The Whitening of the Opioid Epidemic....

I was reading the most recent copy of the Psychiatric News (May 4, 2018) when a story jumped off the page at me.  It was called "How the Opioid Addiction Crisis Was Rendered 'White'.   I knew I had to post about it here because it contains several inaccuracies that typically occur when racial explanations are used to look into any complex phenomenon.

The article is about positions espoused by Helena Hansen, MD, PhD and in fairness it was not written by her.  There is no guarantee that she might consider these accurate depictions of her positions.  The article starts out discussing a 2015 PNAS article on mortality in white middle aged Americans (1) and what the authors termed "deaths of despair" claiming that the new opioid crisis affects these people "linked with social and economic causes: decreasing wages, disappearing jobs, and a diminishing standard of living."  In the same paragraph, the author points out that rate of increase of opioid related deaths is occurring in 55- 64 year old African Americans (see the recent respective slopes in the top 2 graphs used in the article).  For completeness, I suggest going through this data visualization and generating graphs for all of the age ranges, looking at absolute rates and the rate of increase, and comparing those generated graphs to the total deaths bar graph above it.

Dr. Hansen spells out a selective marketing strategy of opioids to white Americans - specifically selling them OxyContin as an opioid painkiller with minimal addictive properties in the 1990s.  She said that was followed up with selling white Americans buprenorphine as  a treatment for addiction.  She describes this as the "whitening" of a new class of opioids "against a backdrop of a long history in which heroin and other drugs of abuse were similarly "racialized" as the substances of choice among blacks and other minorities...."  The racializiation was accompanied with "sinister criminal imagery that ignored the socioeconomic circumstances that had always contributed to addiction in minority communities."

She suggests this racialization or whitening of the opioid epidemic was made possible by:

1.  Deliberate ethnic marketing by Big Pharma.
2.  The pharmaceutical "magic bullet" approach or buprenorphine as a solution to the opioid problem obscuring psychosocial and economic factors.
3.  A health care system that does not make psychosocial treatments equally accessible by "geography, class, or race".

She goes on to point out that the distribution of methadone versus buprenorphine has an unequal distribution with methadone being more inconvenient and distributed primarily in inner city neighborhoods.  Buprenorphine on the other hand is easier to take and is distributed primarily in the suburbs and is more easily available to the white middle class.

She brings up a familiar refrain that promoting addiction as a brain disease devoid of environmental or psychosocial context that "anyone" can get - is really code for "anyone" = "white".  She suggests that white opioid crisis has stimulated discussion of of economic revitalization for the white victims of addiction while the black victims were criminalized.  She concludes that addiction is rooted in "social problems mediated by mental illness" and therefore we need psychiatrists to address this problem.

As an addiction psychiatrist I have addressed all of these themes on this blog in the past.  I can make it as straightforward as possible.   All of the social, economic, and psychosocial explanations of addiction are highly flawed simply because the vast majority of Americans laboring under those conditions do not become addicted.  As far as I  can tell economic revitalization is political rhetoric, especially in the current circumstances where what the government will actually do to address the opioid crisis remains unclear. 

There are two critical variables for addiction.  The first is biology.  There are strong genetic components that correlate with addiction as well as some epigenetic components.  Race is not a factor.  On that same spectrum, genetics determine that some people are protected against addiction by their biologically determined reactions to addictive drugs and alcohol.  This is not speculation on my part it is a known historical fact and scientific fact.  No matter who you are or what your race is - you need this biological disposition to addiction or it probably is not going to happen.

The second variable comes down to exposure.  If there is no exposure of addiction prone individuals to the addicting drug there is no addiction.  That is where Dr. Hansen is partially right.  When Big Pharma targeted physicians to prescribe opioids for trivial pain and maintenance opioids for chronic noncancer pain that brought opioids to a much larger group of people, basically non-metropolitan whites who started to die in rural areas of opioid overdoses.  And it was much more than opioids.

The example I use in my lectures is a teenager in rural northern Minnesota in the 1970s versus today.  Let's say he knows his grandfather died of alcoholic cirrhosis and his father is an alcoholic.  What would he need to do in order to avoid being an alcoholic or addict in the 1970s versus today?  In other words if we assume his genetic make-up is the same and he inherited the family predisposition to alcohol misuse - what does he have to avoid?

In the 1970s there were basically three things: alcohol, tobacco, and cannabis.  In some areas of the country there was an amphetamine epidemic but that had not reached the northern frontiers of the US.  How about in 2018?  Today he has to avoid everything - opioids, alcohol, tobacco, cannabis, synthetic cannabinoids, amphetamine, methamphetamine, and everything he can acquire over the Internet.  We have gone from a country where rural (and white) Americans were relatively sheltered from all of these addictive compounds to where they are widespread and easily accessed.  So easy in fact that you can get many of them (opioids, amphetamines, benzodiazepines) directly from your physicians office.

I disagree with Dr. Hansen's basic theory of this opioid epidemic and how it was "whitened."  This is not a racial issue at all.  As I have been telling my students for nearly a decade now - "Until recently - why was a kid in northern Minnesota relatively protected against opioid addiction relative to a kid in the inner city?"

The answer is that kid in Minnesota - until recently - did not have to walk past any drug dealers on the way to school.

Now they do and the only relevant equation is biological predisposition + exposure = addiction.  That same simple equation is also the most compelling argument against legalization of addictive drugs because by definition it would mean a larger percentage of addictions with increasing exposure.

Men discriminate based on arbitrary definitions of race and class.

Biology does not. That is why anyone white or black can develop an addiction.



George Dawson, MD, DFAPA



Reference:

1:  Case A, Deaton C. Rising midlife morbidity and mortality, US whites.  Proceedings of the National Academy of Sciences Dec 2015, 112 (49) 15078-15083; DOI:10.1073/pnas.1518393112

2:  Moran M.  How the Opioid Addiction Crisis Was Rendered White.  Psychiatric News, May 4, 2018, pages 19 and 23.

3:  Greene, Eddie L.Thomas, Charles R. et al.  Minority Health and Disparities-Related Issues: Part I
Medical Clinics of North America 2005, Volume 89 , Issue 4 , xi - xii

4:  Greene, Eddie L.Thomas, Charles R. et al.  Minority Health and Disparities-Related Issues: Part II
Medical Clinics of North America 2005 , Volume 89 , Issue 5 , xi - xii


Graphics Credit:

1:  National Center for Health Statistics - Drug Poisoning Mortality in the United States, 1999-2016 https://www.cdc.gov/nchs/data-visualization/drug-poisoning-mortality/



Supplementary (too tedious for the post).

