A pain doc explains how she has to lie to prescribe Buprenorphine

princeThis is from “Under The Influence.” It’s by a doctor who writes prescriptions for buprenorphine. For pain. For addicts temporarily but for pain patients indefinitely. She wanted to speak out.

This practitioner calls Suboxone a ‘stealth’ drug. Read it. You’ll see. There is not a lot of press coverage on the use or lack of use on this drug. There is an alliance organization that matches people up with doctors but it says the limitations on how many patients a doctor can treat at one time…waiting lists, they say it’s easier to just get placed in a research study.

Doc, I need some help getting off this stuff.”

My new patient Marshall*, a pale 63-year-old man who lugged around a portable oxygen tank for his breathing problems, had been stuck on pain pills for years. Sharp pain from a gruesome factory injury to his shoulder 25 years ago had evolved into a nightmarish, shock-like nerve pain down his arm to his fingertips. A succession of medical treatments culminated eight years ago in prescriptions for daily use of oxycodone.

It had worked well at first. But after a few years, he descended into a continuous state of opioid withdrawal. At best, he felt mildly anxious and tremulous. Two hours after each dose, he would skid into a wretched state of sweats, gut-knots and dread. His whole body screamed with a pain unrelated to his injury. He craved relief from the next dose.

Sometimes, out of desperation, Marshall would take the next dose early. In exchange for the immediate comfort, he would accept a guaranteed anguish starting days before the next refill was due. His previous doctor had attempted to help by increasing his dose. Symptoms would subside for a month or so, then return with a roar, growing ever more intense. His arm pain had been relegated to a minor annoyance.

The best solution to his cyclical torment was clear to me. I would transition him to a medicine called buprenorphine.

Opioid task forces springing up in the US at the local and national level have begun to cast a spotlight on the surging opioid epidemic and its deadly consequences.

Unfortunately, a sharp focus on the target of opioid “abuse”—non-medical use of pain pills that has led to addiction in an estimated 2 million people in the US, and to heroin use in 1 million—misses a fundamental problem of a much larger scale. Roughly 17 million US adults living with chronic pain are prescribed opioids for daily use. Many, perhaps most, are not thriving.

Yet without these pills, many find life intolerable. Neither patients nor doctors know what to do about it.

A readily available solution—buprenorphine—is a secret weapon largely still waiting to be discovered. And President Obama’s strong emphasis this week on medication-assisted treatment—especially buprenorphine—in his announcement of his plan to combat the opioid crisis, is therefore particularly welcome.

As a family physician, I am in the trenches with patients battling chronic pain. I have seen Marshall’s story played out again and again. Sometimes people are referred to me for help after limping along on opioids for years. Buprenorphine is often the best choice.

Some make the transition seamlessly. Others traverse a rocky road that tests their mettle. Ultimately, most arrive at our intended destination, experiencing a calm normalcy they can hardly believe. A tolerable vestige of their original pain is still present. Opioid withdrawal and its accompanying super-pain, sometimes known as “opioid-induced hyperalgesia,” have vanished.

Patients describe a sense of release from a box or a locked cage. One said, “I felt like a little troll trapped inside a bottle, a horrible feeling. And now I’m free. I’m absolutely thrilled.”

Buprenorphine is better known by one of its brand names, Suboxone, an under-the-tongue film laced with naloxone to deter non-prescribed use. In 2002, buprenorphine–alone or combined with naloxone—was approved by the US Food and Drug Administration as a treatment for people like another of my patients, Luke.

A gentle giant in a black leather jacket, Luke is a 20-year-old convenience store employee who casually enjoyed a Percocet now and then while hanging out with friends. Then he began enjoying one for relaxation daily after work, “like having a beer or two.” Eventually he found himself entangled.

To avoid the agonizing withdrawal symptoms, Luke began spending most of his income buying pills illegally. He risked arrest. He arrived late for work. He could not afford to move out of his parents’ home. The drug’s negative impacts on his life landed him the diagnosis of opioid use disorder—the latest medical term for the condition most people recognize as addiction.

