morphine (“the Army disease”).(1) Drinkers treated their hangovers with opioids. However, the main source of the epidemic was iatrogenic morphine, which coincided with the invention of the hypodermic needles in the 1870s.
When a new amputee is tasked with getting back to their life after losing a part of their body, it involves more than simply creating a prosthetic device to surrogate what was lost. The process is a deeply personal and psychological journey that involves a lot of community, love, and support. Hi-
People frequently think that pain is a purely physical sensation. However, pain has biological, psychological and emotional factors. Pain can cause feelings such as anger, disappointment, hopelessness, sadness and fear, to name a few. “While medical treatments, such as surgical interventions, physical therapy/rehabilitation, and medications, can be helpful in treating chronic pain, psychological treatments are also very important,” says Heather Wright,….
One of the major challenges in healthcare is reconciling the tremendous gap in patients’ access to physicians. This is particularly true for our patients who reside in Eastern Kentucky. The Appalachian Regional Commission recently issued a very somber report showing that the Appalachian region has significantly higher mortality rates, increased incidence of heart disease, cancer, diabetes, depression, and more health risk factors (obesity, smoking, fewer physicians, drug use) than the rest of the country.
Due to the obvious shortages in psychiatric manpower, more and more patients requiring psychiatric care are being seen in primary care as part of a “patient-
Physicians and other medical professionals are often on the front line due to their accessibility to elderly patients. Sometimes being the only individual to see an elder other than their caregiver, the ability to recognize the signs of abuse is vital. According to the Administration on Aging in Washington, D.C., each year hundreds of thousands of older persons are abused, neglected, and exploited. Many victims are people who are older, frail, and vulnerable and cannot help themselves….
The journey a new amputee takes can be long and difficult to navigate. The staff at Hi-
Chiang Mai is Thailand’s second largest city and a peaceful alternative to Bangkok. The capital of Northern Thailand is known for its temples and its markets, and it is one of the main centres for learning traditional Thai massage. Chiang Mai is surrounded by mountains, forests and national parks that are perfect for daytrips and for trekking.
On August 30th, 2009 I was sitting in my college dorm room when I received a call that would change my life forever. I was told my dad had been in a tragic accident and I should find a way to the hospital immediately. I hurriedly packed and my best friend drove me to the hospital three hours away. When I arrived, I found out that my father was in an unfortunate accident that would forever leave him paralyzed from the chest down—a quadriplegic for the rest of his life.
When I reflect on the sacrifices that I’ve made to study medicine, I also note that my mother has altered her life for me to realize my potential. Being diagnosed with autism spectrum disorder could have been a life-
I have a small black planner from Japan that has chronicled my life for the past year. It is a compact and sturdy little book I carry back and forth to work. Since the beginning of my residency, I have had several of these, archived in a striped banker’s box once the year is up. If someone were going to be nosey and read one of these books, they would see a rather humdrum list of appointments, tasks, deadlines, and days of call written down in my indecipherable cursive.
Here I am turning into the alley I know so well. I spot the neighborhood holy man and beggar with his alms bowl. The restaurant he sits alongside is bustling. The matron calls out to me from behind her steaming peanut and palm nut soups. Next door to her I pass the charcoal seller. I smile and jump over the open gutter fronting her roadside business. My heart is beating faster now as I approach my destination. At the threshold of the house I reach out to the wrought iron gate with….
Finally—I was so blessedly close to sleep. So far, my eyelids had been closed for the first four hours of our sixteen-
Were the sacrifices you made to become a physician worth it? This is a question that I get asked at least couple of times every month, mostly by well-
With constantly evolving technology and increasing national exposure, the field of prosthetics has finally begun to garner the attention it has long deserved. While many now know more about prosthetics than ever before, the clinical and technical process involved in designing and creating prosthetic limbs for amputees is still relatively a mystery to most. Increasing exposure and social media attention allow viewers to witness amazing outcomes and aesthetically pleasing prosthetic devices.
The water erupted soon after his fly landed near the riffle’s foam line. “She’s got spirit,” my son roars, gathering extra line. “Watch and learn old man.” The Roaring Fork is a freestone mountain river that rages in torrents in the early summer while washing over boulders and fallen trees. Our Western drift boat is made for this challenge. The flat-
The quality of our family life has a major impact upon the quality of our work life. Family discord and conflict often seeps its way into the workplace, which can result in reduced concentration, increased mistakes, and a greater susceptibility to burnout. Strong physician families actually provide a buffer to workplace stress and offer a place for support and renewal.
