The Opioid Abuse Epidemic: Matters Arising - 

A Doctor’s Perspective and Prescriptive Measures 

Opioid addiction and the recent epidemic spikes have received unprecedented media attention. The images in the media rightfully suggest that communities are heavily decimated by episodic incidents of opioid overdoses. And, unfortunately, data from the Centers for Disease Control and Prevention (CDC) suggests that opioid pain killer overdoses kill more Americans than heroin.

The impetus for this article is a report published in one of our local newspapers titled, “City robbery suspect accused of DUI”. In the article, the writer reported that the state police said the suspect was “high” on Suboxone. While this article is not intended to be a primer on drug addiction, it accentuates the problem with prejudicial precepts about this drug borne largely out of unfamiliarity, and in some quarters, ingnorance.

Let’s be clear: one does not get “high” on Suboxone. One can not overdose on Suboxone because it contains the opiate receptor blocker called Naloxone or Narcan. (Narcan is the drug that paramedics, law enforcement agents and even regular citizens are now allowed to carry, to quickly reverse opiate overdose).

Suboxone is not Methadone! Suboxone is a good and safe drug that has demonstrated unquestionable effectiveness in the treatment of opioid addiction.

It is high time we embraced addiction as a disease - no different from diabetes or hypertension! People afflicted with this disease should be treated with compassion, not contempt; understanding, not scorn; and dignity, not denigration. When society sees addiction as a self-inflicted “condition” (not a disease), and so called “addicts” as “bad people”, and the only “treatment” for them is incarceration, it represents a gross misunderstanding of this disease and makes the task of eradicating or combating it more difficult.

Combating an epidemic requires the involvement of everybody – not just the medical community – because the problem affects everyone directly or indirectly. This involves acquiring a basic understanding of addiction in general and opioid addiction in particular. And, while the eradication of this epidemic requires the combined efforts of the medical community, law enforcement and social services support; stigmatizing it is a disservice to the vulnerably afflicted who need support. Anything short of this tripartite approach is sure to fail.

First, let’s look at the role the medical community can play in this complex solution.

Unfortunately, the stigmatization associated with opioid addiction occasionally brands doctors who wish to help their patients as “pill pushers”. Therefore, many doctors are reluctant to treat addiction.

Other doctors who genuinely want to treat the afflicted may be afraid of being investigated by the regulatory authorities for treating an admittedly poorly understood disease that lacks standardized treatment guidelines as with other chronic diseases like diabetes and cardiovascular disease.

Clearly, despite these apprehensions, doctors should not abdicate their advocacy for their patients. After all, some of the so-called “addicts” may have been addicted by either complying with the prescribed regiment of narcotics and psychotropics by well-intended doctors who want to help resolve their patients’ chronic pain and psychiatric conditions.

So, how can doctors then, in good conscience, fail to admit their complicity in the addiction of these patients, and, worse yet, fail to treat their doctor-induced addiction?

Doctors should not be so intimidated that they fail to uphold the Hippocratic oath and their professional responsibilities to their patients’ well-being and health

Law enforcement certainly has a role to play in the eradication of this epidemic. Clearly, while incarceration is necessary or warranted if criminality is present, recidivism will be greatly reduced if treatment is provided as an associated part of incarceration. If we do not expect patients diagnosed with diabetes or hypertension to be cured without medical attention during incarceration, how then do we expect a different result for those who are opiate-addicted?

Lastly, we must equate the role social services support networks play in wellness and compliance. There is ample research evidence that suggests that social services and support networks are critical in the treatment of addiction.

For example, access to post rehabilitation services, such as drug and alcohol counselling services, availability of jobs, financial support, vocational programs provide necessary structure for sustained abstinence. Alcoholic Anonymous (AA), Narcotics Anonymous (NA) and similar organizations play vital roles, too.

Clearly, eradicating the opioid epidemic requires all vested stakeholders to work together and in tandem with familial and social support networks. Achieving this would also require public enlightenment about addiction, so as to begin discussions that would, hopefully, lead to destigmatized and demystified views about addictions.

In my view, the approach I have articulated here would help afflicted people and those with addictive personalities to seek treatment in a non-judgmental atmosphere and allow more doctors to feel comfortable treating addiction.

