The Fake Opioid Crisis
The Fake Opioid Crisis
As a physician practicing for over 40 years, I can’t comment on all opioid users or all prescribers, but I can comment on my own experience. Seven years ago, when I relocated to small rural community, I was faced with taking over 400 surprise narcotic patients. The more I thought about it, the more I became convinced that I could manage the challenge.
Since about half of these patients were in a nursing home, I thought I would tackle those people first because they probably hadn’t asked to be on opioids. After four months at the nursing home, I had reduced the opioid subscriptions by 200, halving what I started with. Next, I recruited two nurse practitioners to become certified in prescribing buprenorphine. Then I worked with the clinic receptionist to accept fewer new patients who were seeking opioids. Within one year, we had reduced the 400 opioid patients down to 50.
Some of the opioid patients were relatively new and easy to send back out of the practice. Yes, many patients were old farmers whose backs, knees and hips had given out, farmers who were not surgical candidates and could be maintained on a low, steady opioid dose. With the opioid meds, they could live in their own homes, do housework, make a garden, mow their grass, vacuum the floors, and repair their screen doors. These patients remained on a steady low dose of opioids and presented monthly for refills. This was a win-win for everybody. Because they remained active enough to remain at home, we saved the county lots of nursing home dollars and the patients were happier too.
There were, however, 50-year-old patients who had been on opioids for 20 or 30 years. Many of them had migrated to North Dakota from California and Kaiser Permanente. All I could do with these patients was to maintain them on the lowest doses possible and recognize that sometimes things are as good as they can get. Everybody who manages these patients knows how complex and difficult it can be. We have all seen sad situations where these meds are totally withdrawn and families disintegrate. There is a retreat to illegal drugs, food becomes scarce, windows are broken, heat is turned off, parents are arrested and put in jail, and children are taken away. It’s hard to say that such situations are an improvement over carefully metered opioid dosing.
Just sending these patients out of a practice to fend for themselves is neither a good nor a responsible idea. After five years, I had reduced the number of opioid patients from over 400 to 15, but that was as low as I could get the number of patients without participating in their demise. Getting some opioid patients to physically and emotionally withdraw from drugs is not a matter to be taken lightly. It can result in death. So, once we see them in the office, we have some responsibility to not participate in their deaths, one way or another, either by omission or commission.
Enter a spiteful CEO who resented my inability to support some of his ideas. He knew how much work I had done to manage these patients responsibly, with neither too little nor too much medication. In his anger over my not doing his biddiing, he called the DEA, which seemed unable to notice that I had managed well the decrease of the 400 opioid patients to 15 with no deaths from over-medication or under-medication. In my experience with the DEA, it sees “criminals” under every bush. The DEA individual reviewing my opioid prescriptions, without telling me what he was concerned about or allowing me to respond to his concerns, took my DEA certificate. In his own words, “We can do this the easy way or the hard way.” Knowing the propensity of the DEA to slash and burn, I quietly gave in.
Unfortunately, within four months, a 33-year-old childhood onset diabetic and a 38-year-old lady with disseminated intravascular coagulation (DIC) died at home. I had successfully managed these patient’s medical problems for six years. It’s hard to say that these patients are better off after having been “rescued” by the DEA. The actions of the DEA are the proximate cause of these two deaths. Unfortunately, there is no fiduciary responsibility for the DEA and no way to hold the DEA responsible for what is essentially death by failure to treat.
All responsible providers know that patients on opioids can die from treatment or from lack of treatment. One way or another, we as physicians can step on a legal or ethical landmine. Knowing that, we try to stay in the middle. The false dilemma comes from the false assumption that there is some kind of magical connection between prescribing opioids responsibly and the use of illegal opioids. In my experience if people can get legal opioids, they will not seek illegal drugs.
We all know that street drugs kill, but to my knowledge, no one has looked at the fact that the lack of legal drugs can lead to death. At least with legal drugs, we can help prevent patients moving on to illegal drugs which can contain all kinds of contaminants, including fentanyl.
In my over 40 years of managing patients with opioid use, I had had no patient deaths until I could no longer treat my patients with carefully monitored legal opioids.