Dr. Hansen	Dr. Dawson
Deliberate targeting of white people by Big Pharma marketing	Influence was at the physician and institutional level.  Increased access at many levels increased exposure to all Americans. Goal of the pharmaceutical industry is to develop “blockbuster” drugs by marketing and selling to as many physicians and patients as possible.
The pharmaceutical "magic bullet" approach or buprenorphine as a solution to the opioid problem obscuring psychosocial and economic factors.	If it was marketed that way – it was a poor job considering the number of overdoses that could have been prevented since it was released in 2002.  Even today there is widespread reluctance to prescribe it and use it and large social media groups advocating to not use it or taper off it. It is prescribed without considering the race of the patient.  In healthcare systems, a focus on a medication is frequently a way to not provide necessary services for anyone.  The obvious example is closing state mental hospitals and focusing on the success of chlorpromazine.
A health care system that does not make psychosocial treatments equally accessible by "geography, class, or race".	The problems with racial and class disparities in care have been widely known and occurred long before the current opioid epidemic (see ref 3 and 4).  Government sanctioned managed care system has been rationing mental health and addiction care for 30 years for corporate profitability.  Despite continuous discussion of the epidemic there is little evidence that the infrastructure or service for treating addiction has improved in any way.
No broader cultural theory.	Increased cultural permissiveness for drug use as evidence by widespread legalization of cannabis and the promotion of addictive drugs as therapeutic agents can increase the likelihood of illicit use.
Distribution of methadone clinics versus Suboxone prescribers	Suboxone is clearly more convenient but access to prescribers is very limited.  Suboxone patients often have to travel as far as they would have to get to a methadone clinic and then see a provider who does not accept health insurance and charges ala carte fees for service.  A segment of Suboxone users may do better on methadone.
Medical definition of addiction as a neurobiological disease that anyone can get was invented for white people.	Clearly applies to everyone unless you believe that there are some racial characteristics to suggest that one race is more susceptible than another.  As is the case with the majority of human illnesses I don’t believe there are any susceptibilities to acquired illness based on race.
Mental illness is a product of socioeconomic circumstances and a precursor to addiction.	In genetic studies mental illness co-aggregates with addictive disorders, genetic susceptibility to one increases susceptibility to the other.

Another PSA On Pain, Opioids, and Addiction

It turns out that Twitter is an inadequate forum for discussing the issue.  Twitter is an ideal format for discovering if a poster knows anything at all about the problem.  A lot of people don't and they seem to just be there to argue.  I don't have a lot of time to waste on political approaches to medicine.  Political approaches to medicine typified by managed care companies, pharmaceutical benefit managers, and government guidelines that are supposed to improve care but don't are the reasons we have an expensive, fragmented and inefficient health care system.

The apparent political factions on Twitter consist of pain specialists who take the position that pain care and access to opioids is now being rationed and their pain patients are being unjustly treated.  They claim there is a faction of addiction specialists making various claims that they take offense to.  But my experience there is the past few days is that these are all basically red herring arguments.  A few of those claims include the idea that addiction specialists would consider pain patients "drug seekers", would recommend treating pain with only acetaminophen, are calling pain specialists "quacks", and of course that addiction specialists have some interest in distorting and overplaying the dangers of opioids.  In some cases the arguments have gotten to the absurd claim that the pain advocates (or more appropriately anti-addiction contingent) claims that most heroin users start using heroin directly rather than using legitimately prescribed or diverted pain medications first.

Where is the reality in all of this distortion?  The reality centers like most things in medicine in primary care settings.  The hundreds of thousands of internists and family physicians who provide the bulk of care for almost all problems in the US.  As I have posted on this blog many times, the evidence from both the CDC and CMS is that the majority of these physicians do a good job with opioids.  Only a fraction of their number prescribes a disproportionate amount of opioids.  Many of these physicians have a bias to underprescribing if anything.  That means the bulk of physician punitive legislation about mandatory course for opioid prescribing for these physicians will be just that - punitive toward most physicians who already know about prescribing these medications.  That legislation is also untested in terms of whether it will have any impact on the physicians who are overprescribers.

The other facet of the problem is overprescribing in general.  Part of the quality problem in medicine today is that the business and governmental management systems are focused on a brief physician-patient encounter where some medication gets prescribed.  That is the focus of the encounter. Patients expect that and come in the door with a medication request.  That results in predictable overprescriptions of medications from many classes.  The classes that reinforce their own use - opioids, stimulants, and benzodiazepines are more problematic than the rest.

At the extremes of this landscape are the pain specialists on one end and addiction specialists on the other.  Both have a broad spectrum of quality settings from state of the art to nonexistent.  These specialists know this and they know there is very little that can be done about it except to mind your own business and do the best job possible.  There are pain clinics that are "pill mills" where there is an understanding that a cash exchange with a prescriber will get you a script that can be filled on site for opioids.  That prescription is then sold in the parking lot for diversion.  There are other pain clinics where no attention is paid to addiction, psychiatric comorbidity, polypharmacy or the functional capacity of the patient being treated.  There are similarly low quality addiction treatment facilities where people are warehoused with no active treatment.  Where there is no therapeutic environment because nobody in the program is willing to consider that they may have an addiction.  There are programs where there is no medical supervised detoxification.  There are programs where there is no medication assisted treatment for opioids or alcohol use.  There are programs that do not address psychiatric comorbidity.  There are programs based on some sketchy ideas that have no proven relevance in treating addictions.  The houses of both pain and addiction specialists are not perfect because of these serious flaws.  And let's face it - the regulators of every state in the union are to blame for having so many low quality pain and addiction treatment facilities open for business and accepting reimbursement for shoddy services.   