MEDICAL MARIJUANA: THE STIGMA, THE CONTROVERSY AND THE REALITY

On April 17, 2016, SB 3, the Pennsylvania Medical Marijuana Act was signed into law by Gov. Tom Wolf. The law, which is a result of Pennsylvania’s compassionate medical cannabis legislation, went into effect on May 17, 2016, with the first dispensaries serving patients in April 2018.

This law marks a historic moment for use and access to cannabis in Pennsylvania for patients with “serious medical conditions”. The state of Pennsylvania is the first to approve medical marijuana for the treatment of opioid addiction. This is very much a welcome development in light of the national opioid addiction epidemic. This puts the state of Pennsylvania, along with 30 other states and the District of Columbia that have now legalized marijuana for medicinal purposes – and, the trend appears to be growing.

That is a good thing; especially, given the fact that the U.S. Government considers marijuana an illegal substance, and classifies it as a Schedule 1 drug, which means that it has no medicinal value and is highly addictive. Neither of which have been supported by scientific/medical research.

The Pennsylvania Medical Marijuana Act does not define what constitutes a “serious medical condition”, but simply lists 20 medical conditions that are limited to multiple sclerosis, Parkinson’s disease, glaucoma, autism, sickle cell anemia, to mention just a few

Historically, marijuana has been used for medicinal and ceremonial purposes for centuries. Interestingly enough, marijuana was legal in the state of Pennsylvania until the 1930s, when it was proscribed partly due to hysteria caused the movie titled “Reefer Madness”. The town of Hempfield, Pennsylvania is so named because of its robust hemp production in the early 1900s.

THE STIGMA

Marijuana is not known to have the same psychological and physiological withdrawal signs and symptoms that are associated with other classes such as opiates and benzodiazepines. Yet, marijuana has become very stigmatized partly due to the psychoactive effects of Delta-9 tetrahydrocannabinol (THC), its illegality under the law, hitherto, societal/communal morality standards, longstanding misunderstanding/disinformation and outright propaganda. The paucity of scientific evidence to support its medicinal uses, a consequence of lack of research funding, has created fear among practitioners, who believe, rightfully so, that prescribing marijuana may have a negative effect on their practice and personal reputation. Because most medical providers’ expectation that prescribing cannabis would attract the scrutiny of regulatory authorities and jeopardize their medical licenses, they tend to avoid such therapies.

THE CONTROVERSY

Because of the stigma described above, the debate about the use of marijuana for medicinal purposes has been muddied and controversial to the extent that the general society does not quite understand its benefits. And, without incontrovertible scientific evidence to support its efficacy, suspicion and discomfort amongst medical professionals appears to have heightened.

Clearly, a conglomeration of factors, coupled with illegality under federal law and the lack of a wider acceptance of the medicinal uses of cannabis, have contributed to the lack of research in the U.S.

Unfortunately, medical school curricula are conspicuously devoid of information on marijuana (alternative therapies, including homeopathy, in general for that matter), again, partly due to its federalized illegality and lack of scientific research foundation. Consequently, doctors who want to introduce this therapy in their practice often lack knowledge in the medicinal uses of cannabis.

THE REALITY

The United States seems to be on the way side, in terms of this therapy. Countries, such as Israel, Australia, Canada and Germany are currently leaders in research about medicinal uses of marijuana. It is believed that Israel is by far in the lead in this area.

Current cumulative research provides ample evidence that cannabis provides effective treatment for many conditions for which current therapies are inadequate. These include some types of cancer, neurological disorders, psychiatric disorders and chronic pain, to mention a few.

The lack of evidence-based information makes it difficult for doctors to confidently “recommend” (not prescribe) precise strain and dosage information to patients. Available information is mostly anecdotal at this time. The recommendation is for individuals to start slowly and titrate upwards as tolerated.

Unfortunately, most large healthcare institutions are not permitting their providers to “prescribe” medical marijuana, partly due to concerns about possible legal actions by the federal government, dearth of evidence-based information and the aforementioned stigmatization of marijuana.

Also, the state of Pennsylvania needs to revisit its policy because the administration of the program seem to be shrouded under unnecessary secrecy. For example, approved physicians are prohibited from advertising their services to certify patients for medical marijuana. Why? The directive states that patients can find approved physicians on the state’s web portal (medicalmarijuana.pa.gov), which paradoxically lists the physicians’ phone numbers, but not their locations. Why the secrecy? If there was something nefarious about medical marijuana, why approve it in the first place? Authorities must overcome this antiquated mentality of cannabis and adopt more progressive ideas.

