Legislation Restricting Opioid Addiction Treatment Harms Us All

Have you ever been prescribed a medication that didn’t work for you? I have. One formulation of birth control pills made my hair fall out and, ultimately, feel suicidal. When I was quaking with anxiety after the end of my first marriage and was prescribed Xanax, I fell to the floor in a near blackout from the very first dose. In both cases, my physicians expressed compassion and concern, prescribed different medications for the same purposes, the medications worked, I returned to stability, and continued to live my life.

We need open access to addictions treatment medications

If laws had mandated that my physicians were limited to prescribing me only the medications that made me suicidal or caused me to lose consciousness, well, I doubt I’d be here today. It’s a ridiculous concept, isn’t it? Laws mandating what physicians can prescribe for their individual patients with unique needs, case-by-case?

Yet, that is exactly the case. States are passing laws that limit how physicians can prescribe opioid medication for pain patients and for patients with opioid use disorder. In Virginia, bills passed both houses of the General Assembly prohibiting physicians from prescribing buprenorphine (Subutex) to men and non-pregnant women. Physicians must now prescribe buprenorphine with the additive naloxone (Subuxone) instead. As an additive, naloxone has no medical value; its sole purpose is to discourage misuse by injection.

The Virginia bills mean that patients stable on buprenorphine alone in Virginia must now take buprenorphine plus naloxone. Physicians have prescribed buprenorphine alone (Subutex) based on their expertise and their consideration of the patient’s unique needs. Some people can’t take naloxone, whether because of allergy, sensitivity, or other metabolic contraindications unique to that person.

But the bills say that all men and all non-pregnant women, regardless of their unique medical needs, most take buprenorphine with naloxone (Suboxone).

Let’s think this through a minute. Sure, the bills infringe on the individual rights of physicians and patients, and on the physician-patient relationship. Sure, lawmakers are engaging in malpractice by legislating medical treatment. Sure, it’s inhumane to make people take medications that make them ill. Sure, the overt intent of the bills is to discourage buprenorphine misuse by injection,  ostensibly to take action against the opioid addiction crisis that Virginia Governor Terry McAuliffe has declared a public health emergency. Aside from all that, isn’t the primary, unstated intention of the bills to curb health care and criminal justice costs related to opioid misuse? How likely is a buprenorphine control law to do that?

Let’s take a walk in the shoes of someone with opioid use disorder. I’ll go first.

If I were being successfully treated for opioid use disorder, had adverse reactions to the naloxone in Suboxone, and were now stable on Subutex, I would know that science says I may need to take either methadone or buprenorphine indefinitely, perhaps my entire life, to treat my illness. If I learned from my physician that the laws have changed and I now have to switch from Subutex to Suboxone, or to try methadone, let’s check out my options.

Buprenorphine alone is out because of the laws. Methadone is out because, while it’s cheaper than buprenorphine, it’s so highly federally regulated that it must be obtained at a clinic and I don’t live near one in my rural area. Taking buprenorphine with naloxone, Suboxone, makes me ill. Even if I were willing to suffer the additive’s side effects on my own behalf, I’m the primary caregiver for my elderly father and I can’t afford to be sick. I could start to Google for ways others in this situation have tried to solve the problem and would find zero help from credible sources, but some highly suspect ways on message boards for how to hold the Suboxone pill in my mouth to separate out the buprenorphine from the naloxone, then spit out the naloxone… Huh?

I’m backed into a corner. I am no longer allowed to have the medication, Subutex, that kept me well. If I take what makes me ill, Suboxone, I won’t be well enough to care for myself and my father. If I don’t take what makes me ill, Suboxone, and I go off medication-assisted treatment entirely, with relapse rates between 50% and 90% after cessation of buprenorphine, I have a huge chance of that old illness – opioid use disorder – coming back. Counseling won’t make a difference; opioid use disorder could kill me this time. Marijuana might have helped, but it’s not legal in my state.

I’m stable and I’m no more a burden to the health care and criminal justice systems than any other citizen. These new laws now destabilize me and increase the likelihood that I might become very costly indeed.

Which would you choose?

What if we simply stride out of the buprenorphine control, no-win corner and straight out the door into the vista of financial data from the National Institute on Drug Abuse, NIDA: “According to several conservative estimates, every dollar invested in addiction treatment programs yields a return of between $4 and $7 in reduced drug-related crime, criminal justice costs, and theft. When savings related to healthcare are included, total savings can exceed costs by a ratio of 12 to 1.”

Laws controlling buprenorphine limit addictions treatment. Limiting addictions treatment increases costs. Therefore, laws controlling buprenorphine increase costs.