For a moment - let's return to the idealistic world of the Twitter protagonist where the position seems to be "I am all knowing and do a perfect job."  The realities will  differ based on whether you are on the addiction or pain specialist end of the spectrum.  To illustrate, I am on the addiction end and 100% of the people are see have addictions or substance use problems.  On any given day the problematic substances average out to about 30% alcohol, 30% opioids, 20% mixed, 15% stimulants, and 5% cannabis.  Of the opioid users 30-50% have chronic pain problems.  In every case, I have a detailed discussion with the patient about how their substance use problem evolved and what keeps it going.  Over the years I see thousands of people with these problems and in that process come to know a lot about the associated issues.  My opinion is not based on my personal experience or politics.  My opinion is based on understanding the problems of thousands of people that I am supposed to help.  For example, when somebody tells me that the "average" heroin user in this country starts using heroin rather than prescription painkillers - I can say that is unequivocally wrong.  I have heard all of the details about how heroin use begins and it is almost always with a prescribed or diverted pain medication.  When somebody tells me that taking a person who is addicted to opioids and who has chronic pain off of opioids is cruel - I can also say that they are wrong.  I have had those same people tell me that they have never felt better and in less pain in years.   I can also say the following based  both on research, theory and clinical experience:

 1.  A significant portion of the population is predisposed to addiction - 

My estimate would be about 40%.  When a genetically predisposed person uses an intoxicant their reaction to it is markedly different from a person who lacks that predisposition. Opioid users report an energetic hypomanic felling where they have mental clarity like they have never experience before.  In some cases they will say that they felt like they had become the person they always thought that they could be.  This is a highly reinforcing state that leads to more opioid use.

2.  If the population predisposed to addiction is significant - the only limiting factor is access or availability -

This is the basic reality of the current opioid epidemic and of course very drug epidemic (methamphetamine, cocaine) that the US has seen over the past 200 years.  It is quite easy to look down from the high perch of a low availability area with low addiction rates to a high availability area with high addiction rates and conclude that "there is something wrong with those people".  The usual conclusion has been that they are morally defective.  This is how addiction services have been rationed, poorly researched, and fragmented over the years.  Even if you subscribe to a top health plan in the country - it is likely that you will have poor access to quality addiction care because of these attitudes.

3.  The burden of prescribing medications that reinforce their own use falls squarely on the prescriber - 

It is above all else an informed consent issue.  The patient needs to know that the medication they are taking is not a panacea and that there are significant risks up to and including addiction and death.  They also need to know that these medications can have cognitive side effects and affect their day-to-day functioning.  They should not be prescribed solely out of the notion that the physician feels like they need to do something for the patient.  There needs to be a pain diagnosis and treatment plan.  In the case of chronic pain the patient needs to know that there is no known medication that completely alleviates chronic pain and therefore continued dose escalation of opioids is not a solution.  The treatment plan needs to contain more elements than taking the opioid prescription.

An associated prescriber issue is polypharmacy.  Chronic pain is frequently associated with anxiety, depression, and insomnia.  That can lead to a contraindicated polypharmacy environment that includes a benzodiazepine, a z-drug, or a sedating antidepressant used with the opioid.  It can also lead to the patient taking alcohol or diverted sedatives on their own initiative with the opioid.

4.  Chronic pain patients taking opioids need thorough evaluations if possible -  

Some people in the Twitter debate seemed shocked by the idea that opioids are taken for reasons other than pain relief.  I suppose they would be even more shocked if they heard that there are people that take them who get no pain relief at all from them.  They taken them strictly because of the positive euphorigenic effects.  There are also people who take them despite the side effects for the same reason.  The first thing a physician needs to do is step back from the indication - prescription mode that most American physicians have been trained in to take a look at the entire prescribing landscape.

That means that is a person has come to idealize a medication or abusable substance they will start to use it for anything - insomnia, anxiety, depression, or "just to feel right to get through the day."  As many people tell me: "Look doc - if you can't get rid of this depression I know what I can take to feel OK for a couple of hours."  On Twitter and some other blogs readers are incensed that these behaviors exist and yet they are documented in the literature (see paragraph 6).

When I say if possible I am more aware of the fact that patients lie to physicians than non-addiction specialists.  I have had an endless number of patients tell me that they can get whatever addictive medication they want out of one physician or another.  The Mayo clinic had an addiction medicine conference three years ago and one of the presenters was a patient in recovery who basically talked about how he systematically lied to physicians to get opioids for years.  He talked about how he could identify a physician who would give him the script that he wanted and who would not.  In the case of the latter he would just move on to another clinic.

Many non-addiction specialists consider it to be poor form to suggest that patients lie.  That denies the basic reality that everybody lies.  It also denies the reality of addiction, that you are transformed into a person who is dishonest and a person that you never thought that you would become.  In the addiction field it is critical to acknowledge this to help people deal with guilt and shame so that they can recover.  The worst thing that can happen is to collude with dishonesty when the final result is the prescription of an addictive drug.  I do not consider it to be an issue that I can get this history when the physicians being approached for the medication cannot. It is all part of the illness of addiction.  On the other hand, if you are the opioid prescribing physician - the amount of information that you can get asking the direct questions about problematic use is not known until you try it.   

All things considered it is possible to treat people with chronic non-cancer pain with opioids.  I have been involved in that treatment before I switched to seeing only patients with addictions.  I consulted with some of the top pain experts in the state.  All the limits in this post need to be acknowledged and cautiously addressed.  The treatment of chronic pain is not perfect, I know that because I see a lot of the failures.  Addiction treatment is not perfect either.  The treatment needs to be highly individualized.

I wish that I could provide more clear guidance to the patients involved.  As an individual I cannot just start pointing fingers at the places (pain clinics and addiction treatment) that I think should be shut down.  I think that you need to depend a lot on your primary care physician referring you to places that he or she knows will do good work.  On either the addiction or pain end of the spectrum - there has to be more going on than the prescription of medications.

Even the most basic psychological models suggest that other cognitive, emotional, affiliative, spiritual and reconditioning changes need to occur.


George Dawson, MD, DFAPA 

  








   

Infection Disease Docs - Treating Addiction

There was a very interesting commentary in this week's New England Journal of Medicine.  In it the authors describe a case from their infection disease practice of a young man with infectious complications of intravenous heroin use ( Staph. aureus tricuspid valve endocarditis, septic arthritis, and empyema).  He had a history of doing well on buprenorphine maintenance in the past and was offered that treatment again by the Infectious Disease (ID) team as he was leaving inpatient hospital.  They completed the induction phase on the afternoon of discharge and he was discharged on buprenorphine-naloxone (Suboxone).  The ID  faculty at Beth Israel Deaconess Medical Center, a large tertiary care hospital in Boston have all been certified as buprenorphine prescribers and present this as an option to all of their patients with infectious complications of  intravenous substance use.  In addition to the buprenorphine they also provide rescue naloxone to treat acute opioid overdoses, discussions about harm reduction, injection practices, and cravings.  In the case that was presented, there was a discussion of the relapse risk and risk of recurrent infection or death from an accidental overdose.