The qualities of cannabis and its pluripotent potentials should be advertised, not cloaked in secrecy. Research should be encouraged and funded robustly.

So far, at Toftrees Family Medicine (TFM), we have successfully helped five patients discontinue the use of their addictive prescription medications. That is a good thing – especially in midst of a deadly opioid epidemic. Our goal at TFM is to treat patients’ medical condition(s) and attempt to wean them off their addictive medications and/or at least, reduce their total medication burden. How can taking 20 or 30 or 40 different medications be good for any human being? This is phenomenon is not uncommon. Patients are generally happy with the prospects of being weaned off some of their medications.

The use of cannabis should be guided by evidence-based information (which I admit is currently scant) and not by fear and paranoia. A physician’s choice to participate in the medical marijuana program should be guided by the convictions of his or her conscience, medical ethics and ethos - not by the dictates of corporations he or she may be employed by.

Lastly, I end with these words of caution to patients: find a physician who is willing to think beyond the boundaries of traditional medicine; do your own research and share that knowledge with your physician, so that you make joint decisions regarding your care. Take charge of your healthcare!

MEDICAL MARIJUANA: THE CASE FOR DOCTOR FOLLOW-UP VISITS

On April 17, 2016, SB 3, the Pennsylvania Medical Marijuana Act was signed into law by Governor Tom Wolf. The law, which is a result of Pennsylvania’s compassionate medical cannabis legislation, went into effect on May 17, 2016, with the first dispensaries serving patients in April 2018.

In my previous writings, I focused on the stigma, controversy, and the reality of medical marijuana, and the need for patients to take charge of their healthcare in consultation with their primary care physician.

In the article, however, I direct my discourse on a specific provision of the law that requires patients who are prescribed medicinal marijuana to have routine doctor follow-up visits, a sensible approach to healthcare.

THE FACTS

MEDICAL marijuana is not RECREATIONAL marijuana!

Cannabis is a drug!

As with the introduction of any new drug to a patient’s treatment regimen, necessary follow-ups to determine efficacy, monitor for potential adverse reactions, prevent possible drug-drug interactions that may occur, monitor compliance and prevent diversion must be done; these are fundamental standards that ensure efficacy in medical practice.

The law stipulates that physicians must adhere to the Federation of State Medical Boards guidelines for health care providers in patient care. Therefore, the standard of care is regular follow-ups - as determined by the physician. Thus, certifying patients for medical marijuana and not providing follow-up is a contravention of the standard of care provision in the law.

Some who “support” medical marijuana bristle at the idea of doctor follow-ups even when informed of this requirement in the law. Unfortunately, for many of these “supporters” of medical marijuana, it is not far-fetched to say that their goal is really recreational marijuana.

While I am not totally opposed to recreational marijuana, certain conditions must be in place first (in fact, these conditions should have been in place already):

Developing a reliable testing instrument akin to the breathalyzer for alcohol intoxication to determine acute cannabis intoxication; and blood levels to determine cannabis intoxication must be established (such as we have for alcohol) and alternative sentencing/diversion options (such as currently exists for DUIs) must be made available to offenders.

Doctor follow-up is the LAW.

Doctor follow-up is good medicine.

QUESTIONS

Without follow-up:

How would you assess the efficacy (effectiveness) of the drug (cannabis) that you are “prescribing” to your patient? (Doctors cannot currently “prescribe”, only “certify” patients).

How would you assess the response of the patient?

How would you assess any potential adverse drug-drug interactions?

How would you assess any potential allergic reactions?

How would you assess possible diversion or abuse?

How can we ever gather useful data for research, standardization of products and practice and policy development?

THE PROBLEM

Accident rates are rising in legal marijuana states. A report issued by the Insurance Institute for Highway Safety indicates that car accidents reported to police in three states that have legalized marijuana sales –Colorado, Washington, and Oregon – saw 5.2% more accidents than the neighboring states without legalized marijuana.

A second study by the same group estimated that states that had legalized cannabis saw 6% more insurance collision claims than other states.

On aggregate, however, many studies have produced mixed results on the linkage of cannabis and motor vehicle accidents. But more studies, than not, tend to support a linkage between cannabis use and motor vehicle accidents.