Are lawmakers thinking citizens would rather pay $12 in health care and criminal justice system costs rather than $1 for treatment?

And citizens can certainly read the data on how other countries have solved their overdose crises. They loosen, not tighten, access to addictions treatment medications.

If not for humanitarian reasons, then for fiscally sound ones, lawmakers, please, legislate the end of restrictions on addictions treatment and let the people with opioid use disorder have the medications they need and let their physicians prescribe them.

Image: iStock

Disclosure and disclaimer: The opinions expressed here are mine alone and do not necessarily reflect the positions of my employers, co-workers, family members or friends.  This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

Last revised 3/1/17

What It’s Like to Have Alcoholism

Imagine standing at your kitchen counter, pouring crisp, pale, chilled sauvignon blanc into a glass measuring cup to the one cup mark, then pouring that amount into a wine glass. You have resolved to limit your drinking to federal guidelines: 3 drinks tonight, no more than a total of 7 drinks this week. You’re healthy, at home, and not driving, so you’ve allowed yourself a generous 8 ounces, 3 ounces beyond the 5-ounce measure of a standard glass of wine.

Standard measure for wine is 5 ounces

Note your awareness of the need to drink this amount and no more. Sense your willingness to make responsible choices and to be accountable for them by tangible measures.

Bring the wine glass to your lips, take a sip, hold the coolness in your mouth, then swallow. Tilt your head back in near ecstasy at the first hint of alcohol’s initial euphoric effect. Chop vegetables for stir fry, continuing to sip.

Let’s say each sip measures about a tablespoon. In 16 sips, about 1 sip every 2 minutes, that cupful of wine is done in a half hour. You’ve only just finished the food prep. You measure and pour another cupful of wine, cook various combinations of foods with various spices and sauces, and find this second glass gone. You arrange your meal on a plate, measure and pour the third glass of wine, fill a glass with water, and place all three at your seat for dinner.

Alcohol’s initial euphoric effect has passed and you feel its warm, sedative glow. You may or may not be aware of the uncertainty it has brought to your decision-making. You’re not sure how long you’ve been eating, but the third glass of wine is gone and you still have part of your meal left. You dutifully switch to water and pair sips of it with the rest of your meal, sensing with disappointment water’s dulling effect on flavor.

Clear the table and view the kitchen. Pots, dishes, utensils, peels and spills everywhere. And on the counter is the rest of the bottle of wine by its glass measuring cup – intentionally glass instead of metal in case pouring the wine first into metal might interfere with its taste.

Pick up your wine glass, walk over to the counter, and place it by the measuring cup. Look at the wine left in the wine bottle, the measuring cup, and the empty wine glass.

Know with the entirety of your mind, heart and body that you are not going to pour wine into the measuring cup and that you are not going to pour that measure into the wine glass. Feel the power of who you are and what you can do rise within you. Remember your credentials and successes, envision the faces of everyone you love and who loves – even admires – you. Revel in the power of your intelligence, knowledge and experience to guide and lead you, and in your willpower to make choices in your best interests. Feel your heart swell with compassion for yourself and all beings everywhere. Lift your shoulders and shift your weight to feel the strength and health of your body.

Pour the rest of the wine directly into the wine glass.

Feel the horror of knowing you are no longer who you were.

Bring the wine glass to your lips.

Image: iStock

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Legislate Against Smokes and Drinks Before Opioids

Legislators attempting to control what, how much, and how often physicians can prescribe opioid medications to their patients is misdirected. (I have read articles in the past few days on legislators doing so in Virginia, Maine, California, New Jersey and wrote this editorial in opposition: Say No to Laws That Prescribe.)

Cigarette and alcohol use are costly

If legislators truly want to cut costs due to substance misuse, really think limiting supply works, and really think laws control behavior, shouldn’t they first legislate how many cigarettes and drinks each individual American can have per week? After all, tobacco misuse and alcohol misuse each cost our nation more than the misuse of all illegal drugs – including opioids – combined.

Or is the attempt to legislate control of the supply of opioid medications based on other factors? A nod to the hysteria over the latest drug panic? Disdain for people who use illegal substances rather than legal ones? Contempt for people who have problems because they can’t “hold” their substances like people who can “hold their drinks”? Continued belief, despite the data presented most recently in the Surgeon General’s report, that addiction is a moral problem, not a medical one, and that limiting supply will induce choice – exactly what the science says is no longer present for people with substance use disorders?