Buprenorphine is often, in my experience, like a magical key that frees people from their seemingly inescapable dungeon. It is an opioid medication with a unique profile that fits the lock precisely. It blocks withdrawal symptoms and craving. There is no drug “high.” Patients trade sluggishness for a fresh energy. Best of all, the hovering risk of overdose death vanishes.

Buprenorphine was developed decades ago and approved by the FDA in 2002. Yet it remains nearly invisible, despite its potency against a fiendish trio of adversaries: withdrawal symptoms, craving and overdose death. That’s why I call it the Stealth Medicine. It is hidden behind the term “medication-assisted treatment,” which also includes methadone and naloxone. Buprenorphine is the only one doctors can use to treat opioid use disorder in their patients with chronic pain.

Any doctor can prescribe buprenorphine for opioid use disorder, after undergoing a brief training required for authorization, known as a “waiver,” from the Drug Enforcement Agency. Only a tiny minority obtain the waiver, however. Due to federal rules, the number of patients each one can treat is strictly limited—to 100, although President Obama’s plan will increase that to 200—and other prescribers (nurse practitioners and physicians’ assistants) are not eligible for a waiver.

Ironically, there is no such bottleneck on access to the opioid pain pills involved in the deaths of 19,000 people in the US in 2014.

Read more from The Influence:

Meet the Victims of Russia’s War on Methadone

The Anatomy of a Heroin Relapse

…and follow us on Facebook and Twitter.

There are strict rules constraining use of the waiver. For one thing, the patient has to have a diagnosis of opioid use disorder. This diagnosis implies a stark but false distinction between “legitimate pain patients” like Marshall and “drug abusers” like Luke.  The same dreadful craving afflicted Marshall, who lost his struggle to use pills as prescribed, and Luke, who never had a prescription. Buprenorphine brought relief to both.

“Off-label” prescribing for chronic pain is perfectly legal without a waiver. The limited research available supports this practice: It shows that a switch to buprenorphine improves pain and quality of life.

But here’s the catch: Without a diagnosis of opioid use disorder, buprenorphine is rarely covered by insurance. With the diagnosis, it usually is. Under Obamacare, insurance companies must provide coverage for treatment of substance use disorders. Luke pays roughly $10 per month for this otherwise pricey drug, which can run to hundreds of dollars without insurance.

The case of Marshall, the patient with arm pain, illustrates the awkwardness of this situation. He never once used opioids for euphoria or relaxation. He never committed a crime, never harmed a relationship with family or friends, never even pressured his medical providers to obtain more of his drug. A diagnosis of opioid use disorder was a stretch. But I made the diagnosis based on his unwelcome craving, and his inability to resist taking doses earlier than scheduled despite known consequences. This diagnosis allowed him access to this life-saving treatment.

Other insurance quirks can create frustrating obstacles. Lily is a trim and perky middle-aged homeowner, a responsible caregiver to two grown children with special needs. For years, Lily had been prescribed oxycodone for arthritis in her spine. She described what happened.

“The longer you take them, the more they make you hurt. It creates pain. You get tolerant to it. And then you think, I’ll take just a little more, and then you take a little more, and pretty soon you hurt worse than you did before you started taking them. The brain creates this fake pain, a magnified pain that really isn’t there. In between doses you would get a depressed feeling, because you knew you weren’t supposed to take another dose, but you hurt, and this becomes cyclic. When you take buprenorphine, you get your whole mental stability back. You don’t have to worry about driving or feeling dopey. It gives you your life back on a plate.”

Since starting buprenorphine for opioid use disorder, Lily had begun walking two miles a day. For two years, she often had no pain at all. Insurance coverage was in place.

Then the insurance company discovered she was not enrolled in a chemical dependency program. She was thus deemed noncompliant with their requirements for buprenorphine coverage. Payment for the next refill was denied.

A formal treatment program would be overkill even for a patient like Luke, the convenience store employee, although he could certainly benefit from having a counselor. But what about Lily? Such a program would be an irrelevant intrusion.