Our spouses keep long hours. They miss out on a lot of family time and kids’ extracurricular activities. So, when they manage to get vacation time, our spouses generally pack (or get packed for), walk out the door, and enjoy the vacation. They might do a little “Monday morning quarterbacking” on the vacation planning, but that goes with any marriage.
I had the privilege of consulting to the Stewart Home & School (SH&S) 2 decades ago. John D Stewart II MD was practicing general and vascular surgery in Lexington at that time while working part time at the family business in Frankfort. I came to know that John was the 5th generation of Stewarts to manage this institution. I asked him to help me with the history for this article and he graciously complied.
I have known Lexington plastic surgeons Woody, Andy and Mike Moore most of my medical career. Woody and I often hunted quail with other medical colleagues. During our hunting expeditions, Woody would tell me “Moore Stories” (my emphasis). I vowed someday to tell a short story of this family’s medical careers in the heartland of America. Andy has retired from plastic surgery and Woody has retired and moved to North Carolina.
The material for this essay comes from the classic book written by W. Porter Mayo, M.D., Ph.D., a former Lexington Medical Society member who became a history doctorate after he completed his career as a Lexington surgeon. His book, still today is the greatest book written about the Lexington Medical Society, was commissioned by the LMS and published in 1999 to honor the 200th anniversary of the founding of the Lexington Medical Society.
Dr. Daniel Drake was considered the foremost medical educator in America in the 19th century. He gave a presidential address to the Lexington Medical Society on November 14, 1823 when he was inducted to that medical society and accepted the second Presidency in 1824 (Mayo, 1999, pg. 16). When the Lexington Medical Society finally closed in 1834, Dr. Caldwell served as President of the College of Physicians and Surgeons while he was Dean of the Medical Department of….
There is a time honored cliché: you get as much out of it as you put into it. This is true for any endeavor and it certainly pertains to organized medicine. The Lexington Medical Society (LMS) is fortunate to have had members who have been involved in all aspects of the medical profession, exceeding the routine of daily patient care and excelling in other aspects of medical practice.
There is an old saying “behind every successful man, is a strong woman to pick up the slack.” Dr. David Bensema is an internal medicine doctor who was Lexington Medical Society’s president in 2002, and he was Kentucky Medical Association’s President from September 2014-
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In 1997, the American Academy of Pain Medicine (AAPM) and American Pain Society (APS) published a consensus statement that there was lacking evidence implicating opioids to addiction. (6) In 1998, the Veteran’s Health Administration incorporated pain as the “fifth vital sign” into their national strategy for the assessment and treatment of pain. (7) Similarly, JCAHO ( Joint Commission on Accreditation of Healthcare Organizations) embraced the “Pain is the Fifth Vital Sign” and issued standards requiring the use of a pain scale and treatment of pain, especially with opioids. JCAHO also referred to pain management as a patient’s rights issue, inferring sanctions if the pain was not adequately controlled. (8-
The FDA (Food and Drug Administration) granted its approval of Oxycontin in December of 1995 without evidence of efficacy or safety from any clinical trials! Purdue Pharmaceuticals, the manufacturer of Oxycontin, claimed that the long-
Another factor contributing to this perfect storm was Press Ganey, a survey of patients which began in 1985 to identify opportunities to improve patients’ experiences. Collection of data was necessary for improvement; but, the distinction between patient satisfaction and quality of care became blurred. Press Ganey monetized their concept and promoted the notion that patient satisfaction was a proxy for quality of care. (There is still no definitive data to correlate patient satisfaction and quality of care.) The final ingredient was CMS (Centers for Medicare and Medicaid Services). CMS realized that the current pay for volume healthcare system was insolvent; thus, CMS developed the value-
With the aforementioned factors in place, it is easier to understand the following contributors to the opioid epidemic because these factors are unintended responses/ reactions. The predominant thought was that there were too many patients suffering unnecessarily because of inadequate pain management. Physicians needed pain management guidelines, to include the use of opioid medications. Physicians needed education to dispel the concern for addiction. Additionally, insurances were not reimbursing for non-
Since reimbursement to hospitals were tied to patient satisfaction, hospital administrators were forced to implement initiatives to improve patient satisfaction scores and avoid a penalty. CMS only required 300 surveys in a 12-
As the prescription opioid problem escalated, the spike in opioid related overdose deaths caught the public’s eyes. This resulted in a cascade of reflexive responses which unintentionally facilitated the reintroduction of heroin and later fentanyl to Americans. It was easy to see. If the amount of prescription opioids were reduced, there would be less prescription opioids to abuse and that should result in decreases in opioid related overdoses and deaths. Thus, the campaign to limit prescription opioids began. Legislators demanded implementation of prescription drug monitoring programs (PDMPs) to mitigate doctor shopping. It also allowed physicians to identify patients who were already receiving other opioid or scheduled medications. Various medical societies, CDC, and governmental agencies all switched their stances on the treatment of pain, cautioning physicians regarding the danger of opioid addiction. Law enforcement aggressively sought and closed the numerous “pill mills” throughout the country. Naloxone kits were widely dispersed to treat overdoses. The message was clear, physicians must stop overprescribing opioid medications. But other than the American Society of Addiction Medicine (ASAM) or a handful of physicians who were treating addiction, there were no plans for the void which these interventions created. That is, what was the plan for the patients who were already addicted to opioids? With all of the prescription opioids gone, what were these addicted patients going to use?