This group of physicians has provided an outstanding example of what can be done when you are working with a highly motivated group who seizes the opportunity to make a significant difference. Part of their discussion is in terms of expanding their practice outside of the traditional role and expecting some pushback on that.   As I read their report, I thought about how this process might occur within the usual hospital setting.  A psychiatric consultation would be placed.  In tertiary centers a psychiatrist would see the patient, make a detailed assessment and recommend outpatient care somewhere.  That psychiatrist may or may not have a buprenorphine license.  Depending on location, there may not be a buprenorphine provider to refer the patient to.  In the case of intravenous heroin use that practically guarantees a relapse to heroin at the time of discharge with the attendant mortality and morbidity.  In this case the patient is familiar with the same treatment team that discusses the issue with him and gets him on Suboxone prior to discharge.  In today's world of rationed medical care - I cannot think of a more perfect intervention for high risk patients from an addiction standpoint.

The use of buprenorphine to treat opioids use disorders is not a perfect solution but it helps a large number of patients remain abstinent in general treatment populations.  The patient described in this paper was perhaps more highly motivated than most due to his complicated illnesses.  The authors experience reflects the fact that they clearly know the treatment process is complicated but view what they are doing as a bridge to long term care for opioid use disorders.  I agree with them completely.

There are a few considerations that they did not touch on that I think are important.  The personal characteristics of the physicians in this group is a major factor.   They discuss the history of their specialty as one that values social justice and public health.  They suggest this was a primary factor in allowing them to not get caught up in the stigma of treating addicts and the associated lack of resources.  I witnessed this first hand in the 1980s and 1990s when ID physicians and clinic staff were dealing with the HIV epidemic.  That went on for years before there was adequate treatment and the death toll was high.  Many ID clinics provided critical support to patient and their families during that  time.  I don't think that they ever got any recognition for that role.  Treating addiction above all else takes emotional neutrality and that was a characteristic I observed first hand in HIV clinics.        

I certainly hope that this group gets the credit for innovation and hard work that goes with this approach.  They mention a couple of other groups who have picked up on this approach.  At the same time I have concerns about how other groups may view this article.  The billing and coding system and clinic structures are generally not setup to allocate enough time to deal with two very complicated problems.  In the outpatient setting, sober homes set up to deal with the substance use and medical complications are extremely rare.  In some cases, sober homes and halfway houses refuse to accept patients taking Suboxone or other potentially addictive drugs.  It takes dedicated social work or case management staff to negotiate those problems.  It also takes some level of administrative support to know that discharging a patient as soon as possible when they are in opioid withdrawal makes little sense.

Time and burnout are also relevant factors.  The primitive state of productivity based medical administration needs to be able to accommodate this level of complex care and allot physicians enough time to provide both medical and addiction services.  I have over 20 years of experience in providing both medical and psychiatric services on inpatient settings.  Even though I enjoyed doing it - there was a tremendous time penalty associated with the additional work and that can easily lead to burnout.  If addiction care expands among specialists and generalists - they need the additional times and reimbursement to provide this level of care.

None of these considerations detracts from the accomplishment of this department of infectious disease doctors.  Taking on this additional role is especially striking in an era where patients are told that they can only discuss one problem per clinic visit with their doctors.  This approach is a shining example of the highest level of medical professionalism and my hat is off to them.


George Dawson, MD, DFAPA

1: Rapoport AB, Rowley CF. Stretching the Scope - Becoming Frontline Addiction-Medicine Providers. N Engl J Med. 2017 Aug 24;377(8):705-707. doi: 10.1056/NEJMp1706492. PubMed PMID: 28834479. (free full text).

Enhancing The Volkow-Collins Approach To The Opioid Epidemic

Nora Volkow, MD - Director of the National Institute on Drug Abuse and Francis S. Collins, MD, PhD - Director of the National Institutes of Health co-authored a paper on the role of science in the current opioid crisis.  Full text of the article is available free online from the New England Journal of Medicine at the reference given below.  In the article the authors review the scientific interventions at three levels of care in treating opioid addiction and use, treating and preventing overdoses, and the treatment of chronic pain.  The treatment of chronic non-cancer pain (CNCP) with opioids can be realistically viewed as the precipitant of this epidemic.  The brief 4 page review is a good rapid review of the science behind these interventions.  The level of cooperation between NIDA and NIH with private industry may surprise a few people but as the authors point out -  the level of mortality with the current epidemic needs to be approached with urgency at all levels.

At the level of opioid overdose prevention and reversal - more potent and long lasting opioid antagonists are being developed to counter exposure to fentanyl and carfentanil appearing at an increasing rate on the street.  Narcan Nasal Spray is probably the most effective and practical outcome of the industry-NIDA partnership.  A wearable device that can detect signals of an impending overdose and administer a μ-opioid receptor antagonist is mentioned.  At the level of addiction treatment methadone, buprenorphine, and extended-release naltrexone are all mentioned as current treatments for opioid use disorder.  Access to providers is discussed as a limiting factor.  vaccines and novel receptor approaches are discussed as potentially new pharmacological approaches to the problem.  New approaches to chronic pain are discussed in greater detail.  Cooperation between the NIH and industry is emphasized again in terms of getting these approaches to market and clinical use.  In the concluding section - the emphasis on NIH-industry partnerships is a central theme.  The argument makes imminent sense, but after two decades of rancorous debate about the effects of pharmaceutical company pizza on prescribing - this level of access to the highest level of taxpayer funded research is somewhat stunning.

But what else might be immediately useful?  I can concentrate just on buprenorphine and come up with a couple.  Anyone working with this compound and people who are addicted to opioids routinely encounters problems with its use.  It is common to treat people who still have withdrawal symptoms and cravings on the  recommended doses and remain at high risk for relapse even after being treated with what is described as one of the best current therapies.  Taking a look at the recommended dose range from the package insert:

The upper limit of the recommended dose is 24mg/6mg buprenorphine/naloxone per day for SUBOXONE. The reported lack of significant increase in brain mu‐receptor occupancy between doses of 16 mg and 32 mg implies that there should be little difference in clinical effectiveness at doses between 16 mg and 24 mg in most patients. When a patient expresses a need for a higher dose, consider the possible causes (e.g., environmental stressors or psychosocial issues that increase cravings or possible drug interactions). Before increasing the patient’s dose, explore other alternatives. Also consider the possibility that the patient may be exaggerating symptoms to obtain additional medication for diversion. (p 34-35).