While specific cannabis use and motor vehicle accident statistics for Center County, Pennsylvania are not currently available, the National Safety Council, reports that Pennsylvania’s motor-vehicle deaths in the first six months of 2018 increased by 10 percent from the same period in 2017, tied for the third largest jump in the country with Nevada. {Although, in 2017, Pennsylvania saw the lowest number of overall traffic fatalities on record –1137. Alcohol-related fatalities dropped from 297 in 2016 to 293 in 2017, according to the 2017 edition of the Pennsylvania Crash Facts & Statistics booklet published by the Bureau of Maintenance and Operations of the Pennsylvania Department of Transportation (DOT)}

Two studies presented in October 2018, at the Combining alcohol - and Drug-Impaired Driving summit at the insurance Institute’s Vehicles Research Center, showed that states that legalized marijuana are seeing more car crashes overall.

Post motor vehicle accident analyses show that people are combining marijuana with prescription opioids, amphetamines, heroin, alcohol and other illegal substances.

So, it is safe to conclude that without doctor follow-ups, critical data for needed medical research, standardization of drug quality and practice guidelines and policy development may be lacking.

THE SOLUTION

Enforce follow-up visits. The regulatory authorities most enforce the follow-up provision in the law to ensure compliance with the law in order to ensure the desired health outcomes.

Incentivize more physicians to “prescribe” medical marijuana. Currently, for a variety of reasons, including the fact the Federal Government is yet to recognize medical marijuana, many doctors are reluctant to participate in the medical marijuana program. Therefore, the Federal Government should recognize medical marijuana and change the Schedule I classification of cannabis. (By definition, a Schedule I is a drug without medicinal value and is highly addictive). Clearly, this definition does not accurately describe cannabis.

Devote adequate resources to treatment and education. The state government must ensure that revenues derived from medical marijuana sales are adequately channeled to treatment for drug addiction and provide support for educational and prevention initiatives.

Develop a reliable test to determine acute intoxication. A reliable instrument similar the breathalyzer for alcohol, must be developed to accurately measure acute cannabis intoxication.

Establish clear impairment limits as measured by blood tetrahydrocannabinol (THC) levels – similar to blood alcohol concentration (BAC) levels.

Develop comprehensive/standardized medical marijuana use as a drug. The Federal Government should reclassify cannabis as a Schedule IV or V drug in order to spur rigorous and robust research, to develop evidence-based uses of cannabis for medicinal purposes.

Regulate non-medical persons in the medical marijuana business. The reluctance of many physicians to get involved in medical marijuana certification has created a lacuna for some unscrupulous business entities, whose sole motive is profit, to “fill” the vacuum. These fly-by-night outfits, with dubious medical affiliations, flock into town, rent shifting addresses or use make-shift locations, certify patients and provide no follow-ups, which is a direct violation of the law and medical ethics and practice. This jeopardizes patients’ health and contributes to diversion for recreational uses, contributing to the aforementioned unintended consequences, including rising motor vehicle accident rates and other related crimes.

And, finally, my professional opinion leads me to believe that if this menace is not curbed with the urgency it requires, forces opposed to medical marijuana will gain substantial leverage in their continued attempt to repeal the law. All well-meaning interests involved in legitimate MEDICAL marijuana must assiduously work to safeguard the program, so that deserving patients will continue to have access to controlled and legislatively sanctioned MEDICAL marijuana.

THE OPIOID EPIDEMIC AND THE MEDICINE OF FEAR

Recently, President Donald J. Trump declared the opioid epidemic a national emergency and has proposed the sum of $6 billion in next year’s budget to fight the epidemic.

It is estimated that 29,000 people die from drug overdose every year. Drug overdoses are now the leading cause of death among Americans under age 50, according to THE BUZZ – The National Center on Addiction and Substance Abuse’s online forum.

About 75% of all opioid misuse starts with people using medication that was not prescribed for them – obtained from friends, family members or street drug dealers.

Contrary to popular belief, few people become addicted from physician-prescribed opiates. A Cochran Review report indicates that 8 – 12% of patients prescribed opiates become addicted.

THE PROBLEM

Yet, despite these glaring facts, most doctors are reluctant to treat addiction. In contrast, during the Ebola virus epidemic, all doctors were required to address the epidemic in some fashion. At the very least, doctors were required to inquire about possible exposure, including recent travel to Ebola endemic areas, regardless of the nature of the patient’s visit.