I re-prescribed buprenorphine for Lily, this time using a diagnosis of pain. Coverage was denied. I appealed. Ultimately I talked with the medical director. He politely informed me, “Buprenorphine is not a good medicine for chronic pain, so it is not an option for your patient. But we will cover oxycodone.” Lily has since switched to a more flexible insurance company.

Robin, a stylish business executive, got coverage because she met criteria for opioid use disorder; after discovering buprenorphine’s unique effectiveness for her fibromyalgia, but before she found me to prescribe it, she had guiltily resorted to buying it off the street.

But what about Sally, a sweet 50-year-old lady on opioids for many years after an injury to her lower back? In a classic example of opioid-induced hyperalgesia, she described intolerable shoulder and neck pain after a demanding night at the community center playing bingo. She has always been meticulous about using her pain medicine as instructed, so she doesn’t meet criteria for opioid use disorder. But with exaggerated pain sensitivity, she might still benefit from buprenorphine.

The tides are turning. Many national leaders are now recognizing opioid addiction as a disease and not a crime. Now we need a more nuanced view of the challenge people face when their chronic pain is poorly controlled by opioids. Many struggle to use their prescribed pain pills as directed. Whether they succeed or fail, buprenorphine may improve their quality of life.

A sea change would be possible if millions of patients with chronic pain were switched to buprenorphine from daily pain pills. This would dry up the flood of opioids leaking out to the streets. Fewer young people would find pills and be tempted to try them. Fewer still would graduate to a gritty life of heroin use, or risk a death from overdose.

Doctors, patients, insurers and policy makers: Take note.

*Patients’ names have been changed.


Lucinda Grande, MD is a board-certified family physician who practices in Lacey, Washington. She specializes in chronic pain and addiction medicine. She has prescribed buprenorphine for opioid use disorder for four years, and currently prescribes it to 70 patients.

 

My Friend Dyane…take a look. All her efforts at advocacy is paying off for her and others…

Successful Working Mother Battles Bi-Polar Disorder

 

How do women measure success? Is it by mothering and having a career? How do they carry out both forms of work to their satisfaction? What helps? What hurts?

This is a weekly series about successful women who participate in the workforce in a range of ways building their careers while mothering. These women fly under the radar of the media but need to be heard. They are silently successful and warrant recognition. They are compassionate, persistently hardworking women who deserve our admiration and offer advice to new mothers. Each week I will spotlight a different remarkable woman.

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Dyane Leshin-Harwood has two daughters, ages 3 and 10. She is a successful free-lance writer, author of Birth of a New Brain – Healing from Postpartum Bipolar Disorder to be published in the fall of 2017. She is also the founder of Depression and Bipolar Support Alliance (DBSA), Santa Cruz County, CA, and a member of the International Society of Bipolar Disorders, the Marce Society for Perinatal Mental Health, Postpartum Support International.

After Dyane’s second child was born she was faced with a postpartum health crisis, diagnosed with bipolar, peripartum onset, also known as postpartum bipolar disorder. She tells her story with deep devotion to her children and compassion:

“My mothering and writing fell to the wayside for the next seven years as I suffered through seven psychiatric unit hospitalizations, took over 30 medications to no avail, and requested two round of electroconvulsive therapy which I credit with saving my life. I tried my best during those years to be an attentive mother to my young girls, but I was a depressed shadow of my former self most of the time. Despite my guilt for not being the mother I hoped to be during those years, all I can do now is prioritize my hard-won mental health stability and be there for my family as a present and loving parent.”

Dyane describes the importance of motherhood to her while building her career:

“I always wanted to be a mother. Being a mother has literally saved my life. If not for my daughters, I wouldn’t have asked my husband to take me to the E.R. when I was acutely suicidal. I don’t take being a mother for granted – it’s a gift, an opportunity…and while I won’t lie and say it’s easy (with two daughters close in age who are either best friends or fight like little banshees, it’s never easy!), I’m profoundly grateful to be a mom.”

