While walking into the emergency department (ED) for a Friday night shift, I heard the patch on the EMS radio reporting a patient found down, unresponsive, not breathing and cyanotic on the sidewalk.  An initial dose of naloxone had restored the patient’s respiratory drive, but ongoing resuscitation was in progress, with a five minute ETA.  For me, the prehospital EMS providers and my department colleagues, it was yet another shift treating a patient with an acute life threatening opioid overdose.  Over the next five hours of the same shift, there were three more opioid overdoses, each as severe as the first. All required supportive care and were eventually discharged from the ED. Fortunately, none died, unlike others in the days and weeks before.  Three of the four patients had a history of being prescribed, or using illicitly, methadone and/or buprenorphine, with no recent or related history of abusing prescription narcotics. Two of the patients reported never being fully rehabilitated from their opiate addictions nor weaned from either of the opioid agonists.

Many clinical and legal experts consider the usual suspects, prescriptions for narcotic pills, as the basis for the spike in heroin addiction.  However, there remains another key area of notable disparity, a very treacherous source of abuse on the provider side of the equation.  There is wide variation between the practices of pain centers and their respective prescribing practices, which should be consistently regulated throughout the states, ideally utilizing a shared registry and holding all to the same standard of care and conduct, without exceptions or loop holes. Unfortunately, this is not the case while there remains the ability to exploit the commercial and financial gains of addiction treatment through operationalizing centers even when there is concern for atypical circumstances.  There is ongoing exposure and opportunity to refine regulatory oversight, where clinical and business practices should remain as one entity. If there are medical practice issues, then business practices should not be sheltered, or vice versa, which has not been the case in many states.

A November 2013 New York Times article, The Double Edged Drug, Addiction Treatment with a Dark Side, by Deborah Sontag, explores the convoluted history of buprenorphine. I highly recommend reading the full article but the following excerpts help illustrate the point.

“At a recent meeting of the addiction medicine society, ‘the buprenorphine sessions were all packed with doctors who wanted to get in on the gold rush,’ he [Dr. Robert L. Dupont, the first director of the national drug abuse institute] said. ‘It seems to me like they are repeating the experience of pain doctors in terms of reckless disregard of the nonmedical use of the drug.’” 

“In addition, with a recent regulation change, for-profit addiction companies that run methadone clinics are expanding their buprenorphine programs, which have no patient limits, and some state governments are pressing federally funded health centers to increase nonprofit buprenorphine treatment.” 

“In August, the Pennsylvania attorney general announced Dr. Radecki’s arrest on charges of improper prescribing and trading addiction drugs for sex. His lawyer, John Froese, said Dr. Radecki ‘denies that he ever prescribed any medicine that was not helpful to his patients’ or had sexual relationships with his buprenorphine patients.  Dr. Radecki lost his Illinois license for just such a relationship, and his Pennsylvania license was made probationary in 2007. Nonetheless, the federal government subsequently authorized him to prescribe buprenorphine and then expand his patient load.”

As mentioned in two prior blogs, it is the prescribing practices of a vast minority that reflects poorly on the majority of providers.  Stricter sensible regulatory processes should make a noticeable public health impact on saving lives, but must dually address clinical and business practices attached to the circumstances. As it has been shown, addressing one without the other is not at all effective.

Regards,

Lukas Kolm, MD, MPH, FACEP

Please send your comments or questions to president@nhms.org or post a comment below.