And:

The recommended target dose is 16 mg buprenorphine/4 mg naloxone per day. Clinical studies have shown that this is a clinically effective dose. Although lower doses may be effective in some patients, for most patients, a 16 mg dose should alleviate withdrawal symptoms and block or attenuate the effects of other opioid agonists for at least 24 hours. (p. 34)

In clinical practice there is a wide range of effects to buprenorphine doses.  The FDA approved considerations show the subjectivity involved in adjusting the dose.  But that is even an understatement.  There needs to be a much greater investigation of the causes of continued craving and withdrawal symptoms when the patient is taking a recommended dose of buprenorphine.  This may be a genetically determined phenomenon either at the pharmacokinetic or pharmacodynamic level.  That is only partially accounted for by drug interactions.

Investigation of withdrawal symptoms and continued craving is more than just a passing concern.  It potentially determines who will be able to remain on maintenance therapy and stay off of heroin.  It is important because a significant number of these patients are being actively treated for psychiatric disorders with antidepressants, anxiolytics, atypical  antipsychotics and mood stabilizers.  How much of that medication use is due to inadequate treatment with buprenorphine and the common symptoms of insomnia, anxiety, and depression associated with opioid withdrawal.  These are all very complex clinical situations.  Many of these patients have a life long history of stress intolerance and there can be a reluctance on the part of clinicians especially if they have no mental health training to explore and treat those problems.  Once the patient has been indoctrinated into the idea that a maintenance medication is going to help them stay off heroin - it is a difficult transition to now say that all of these other factors are now important and need to be addressed.  That is especially true when some of the existing buprenorphine studies minimize counseling or are publicly presented as "counseling adds nothing to the results obtained with buprenorphine."  Finally, there is a large social media movement of people who want to stop buprenorphine and are warning others about it.  What is behind this widespread dissatisfaction and what needs to be done to resolve it?  The overall impression that all of the issues in this paragraph leaves is that buprenorphine is another heavily hyped medication that does not live up to the claims.  All of these areas could use much clearer input from NIDA through additional scientific investigation.

Additional studies on drug interactions with buprenorphine are critically needed.  I use a standard commercially available drug interaction software package.  Any time I enter a psychiatric medication I get a warning to consider to modify therapy and a list of 230 potential drug-drug pharmacodynamic interactions at the CNS level.  Since there is a high prevalence of patients on maintenance psychiatric medications this represents a deterrent to some physicians, especially if they are not psychiatrists and they are in a state with an unfavorable malpractice environment.

The next issue is determining who is susceptible to opioid overuse and dependence.  In my mind the phenotype is very clear.  The person who takes the first opioid tells me that they either "fall in love with it" or they experienced an intense euphoric and almost hypomanic effect.  They felt transformed by the medication into a person that they had always wanted to be.  Side effects are modestly effective deterrents, but I have been told that side effects and a complete lack of analgesia are acceptable in order to get the intense, euphoric high.  How can these people be identified?  The authors discuss biomarkers for pain and pain relief - but the single-most important biomarker would identify this high risk group of patients for addiction.  There are currently commercial databases out there that poll their members on various traits and symptoms.  Can NIH or NIDA design the polling questions and look for markers in these existing databases?

Even before that marker is identified, is there a simple strategy that could be used in clinical practice? Could a clinician tell a patient to self monitor for the intense euphoria and report back to the physician as soon as possible if it occurs?  Could the patient be told to just dispose of the pills by bringing them in to the pharmacy if euphoria and thoughts of dose escalation occur?

These are some thoughts that come to mind that might be immediately useful.  They would address both the limitations of medication assisted treatment and identifying the at-risk population for primary prevention of opioid use problems.                
    

     
George Dawson, MD, DFAPA

1: Volkow ND, Collins FS. The Role of Science in Addressing the Opioid Crisis. N Engl J Med. 2017 May 31. doi: 10.1056/NEJMsr1706626. [Epub ahead of print] PubMed PMID: 28564549.

Minnesota Street Drug Bulletin - Carfentanil

Opioids morphine (upper left) and hydrocodone (lower left) and synthetic opioids fentanyl (upper right) and carfentanil (lower right)

I don't know how widely known the issue with potent opioids  on the street is - but I am concerned that the information is not getting out to the people who need to hear it.  There are warnings that are read mostly by health care providers.  There are politicians talking about tougher penalties and legal approaches to solving the problem.  Like many people, I don't believe that the War on Drugs has been very successful.  At the same time, there are not many readily available options, there is a historical precedent for control of narcotics, and we will never know what the outcome might have been without legal action against illicit drugs.  I don't think that a failed War on Drugs means that there should be mass legalization of drugs.  The reason is obvious.  We are in the middle of an opioid epidemic that has been initiated and sustained by legal prescription opioids.  This epidemic says more about the nature of addiction than legal deterrents.  It is very clear that people with addictions will not hesitate to obtain what once were legally prescribed medications and use them.  It is very clear that designating legal addictive drugs does not reduce the black market for highly addictive drugs or create more tax revenues for governments - both common arguments for drug legalization.  All of these abstract arguments don't reflect what happens on the street.

I have personally talked with hundreds of opioid addicts over the course of my career.  In the 1980s and 1990s - there was a small population of users largely due to limited access.  Heroin and illicit opioid prices were relatively high and the barriers to use were also high.  Widespread exposure to opioids in high school was unheard of.  Most of the people I treated were part of a small, relatively fixed population of heroin users and some were on methadone maintenance.  That has all drastically changed in the last 15 years.

Now it is common for me to talk with young people in their 20s who were exposed to opioids when they got opioid prescriptions for injuries that used to be treated with ibuprofen or acetaminophen.  In some cases their peers in high school suggested they should try taking hydrocodone or oxycodone to get high.  In many cases those drugs were scavenged from unused medications in the family medicine cabinet.  Like many people in their teens and early 20s there is a cultural movement among users that they have a special body of knowledge about these drugs.  That reinforces drug taking behavior and keeps them in contact with people who are actively using and supplying these drugs.  In some cases it leads to mistakes in how the drugs are taken and what they are mixed with.  Drug users often have illusory relationships with drug dealers that makes it seem like these dealers care more about them than their friends and family do.  With continued and progressive use, opioid users might not notice how their judgment is more and more impaired - often to the point that they don't care if they die in the process of trying to get high.  To be clear, these people will deny any intent to harm themselves but get to a situation where they are using a questionable amount of drugs and realize it could be a problem but at that point they no longer care.  Heroin overdoses and deaths are common in small towns across America.  That was unheard of in the 20th century.