“At forty-five, I’ve maintained mental stability for over two years which has allowed me to be an involved parent. I consider this to be a profound achievement due to my lengthy battle with postpartum bipolar disorder. Landing my book deal has been an incredible privilege and I can’t wait to see my book through to completion. I created a support group for women with postpartum mood disorders that is going well. It has been fulfilling to see other women who suffer with depression, bipolar, anxiety, and trauma come together and support one another.”

Dyane has advice for new mothers with mental disorders who want to embark on careers while mothering with a significant support system:

“As a mom who runs a support group, I’ve witnessed the power of finding support and empathy with other mothers. There are Meetup.com groups for working mothers, for both new moms and those who are a bit more experienced. There are support groups associated with the maternity wings of hospitals as well. I’d call the closest maternity hospital for referrals. If you’ve suffered with postpartum mood disorder, Postpartum Support International is a fantastic resource for groups. “

Please leave comments for Dyane, a mother, writer, blogger and mental health advocate. She’s been honored as a “Story of Hope of Recovery” by the International Bipolar Foundation, a “Life Unlimited” by the Depression and Bipolar Support Alliance, and a Psych Central Mental Health Hero.

In sum, Dyane says, “I write to share and connect with other people worldwide who have suffered with bipolar disorder like I have. I write to help other moms know they aren’t alone with their perinatal mood and anxiety disorders. Follow Dyane @birthofnewbrain on twitter.

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Laurie Hollman, Ph.D. is a psychoanalyst with a recent book, Unlocking Parental Intelligence: Finding Meaning in Your Child’s Behavior, found on Amazon, Barnes and Noble, Familius and wherever books are found.

If you would like to participate in this series as a successful career woman and mother, contact Laurie and she’ll be glad to include you.

I Read Scott Weiland’s (Stone Temple Pilots singer songwriter) book

 

 

albumcoverI just finished Scott Weilands’ (former singer-songwriter for Stone Temple Pilots) memoirs.

 

Alcohol- being a self confessed, resigned to his fate drunk was his last vice and it’s what ultimately led him back to crack, which he felt cocaine as an evil drug that conjured up negative forces (I concur with that it happened to me in the 80s).

 

He had congenital cardiomyopathy, his brother died of crack and cardiac arrest and so did he.

 

This guy was a poet. His lyrics didn’t make sense but they did. And so many of his lyrics were about ‘selling out.’

 

“I’m not dead and I’m not for sale.”

“What’s real and what’s for sale.”

 

He married a supermodel who was also a drug addict and bipolar but to bear children she needed to stay straight, which she did.

 

She left him and was interviewed in bipolar magazine which is why I thought they would like my story about him.

Out of my mind with atypical antipsychotic related metabolic issues

Hi, it’s Allison.

 

I know your time is valuable which is why I’m hoping you’ll accept my check for reading and evaluating this letter about my metabolism.

I’m really strugging.

On a day to day basis, I journal my food and my hunger level. I’m rarely satiated-famished all day with a hunger level of 7. It’s hard to focus on anything, especially my writing and/or daily duties like hygiene and self-care when all I do is prepare healthy food to carry around with me so I can eat every hour.

The hunger is worse when I take my Metformin. Why do you think that might be?

Eating, even low carb meals makes it worse. I can’t figure this out and need your help.

I don’t have hunger pangs but a feeling of jittery irritability and the feeling that I’d do anything to get some food. Not sugar necessarily but I did faint recently in Kohl’s and had to eat half a candy bar.

So the only time I’m able to do anything with a clear is in the morning before I’ve eaten. It’s my ‘golden time.’

It’s hard to ‘do the right thing’ when the right thing makes life harder.

As you know, I’m on Clozaril, the drug causing this metabolic problem. But it helps me greatly with Tardive Dyskinesia, stabilizes my moods, helps me sleep predictably and regularly, even though I’m in pain most of the time.

I know you recommended I try Saphris or Latuda but those drugs likely as heck, according to my shrink, would aggravate my TD the same way Invega, Invega IM, Geodon, Risperdal and Zyprexa did. At the end of a three year period of no symptom control, even the sedating seroquel aggravated the tic, or rather; thrashing. Forget about sleep or signing my name. It was a horrible period of time.