Coincidentally, it was around this time that several states were decriminalizing marijuana. More American marijuana customers were growing their own supply. The wholesale price of marijuana dropped from $100 per kilogram to less than $25. Farmers in Mexico, particularly the “Golden Triangle,” the region of Mexico’s Sinaloa state which produced the country’s most dangerous gangsters and largest marijuana producers, quickly changed their crop to opium poppies, heroin. With a large, eager American demand from addicts who had their supply of prescription opioids quickly removed, the Mexican heroin suppliers had an immediate market. Not only was there an abundant supply of opioids (heroin from Mexican suppliers), the cost of heroin was relatively cheaper. The prices of prescription opioids or heroin depend upon location, availability on the streets, and the heroin’s “purity.” The current market value of Oxycodone is about $1 per milligram and based upon patient testimonies during treatment, a typical addict will use 80-
Strategies to Combat the Opioid Epidemic
To effectively implement strategies to combat the current U.S. opioid epidemic, there are certain myths regarding addiction which require dispelling. The most significant misconception is that addiction is related to poor individual choices, moral failures, and/or weak willpower. Compulsion to use drugs is a voluntary choice. MAT, also previously known as opioid replacement therapy, is substituting one addiction with another. The best way to combat opioid addiction is without medication. These attributes (stereotypes) contribute to the stigma which often shame people who have addiction, their family members and associates. These fallacies will harm those who are at most risk! Similar to other medical conditions (emphysema, heart disease, hypertension, diabetes), voluntary unhealthy behaviors (or choices) do contribute to the disease. We promote proper dietary changes to the diabetic who consumes excessive sweets. We discourage patients who smoke. We encourage our patients to exercise. But we do not withhold evidence-
Abstinence, the complete cessation of drug use, has been the gold standard for addiction treatment in the U.S. for many years. Originally created for alcoholism, the model is currently used to treat all addictions. After the creation of AA (Alcoholics Anonymous) in 1935 and the publication of “The Big Book,” written by William Wilson to describe how to recover from alcoholism, the model (also referred to as the Minnesota Model) was spread to not-
Multidisciplinary approaches to limit the supply of prescription opioids have been successful. Dr. Patrice Harris, Chair of the AMA Opioid Task Force, announced Apr 19, 2018 that between 2013 and 2017, there was a 22% decrease (55 million less) in opioid prescriptions. (20) Physicians and patients are aware of the dangers of opioid addiction. Many professional organizations have created pain management guidelines for physicians. Regulatory and legislative organizations have tightened restrictions for the prescribing and monitoring of opioid pain medications. Naloxone kits are readily available to mitigate overdose deaths. Law enforcement has diligently worked to disrupt the heroin traffic. And most important, there has been tremendous promotion of treatment for people already addicted to opioids. This intervention was lacking during the initial response to the prescription opioid crisis. Successful interventions to limit the supply of prescription opioid drugs created an imbalance of supply versus demand and drug dealers exploited the opportunity with heroin to satisfy the unmet demand for opioids. Learning from the 2010 experience, future strategies to combat the opioid epidemic must include interventions to limit both supply and demand. If treatment for opioid dependence becomes easier to attain than other opioids to relieve withdrawal symptoms, the demand for opioids will decrease. As the demand decreases, the supply will initially rise which will devalue the illicit opioids (heroin, fentanyl), and eventually cause supply to decrease. For example, New York City recently used this approach to tackle the tobacco problem. The city banned smoking in public spaces and significantly raised the taxes on cigarettes. Simultaneously, the city promoted and facilitated the public’s access to free nicotine patches or free nicotine gum. The intervention was successful!