Against that backdrop - carfentanil has hit the streets in Minnesota.  Carfentanil is an extremely potent opioid that was never intended for therapeutic use in humans.  It is a large animal veterinary tranquilizer.  Its toxicity in humans is not disputed.  The most significant incident was the use of a gas that probably contained carfentanil in a hostage situation at the Dubrovka theatre in Moscow.  There were 40 Chechen rebels holding 912 hostages.  Russian security forces pumped in a gas that killed all of the rebels and 130 hostages.  The gas was described as a sleeping gas and later fentanyl.  Recent research suggests that the gas was a combination of carfentanil and remifentanil.  Some authors suggest that this was an anesthetic, but I have not been able to find any clinical application of this opioid in humans.  Potent opioids like fentanyl are used as anesthetic agents as well as pain medications.  

One of the ways that drug dealers amplify their profits is by taking a relatively inexpensive but potent product and diluting it down and selling the diluted product.  I have a previous post that shows how drug dealers can take $3800 of the synthetic cannabinoid AMB-FUBINACA and produce about a half million dollars worth of product containing about 64 mg of the original compound sprayed over shredded plant material.  I am not about to post how carfentanil can be diluted.  There are media reports that talk about how much more potent the drug is relative to both fentanyl and morphine.  Anyone trying to guess about how the raw drug can be cut is making a big mistake.  The amount of drug that can lead to a lethal overdose is so small that any non-uniform distribution in a powder or tablet can result in a lethal overdose.  The drug is so potent that even touching the powder can result in an overdose and health care workers have been warned not to touch the powder for that reason.

The problem is that carfentanil is being sold as a number of different products on the street. People are being given carfentanil as powders and tablets and being told that it is heroin, oxycodone, hydrocodone, and even benzodiazepines. This is an extremely dangerous practice and several Minnesotans have already died because of it.

Don't make the mistake of even trying opioids to get high. If you are currently addicted to opioids go to detox and get treatment. Don't make the mistake that you have another 5 or 10 years to get clean.  If you need to take opioids, get Medication Assisted Treatment with buprenorphine or methadone, rather than continuing to use what is available on the street.  With FDA approved medications used under a physician's supervision - you know exactly what you are getting.  The Minnesota Department of Health recommends education in overdose prevention and naloxone administration.

I can tell you that you can't trust what you are buying on the street.

But deep down you already know that.  Carfentanil is just another clear-cut example.



George Dawson, MD, DFAPA        


References:

1:  Influx of Fentanyl-laced Counterfeit Pills and Toxic Fentanyl-related Compounds Further Increases Risk of Fentanyl-related Overdose and Fatalities.

2:  Health Advisory: Drug Overdose Deaths Linked to Carfentanil Minnesota Department of Health Mar 31, 2017 12:00 CDT

3:  Carfentanil Medline references


Attribution:

All molecules at the top of this post were downloaded from PubChem and are in the public domain.




            

Why Buprenorphine Is No Panacea for Opioid Addiction - An Insider View

That's right - I am an insider in the current opioid epidemic.  I only treat people with addictions.  I am licensed to prescribe buprenorphine and have been for 10 years, but in my current position my role is to do independent psychiatric assessments and treat associated psychiatric comorbidity.  Opioid detox is done by addictionologists and the maintenance decision is made by a multidisciplinary committee.  In that capacity I see a wide variety of people who end up addicted to opioids and eligible for opioid maintenance treatment.  I see them in various stages of detoxification/withdrawal and maintenance.  I know what works and what does not work.  Forget what you read about from all of the politicians and administrators - buprenorphine containing products (Suboxone, Subutex, etc) are not a panacea for opioid addiction.  It takes more than a pill to stop an addiction to opioids and more importantly assist in long term recovery.  Forget what you hear about how cravings to use a substance not predicting future use.  I can predict who will be able to remain abstinent from a drug with a high degree of certainty.  Anybody who suggests that is not possible does not know what they are talking about.

What follows is a discussion of some of the factors that limit the utility of buprenorphine based products in the treatment of opioid addiction and the reasons for these limitations.  Before getting into it it I want to clarify that I do support the use of buprenorphine for the treatment of opioid addiction.  People on medication assisted treatment with buprenorphine are about twice as likely to remain off opioids as people without this treatment.  They are more likely to remain in treatment and are less likely to develop Hepatitis C seroconversion.  But there are a lot of factors that are not discussed along the way when politicians talk about widespread use of buprenorphine as the best way to address the current opioid epidemic.  I had thought about including a comprehensive table on results to look at the limitations but decided against it - due to complexity.  If you would like to see what that table looks like - let me know and I will finish it.  For now here are a few of the issues as I see it.

1.  Indefinite maintenance:  Nobody wants to be on indefinite maintenance medication - even people with known chronic medical conditions like hypertension and asthma much less opioid addiction.  The first consideration is that the person with an opioid addiction needs to view it as a chronic medical problem and most addicts do not.  That is especially true for addicts in their 20s who may have started using as early as their teenage years.  Their general attitude is that they will quit some day, but not before they have acquired enough time getting high.  That is nothing particularly unique in terms of the rationalizations that accompany addictions, but at this point in time mapped onto this demographic it may be a unique problem.  It certainly is not conducive to realizing the need to take a maintenance medication every day.  It is common in clinical practice to see a number of patients who stay on buprenorphine for a few months at a time and "go back to using heroin for a while."  The attitude about prescribing buprenorphine seems to be just to keep prescribing it and at some point a stable maintenance situation will result.  I don't think there is any evidence that will happen.  Since opioid addiction is generally a chronic condition going on and off maintenance would seem to be more likely than indefinite maintenance.  There is confusion among some prescribing physicians whether or not repeated relapses is a relative contraindication to future opioid buprenorphine use or it it means referral to a methadone maintenance clinic.  The real life problem is the patient who cannot tolerate withdrawal symptoms, may have a history of buprenorphine diversion, and has no easy access to a methadone program.    

2. Buprenorphine has definite street value:  Every opioid user knows this to be true.  Buprenorphine can generally be sold and the proceeds will result in being able to purchase 3 - 4 times the equivalent amount of heroin.  The other option is just to resume heroin and use the buprenorphine to cover heroin withdrawal when the drug is in short supply or there are not any reliable street sources.  As previously indicated this sort of diversion is a contraindication if the patient is using it as a consistent way to cover withdrawal from other opioids or to acquire other opioids. 