I am one of the unlucky few who can’t take the highly effective first line treatment Benztropin (Cogentin).

I pay a high price for TD symptom relief beyond metabolic difficulties. Weight management is epic. Thank god I love exercise (weight train and 8 hours of cardio a week), and changed my diet to 95% raw foods.

I have monthly blood for absolute neutrophils and WBC, had to reduce my Enbrel for psoriasis and have to really take care of myself to have good labs. It’s a pain in the but safety protocol Teva and the other generic giants have in place to prevent agranular cytosis. (sp?)

As for your suggestion that I ‘get off Clozaril,’ I’ve tried. I put myself in intensive outpatient so I could try in a supervised setting. First we tried Invega, Seroquel, Risperdal, Abilify and Zyprexa, all of which aggravated my symptoms even more. You probably already know that atypical and traditional antipsychotics as well as Reglan cause Tardive Dyskinesia in the first place.

This is totally illogical but when one removes the causal drugs, even carefully titrating lower and lower there’s this “Withdrawal Emergent Syndrome” where the symptoms are wildly worse. I was admitted to the ER three times for this and as you might imagine, the ER docs just wrung their hands, shaking their heads. You’d have thought they were the ones in observation from the looks of their faces!

I’ve had bipolar I since my first full blown manic episode in ’89. For a long-termer like me, Lithium would have been worse. I’m glad it’s my only drug allergy or I might be on dialysis by now, much worse than what I deal with currently.

I need you to help me buy time on this metabolic thing, help me delay the progression. (Hopefully until after I die).

I’ve already had five foot surgeries (Fusions bilateral and more) from professional sports overuse injuries (pro beach volleyball in LA), and I really like what’s left of my feet!! LoL!

Is there any way that I could have my blood sugar levels monitored more frequently as I employ changes in my weight training, diet, herbs and other holistic approaches? I’m finding Cinnamon helps with the hunger but online the reports are mixed. You’re pretty advanced and I think you could really help me delay diabetes.

I might even try pancreatic supporting chiro and possibly acupuncture. But first I need to find out if my Metformin is too high or why I’m starving all the time.

I’d like to do this and ask you if you think I should see an endocrinologist.

Thanks so much for reading my missive. My shrink says I’m an ‘exotic.’ Thank God he puts up with me. I’ve stayed out of the inpatient psych ward for sixteen terrific years save a few long term bipolar depression relapses. Now that I’m writing for four different mags, life is pretty good, except when I’m hungry all the time!

 

Sincerely,

Allison Strong

 

Comments anyone? Anyone else out there struggling with these issues? I really hope to buy time until science catches up to this problem. Believe me, they’re scrambling. There’s just too much good money to be made!!!

Kurt Cobain,RIP and I truly mean it.b

Kurt Cobain,RIP and I truly mean it.

Heck Montage was released this week. We can see it on HBO Monday Night. Can’t wait.  The director has a good track record documenting enigmatic icons with conflicting swirling stories about them. It’s a documentary during Which Courtney Love and her daughter went to court over rights, etc.  Filming had to be shut down here and there for periods of a year or more.

But the documentary apparently features great images and clips of the band playing live. I’ve heard that he had chronic stomach pain and some sort of depression. Hard to tell,  though with all the drugs in his system. HeWANTED to do it. Somepeople try to commit suicide as a cry for help. He didn’t.  I’ve done some research since posting this on Twitter and am going to do a blog on what I know after watching the documentary.

Montage of Heck: More Questions.than..

Montage of Heck: More Questions…than

The HBO Documentary, thought truly Avant-Garde left me with more questions than answers. They seemed so happy. But maybe he felt he wasn’t the man he needed to be: the father, the rock star, the provider, and the husband. I thought they really minimalized Courtney’s would-be affair. Betrayal is betrayal, be it in the mind or body, methinks, Nirvana’s “All Apologies” is one of my favorite songs ever.