So, why in the face of a deadly epidemic (especially since 8-12% of it is likely due to the prescriptions that we as doctors prescribe, ostensibly to help patients) do many doctors choose to remain indifferent. Isn’t this wanton abdication of our responsibility to patients that we have sworn to help?

We must acknowledge our complicity (no matter how altruistic our original intent) in the addiction of some of our patients - no matter how few. It is hypocritical to not acknowledge it, and worse, refuse to address it.

JUDGE NOT: COMPASSION AND UNDERSTANDING IS WHAT IS NEEDED

The reason is simple.

Addiction has been stigmatized and bastardized by society at large; unfortunately, this includes those best positioned to help people afflicted with the disease of addiction – medical doctors.

Society for the most part, simply does not recognize addiction as a disease. Some believe that addiction is a self-inflicted “condition” that can easily be cured or eradicated if the so-called “addicts” would “just stop doing it to themselves”.

People afflicted with addiction are seen as weak of mind and body; lack character and are deplorables, that do not deserve help.

And, by extension, doctors involved in the treatment of addiction are smeared by the same brush and perceived as doing something nefarious. Unfortunately, some doctors harbor these beliefs, too. Society, it seems, simply does not want to accept the notion of addiction as a disease and just wants to magically wish the problem away.

Perhaps, the most prescient reason that some doctors are reluctant to treat addiction is the fear of being investigated by various regulatory authorities.

In the era of unacceptable numbers of drug overdose deaths, prescribers are under increasing scrutiny (as it should be) and many doctors simply do not want to chance being investigated. So, they abstain.

THE PENDULUM HAS SWUNG TOO FAR: CONSEQUENCES FOR SOCIETY

Unfortunately, most doctors, including Pain Clinics are now refusing to prescribe narcotics even for patients that deserve to have their chronic pain treated.

The result is that emergency rooms are bombarded daily by patients seeking treatment for their pain. Patients are also turning to heroin and other drugs available on the streets, contributing to the increasing problem of drug diversion and associated criminality, including prostitution, breaking-and-entering and financial fraud.

THE SOLUTION

Doctors must not abdicate their responsibilities to patients for fear of being scrutinized. They must exercise due diligence in documenting a patient’s condition properly and prescribing responsibly. Patients with legitimate pain deserve to have their pain treated; they must not be sacrificed at the altar of expediency and fear. Doing so, contributes to the afore mentioned drug diversion and burgeoning criminality.

In the same vein, patients suffering with addiction equally, should have their addiction treated with knowledge and compassion – not scorn and avarice. When Pain Clinics (somewhat regarded as the last bastion of pain management) start turning patients away for fear of scrutiny, we have a problem. Doctors must remain strong advocates for their patients.

MEDICAL MARIJUANA

Although, controversial to some, medical marijuana certainly has demonstrated remarkable efficacy in treating many conditions, including chronic pain, anxiety, depression, PTSD and addiction, to mention but a few.

In the state of Colorado, statistics show that abuse of prescription opiates has been reduced significantly, as are related crimes since the introduction of medical marijuana. According to the Denver Post newspaper, a 2017 study published in the American Journal of Public Health, showed that prescription drug overdose deaths were reduced by 6.5% from 2000 to 2014.

I hope to be able to replicate similar results in my Practice, as the Pennsylvania medical marijuana program gets underway.

Be reminded that analog ideas in a digital world will no longer suffice. The so called “War on Drugs” as a strategy, has failed woefully.

The Trump Justice Department, headed by Attorney General Jeff Sessions, has declared war on medical marijuana states such as California and Colorado by declaring these states’ marijuana laws illegal and are now attempting to enforce archaic federal laws in these states.

In Pennsylvania, doctors that are certified to “recommend” (not prescribe) medical marijuana are paradoxically not allowed to “advertise” it, as if there is something surreptitious about medical marijuana. Also, incredibly, patients are compelled to have tried and failed addictive prescription opiates before they can qualify for medical marijuana.

On the other hand, progressive policies such as allowing ordinary citizens, law enforcement agents and paramedics to carry and administer Narcan (Naloxone) and providing more access to treatment and education are welcome.

The medicine of fear exacerbates the opioid epidemic. People struggling with chronic pain and/or addiction do not (and can not) “just stop” seeking relief for their pain or addiction. They will always find ways to address their condition, including looking to the streets for help.