3. There are a small but significant number of users who can abuse the drug:

The original buprenorphine/naloxone combination preparation was designed to prevent intravenous use of the crushed buprenorphine tablets.  Since then, there has been some evidence that the naloxone component also reduces the euphorigenic component from buprenorphine and makes increased self administration less likely (1).  Patients maintained on low dose buprenorphine alone report positive subjective ratings with both additional intravenous and intranasal buprenorphine indicating potential abuse liability (2).  The combination buprenorphine/naloxone occurred after a number of overdoses in Europe and it confers decreased intravenous abuse liability, but it does not eliminate it (3).  In an earlier high dose study of intravenous and sublingual buprenorphine doses up to 16 mg in experienced opioid users produced consistently positive but variable mood effects.   In morphine maintained heroin users intravenous buprenorphine was the only opioid not administered at levels greater than placebo compared with intravenous fentanyl, oxycodone, or heroin (4).  That is an expected effect due to the partial antagonist effect of buprenorphine.  The authors comment that in research setting buprenorphine inconsistently precipitates withdrawal in opioid dependent subject in research settings.  For example moderate to severe withdrawal occurs in subjects taking 60 mg/day of methadone but no to mild withdrawal (from 2 and 8 mg buprenorphine doses) in subjects taking 25-30 mg/day of methadone.  Other studies  looking at rapid dose induction in heroin dependent men resulted positive ratings and experiencing the buprenorphine as an opioid agonist rather than an antagonist.  This same variability is noted clinical, largely by patient history and there seem to be a small number of patients who can escalate the dose beyond the theoretical ceiling due to opioid antagonism.  There is limited information on escalating the oral dose of buprenorphine or buprenorphine/naloxone.  In one study (5), 19 subject were maintained on 4 mg/day of buprenorphine alone and then were given 2 mg increments at 2 hour intervals for a total of three doses of buprenorphine alone.  In this study the authors thought that abuse liability based on subjective ratings was low.   All of this variability can be observed at the clinical level and it is very important that the prescribing clinicians know the individual and their response patterns very well.  

4. The existential condition of 20 year olds:    

One of the unique aspects of the current opioid epidemic is the number of young people that it affects.  Unused medicine cabinet opioids have been identified by the CDC as an important gateway drug to heroin use.  Using prescription opioids increased the likelihood of heroin use 55 times.  This same cohort is caught in a culture that is swinging toward increased permissiveness of substance use with broadened legalization of cannabis and excessive stimulant prescriptions for attention deficit~hyperactivity disorder and a subculture of performance enhancement in colleges and universities.  One of the logical extensions of these cultural currents is to see drugs as a solution to a problem and opioids are viewed as being no different.  A unique aspect of alcohol and drug taking in American culture has been that the early twenties is a time to do it and get it out of your system.  A large number of young opioid addicts who continue to use and routinely go off and on buprenorphine maintenance will say that they felt like they were too young to stop using.  They wanted to keep on going for a while before they stopped.  Most 20 year olds have a sense of invulnerability and that also plays a role in the use of dangerous drugs and alcohol.              

5.  Inadequate dosing

One of the main lessons that an addiction psychiatrist learns early on is that opioid use and withdrawal is a great mimic of psychiatric conditions specifically insomnia, anxiety and depression.  Practically everyone in withdrawal experiences these syndromes at one point or another.  There is a natural tendency during a psychiatric interview to describe practically all of the recent history as being dominated by the withdrawal symptoms.  Conversely, when the correct dose of buprenorphine is prescribed all of the insomnia, depression, and anxiety clears and it clears completely.  There are no associated psychiatric problems and the patients does not need any additional pharmacological therapies.  This cannot be emphasized enough because opioid users will naturally end up on benzodiazepines and z-drugs for sleep and anxiety and both are contraindicated with opioids.  Even antidepressants are a potential problem due to case reports of buprenorphine based products and antidepressants causing serotonin syndrome.  That is an admittedly rare syndrome, but potentially very serious if it occurs.        

The second issue is dose adequacy in terms of cravings about opioids.  By definition cravings are an intense urge to use opioids.  At the height of opioid withdrawal they occur with the withdrawal symptoms.  As buprenorphine maintenance is established they may occur at times during the day when there are breakthrough withdrawal symptoms.  Eventually even when the acute withdrawal symptoms are treated cravings can persist.  The ideal response is that cravings to use are eliminated as well as any thoughts about using or acquiring opioids.  This is possible during treatment but results vary from person to person especially as the physician attempts to establish the proper maintenance dose of buprenorphine.  In my experience cravings and intense thoughts about using are poor prognostic factors due to heightened relapse potential.    

The subpopulation of people addicted to opioids from chronic pain treatment can generally benefit from seeing physicians with expertise in pain management with buprenorphine preparations.  It may require split dosing and other adjustments.

6.  The lack of appropriate prescribing 

This can occur in several ways.  There can be a lack of physicians who are licensed to prescribe buprenorphine.  There can also be physicians available to prescribe it who are not able to maintain patients on the drug.  Finally there are physicians who are overcharging for the services they provide and that leads to patient dissatisfaction and discontinuing the buprenorphine strictly on that basis.

All of these problems can be addressed.  They can be addressed by providing good medical care.  They can also be addressed by addressing the 30 year old problem of rationing services for addiction and mental health services.  Any person going in to be seen by a physician for opioid use problems needs to feel like they are understood.  They have to be able to communicate with that physician about their addiction.  They have to know that their physician understands addiction and is not just there to provide prescriptions.

Treating opioid addiction is more than prescribing a medication.  It requires a relationship  with a competent physician.  That competent physician needs to be technically competent to prescribe the drug and discuss all of the above issues with every patient with an opioid addiction and every one of those patients who will take buprenorphine.

That is the same as the general plan for just about any complex medical problem.      

George Dawson, MD, DFAPA

References:

1: Jones JD, Sullivan MA, Vosburg SK, Manubay JM, Mogali S, Metz V, Comer SD. Abuse potential of intranasal buprenorphine versus buprenorphine/naloxone in buprenorphine-maintained heroin users. Addict Biol. 2015 Jul;20(4):784-98. doi: 10.1111/adb.12163. PubMed PMID: 25060839.

2:  Jones JD, Madera G, Comer SD. The reinforcing and subjective effects ofintravenous and intranasal buprenorphine in heroin users. Pharmacol Biochem Behav. 2014 Jul;122:299-306. doi: 10.1016/j.pbb.2014.04.012. PubMed PMID: 24793093; PubMed Central PMCID: PMC4094364.

