Pain Management, Part II: Opiate Addiction

This country is opiate happy (and pretty much has been since the 1800s). From hydrocodone to heroin and everything in between, people are swallowing, snorting, and shooting themselves silly with the junk. Doctors are quicker to write prescriptions for opiates at high doses and a seemingly infinite number of refills. I have seen patients with hydrocodone and oxycodone habits that have lasted since I took up my current post 12 years ago and I swear that I feel my soul blacken every time I dispense another round to them. As I said last time, no one was practicing medicine this way when I graduated in 1994. I didn't sign up for this.

From the illicit to the perfectly legal, there are opiate addicts all over the place. Some of them wake up to the havoc they have wrought on themselves and those around them, decide that they are drug addicts, and set out to get clean. There are 2 ways of doing this: going cold turkey and entering a 12-step recovery program such as Narcotics Anonymous or Celebrate Recovery (the program I attend) or replacing the narcotic one is addicted to with a slightly less dangerous narcotic, such as methadone or buprenorphine-naloxone sublingual (BNS) films and tablets.

While I have no problem with BNS itself, its use in the medical “profession” leaves much to be desired. What the substitute narcotic does is get the addict high enough to function without being in withdrawal but not so high to be in oblivion. The original approach was to have a patient taper down over a 6-month period. I Googled "BNS therapy duration" and couldn't find a finite taper on any page. For some, BNS turns out to be a lifetime maintenance medication.

Here is why this is a complete racket: Only a specially credentialed physician can dispense BNS. Some of the more soulless practitioners don't take insurance for BNS patients and grab upward of $150 for 10 minutes of work. Do no harm? HA!

When you see a patient travel 60 miles for a BNS script, you know something is up. The "legitimacy" of the Rx is not to be questioned, because everything is legally right on paper. The ethics of the situation, however, are highly suspect.

These "doctors" are simply stringing out patients for a lot of money over time, ad infinitum. They are licensed narcotics peddlers, who somehow manage to sleep at night, convinced that they are saving society. Sadder than this is when you see a heavy narc prescribing doctor get a BNS license and keep the patient on the hook forever. Whatever board of review granted that licensure really needs to be given a second look. Medical ethics are not what they used to be.

Between pain management and addiction management, we have painted a really rosy picture of medicine. In Star Wars terms, this is the Dark Side of the Force. It is the underbelly of an already rotten city. In the next installment, we will talk about how to change the law and make a lot of this mess go away. Until then, peace.

Jay Sochoka, RPh, would like to see more people in 12-step recovery programs.