Facilitation of access to opioid treatment is beneficial; but, there are potential pitfalls. Buprenorphine is an opioid agonist and will induce mu opioid effects to include euphoria, particularly opioid naïve individuals, and respiratory depression. Because buprenorphine is an opioid partial agonist, the ceiling effect will limit the potency of the euphoria and similarly the respiratory depression risk. Fatal overdoses solely due to buprenorphine are rare. (21) Most overdoses involving buprenorphine occur when other drugs are taken concomitantly, (22.23) usually benzodiazepines and/or alcohol. (Buprenorphine has the ceiling effect to mitigate respiratory depression; but, benzodiazepines and alcohol do not.) Despite buprenorphine’s safety profile, ceiling effect, and lower abuse potential, once buprenorphine becomes “more available,” and/or cheaper, it will become the next abused and diverted drug problem. Yokell et al. conducted an international review of buprenorphine diversion, misuse, and illicit use. (24) The authors reported that since France’s adoption of buprenorphine for OUD in 1995, about 20% of buprenorphine patients were misusing the drug intravenously (snorting is also a common delivery mechanism). In Finland where buprenorphine has been used for pain management since 1997 and OUD since 2002, buprenorphine has become the most commonly abused drug. The authors noted that the rise in buprenorphine use in Finland coincided with a decrease in availability of heroin in 2001. Despite reported diversion and misuse, buprenorphine was ranked as the least-
While it is desirable to promote MAT for treatment of opioid addiction, it may be more prudent to encourage treatment which includes MAT, counseling/behavioral therapies, and case management. We want to encourage the use of buprenorphine as treatment, not simply the use of buprenorphine. Promoting many prescribers to simply write for buprenorphine without supporting psychotherapy and case management may create a future state where buprenorphine becomes the next drug crisis. National Institute on Drug Abuse’s principles of effective treatment for drug addiction includes counseling and other behavioral therapies and addressing all of the patient’s needs, not just his or her drug use. Patients with opioid addiction have many complex socioeconomic and legal issues. Combine this with poor coping and inadequate social skills (neglected during long-
The third crucial element necessary for successful strategies to combat the opioid epidemic is improving the current management of chronic pain. In 2011, the Institute of Medicine (IOM) published “Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education and Research,” the most comprehensive report on pain in America. (25) IOM reported that 116 million Americans suffer from chronic pain (1 in 3 adults) and estimated $560 billion in healthcare and lost productivity costs. “Human suffering is often unnecessary – millions of people get inadequate pain relief for conditions that could be treated or managed.” This is one tough quandary! There is an opioid epidemic and everyone is doing their part to reduce the use of opioids. But what about the patients who have legitimate chronic pain? Not all of these patients require opioid pain medications; but, what are their options? There are not enough pain specialists to properly diagnose or perform injections/procedures. Despite general support for non-
The opioid epidemic began with a well-
America’s first epidemic of opioid addiction occurred in the 1840s. Mothers dosed themselves and their children with opium tinctures and opioid containing medicines. Soldiers in the U.S. Civil War treated their injuries and diarrhea with morphine (“the Army disease”).(1) Drinkers treated their hangovers with opioids. However, the main source of the epidemic was iatrogenic morphine, which coincided with the invention of the hypodermic needles in the 1870s. It has been estimated that consumption of opioids soared 538% from 1840 to 1890. The Institute of Medicine estimated that by 1900, about 300,000 Americans were addicted to opiates. (2)
There were few alternatives to symptomatic treatment during the nineteenth century. The pathology of diseases, particularly chronic pain, was poorly understood. An injection of morphine magically alleviated most symptoms, particularly pain. Patients appreciated the relief and doctors felt empowered. Fast forward to present day. Despite our tremendous advancements in medicine, there are many diseases including chronic pain that continue to elude our understanding. Physicians overprescribe opioids. Physicians also overprescribe diagnostic evaluations, labs, imaging and antibiotics. But, these are all well-
or visitor inappropriately abuses them. But the physicians’ contribution to the opioid epidemic also has a sinister side. There are, unfortunately, colleagues who have participated in “pill mill” operations, accepting cash payments in exchange for opioid prescriptions regardless of ailment. (Between 1992-
In 1980, NEJM published a one paragraph letter from Jane Porter and Hershel Jick, MD, reporting that during their retrospective review of 11,882 hospitalized patients who received narcotics, only four (4) patients were found to have “well documented addiction.” (3) In 1986, doctors Kathleen Foley and Russel Portenoy published in Pain that iatrogenic addiction risk was low in 38 chronic non-
Tuyen Tran, MD emigrated from South Vietnam after the war. He completed his undergraduate in biology/chemistry and medical school at the University of Missouri – Kansas City in a six year program. His is currently boarded in internal medicine and addiction medicine.