3: Comer SD, Sullivan MA, Vosburg SK, Manubay J, Amass L, Cooper ZD, Saccone P,Kleber HD. Abuse liability of intravenous buprenorphine/naloxone and buprenorphine alone in buprenorphine-maintained intravenous heroin abusers. Addiction. 2010 Apr;105(4):709-18. doi: 10.1111/j.1360-0443.2009.02843.x. Erratum in: Addiction. 2010 Jul;105(7):1332. PubMed PMID: 20403021.

4: Comer SD, Sullivan MA, Whittington RA, Vosburg SK, Kowalczyk WJ. Abuse liability of prescription opioids compared to heroin in morphine-maintained heroin abusers. Neuropsychopharmacology. 2008 Apr;33(5):1179-91. PubMed PMID: 17581533.

5: Singhal A, Tripathi BM, Pal HR, Jena R, Jain R. Subjective effects ofadditional doses of buprenorphine in patients on buprenorphine maintenance. Addict Behav. 2007 Feb;32(2):320-31. PubMed PMID: 16814937.

6: Umbricht A, Huestis MA, Cone EJ, Preston KL. Effects of high-dose intravenous buprenorphine in experienced opioid abusers. J Clin Psychopharmacol. 2004 Oct;24(5):479-87. PubMed PMID: 15349002.

The Reality Of Burprenorphine Therapy

It is increasingly popular for politicians and healthcare businesses to discuss their ideas about how to end the opioid epidemic that they started.  One of the common themes is widespread availability of both buprenorphine maintenance therapy and naloxone opioid antagonist therapy for acute overdoses.  I am certainly not opposed to either and in fact work in an addiction treatment environment where these are two of several medication assisted therapies used to treat addictive disorders.  I am skeptical of the idea that broad prescribing of these therapies in either primary care clinics or some treatment settings will ever occur.  Naloxone will be more readily available because there is a movement to create easy access without a prescription.  That will never happen with buprenorphine.  Last week - an article in JAMA backs up my skepticism (1).

The JAMA article looks at 3234 buprenorphine prescribers in the 7 states with the most buprenorphine prescribers.  In their introduction the authors talk about the policy initiatives to increase the maximum patients per prescriber from 30 to 100 patients after a year.  The average monthly patient census per month varied from 7 - 22 patients and a median monthly patient census of 13 patients.  The duration of treatment episode was 53 days.  This illustrates that the monthly census was well below the allowed limits and the duration of treatment was well below the recommended maintenance guideline of 12 months.  They cite evidence that novice prescribers wanted more access to substance use counselors or other prescribers with more experience as potential limiting factors.

The authors of this article do not offer other explanations for the low rate of buprenorphine prescribing.  I have a few.  I really do not like stigma arguments.  To me stigma seems like an excuse for not being able to overcome societal biases toward a particular problem.  I don't see how you can train to be a physician and not have most of these biases wrung out of you.  With addictions and mental illnesses there may be a stronger bias based on personal experience.  Some physicians may have come from a family where the the father was an alcoholic or a heroin addict living homeless on the street and everybody was used to that idea.  Some physicians may have come from families where the father was still drinking and dying of cirrhosis and the familiy opinion was that he "has a right to drink himself to death" rather than get treatment that he did not want in order to stop drinking.  Other physicians may have come from families where father and his father both had severe alcoholism.  Grandfather drank himself to death by the time he was 50.  Father got treatment for his alcohol problem and was in stable recovery for years.  All of these personal experiences and the reactions to them will affect how a physician approaches alcoholism and addiction.

Those biases are all part the the inevitable decision-making process that leads physicians down specific career paths.  I have lost count of the number of times that another specialist told me that they really liked psychiatry and were considering the residency except for certain features of the field.  A couple of examples include needing to try to predict suicide and aggression and live with the consequences or dealing with a certain diagnostic group like patients with severe personality disorders.  People are less specific about addictions, probably because as medical students and interns we all see the severe effects.  Most of the acute care hospitals where physicians train have 30-50% of their admissions based on the acute effects of alcohol or drug use.  That includes many admissions for acute hepatitis, hepatic encephalopathy from cirrhosis, acute alcohol poisoning, acute overdoses on addictive drugs, and various psychiatric morbidities like delirium and psychosis from the acute effects of addictive drugs.  It is less obvious but addictive drugs and alcohol are also overrepresented as reasons for admission to surgical trauma units and burn units.  Most interns and residents see these effects first hand and develop both short term and long term perspectives on these problems.

This seems like another case of managers and politicians not appreciating the intense interpersonal aspects of medicine.  Physicians are all not foot soldiers just waiting for the next assignment from a policy maker.  Physicians have probably carefully selected the type of practice they want to be in and there are more than the technical aspects of the speciality that were considered.  It takes a unique skill set to treat people with addictions.  Treating and maintaining an opioid addict in treatment long enough with buprenorphine maintenance for them to realize any benefit is a very unique skill.  Being affiliated with other buprenorphine prescribers is also a necessity to provide cross coverage for patients.  Speciality care centers for addiction seem like an idea to me that does not get a lot of consideration.  Trying to run a buprenorphine maintenance program in a practice environment that is rationed to the degree it currently is does not seem feasible to me.  Adding buprenorphine maintenance as just another task for a busy primary care physician practicing primary care medicine is not likely to work.  It should be obvious that these physicians have  more than enough to do right now.

There is a lot more to it than increasing the maximum numbers of opioid addicted patients on buprenorphine maintenance and trying to treat as many people as possible.  The data from this paper illustrates that.  There is also the issue of the preventing the pool of opioid users from increasing while trying to treat those who are currently dependent on these drugs.  That seems like the best long term option to me.

Addressing this complicated problem takes more than a licensed buprenorphine prescribing physician sitting behind a desk who is willing to prescribe it.  It takes better infrastructure including managers who are enlightened enough to get that physician the kind of resources they need to do the work.  I never hear politicians or policymakers talking about that.


George Dawson, MD, DFAPA


Reference:

1: Stein BD, Sorbero M, Dick AW, Pacula RL, Burns RM, Gordon AJ. Physician Capacity to Treat Opioid Use Disorder With Buprenorphine-Assisted Treatment. JAMA. 2016 Sep 20;316(11):1211-1212. doi: 10.1001/jama.2016.10542. PubMed PMID: 27654608.