I would like to ask legislators to be really clear about their motivations with regard to alcohol and drug legislation and about whether even common sense predicts the likelihood that the means they propose will achieve desired ends. I would ask them to double check their scientific understanding of addiction, and to do a cost vs. benefit analysis on individual rights with every piece of drug legislation they consider.

Further, I would ask legislators to examine their logic with regard to controlling how any medications for substance use disorder are prescribed, beyond the fact that most are professionally unqualified to do so.

One in 7 Americans is expected to develop substance use disorder. One in 6 Americans with substance use disorder experienced trauma in their lives. One in 6 American men and 5 in 10 American women have experienced trauma at least once in their lives. The supply to control isn’t substances but access to help. Legislating mental health evaluations for all Americans for signs of trauma and correlated substance misuse makes more sense than legislating control of the substances that ease their anguish.

Disclosure and disclaimer: The opinions expressed here are mine alone and do not necessarily reflect the positions of my employers, co-workers, family members or friends.  This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

Vote No on Laws That Prescribe

Regardless of why and how people develop substance use disorders, a.k.a.  addictions, 20 million Americans have them now, 1 in 7 is expected to get them, a person dies of a drug overdose every 19 minutes in the U.S., and only a fraction of those who need help are receiving it. Whether we approve of it or not, addiction is a national crisis. Not doing something effective about it strains our system and our people.

The two top treatments for opioid use disorder are the medications methadone and buprenorphine. Burpenorphine is dispensed primarily in two formulations, buprenorphine alone, brand name Subutex, and buprenorphine with naloxone, brand name Suboxone.

The purpose of adding naloxone to buprenorphine is political, not medical. Law makers have required pharmaceutical companies to include naloxone in the formulation of Suboxone in an attempt to prevent misuse of buprenorphine. Neither data about opioid use and misuse, nor the biochemistry of the metabolism of buprenorphine or naloxone, support including naloxone with buprenorphine as an effective method for preventing opioid misuse. Illogically, however, this requirement exists.

Each human’s physiology is unique and, therefore, each person’s response to medications is unique. Some people with opioid use disorder are able to tolerate Suboxone, i.e. buprenorphine with naloxone. Some people cannot. They have allergic reactions to naloxone, naloxone sensitivity, or pre-existing medical conditions for which the presence of naloxone creates complications. The expertise of medical professionals is required to determine what medications are suitable for each patient on an individual, case-by-case basis.

Virginia General Assembly House Bill 2163 entitled “Buprenorphine without naloxone; prescription limitation,” states “products containing buprenorphine without naloxone shall be issued only for a patient who is pregnant.” HB 2163 has passed the House of Delegates and is currently being discussed in the Senate Education and Health Committee. A similarly worded bill, Senate Bill 1178 has passed the Virginia Senate and is currently being discussed in the House Health, Welfare and Institutions Committee.

Virginia HB 2163 and SB 1178 mean that all men and non-pregnant women currently stable on Subutex must stop taking it and switch to taking Suboxone instead. HB 2163 and SB 1178 mean that all new cases of opioid use disorder in men and non-pregnant women in Virginia must be treated with Suboxone even if Subutex is the medically prudent, even medically imperative option.

Virginia HB 2163 and SB 1178 legislate medical malpractice.

In addition, the proposed bills mean that those taking Subutex who cannot take Suboxone will be forced to find another option. Access to the alternative top treatment, methadone, is virtually non-existent in our locale.* Treatment with naltrexone, while helpful to some, does not directly affect the areas of the brain most specific to opioid use (those treated by methadone and buprenorphine).

Those without buprenorphine in a form they can take, without access to methadone, and who find naltrexone ineffective, will have to do without treatment for opioid use disorder.

Of people with opioid use disorder who abstain from opioids without maintenance therapy, also termed medication-assisted treatment (MAT), 50-90% are likely to return to use. And, as reported by Maia Szalavitz, “[M]aintenance is the only treatment known to reduce drug-related mortality, which it cuts by more than 70 percent.”

Those desperate not to return to use do what people desperate for opioid use disorder treatment who languish on wait lists do as well: find friends or family members who are on buprenorphine and ask to share their doses. And those friends and family members risk and sacrifice to share their prescriptions in an attempt to save loved ones stricken by life-threatening opioid use disorder. Or, less often, they buy it from strangers, a.k.a. “dealers,” to self-treat opioid addiction.

Virginia HB 2163 and SB 1178 cruelly back its citizens into a corner, offering no healthful choices to benefit individuals with opioid use disorder or the Commonwealth as a whole.

I called my Virginia State Senator today. This is what I said:

“My name is Anne Giles and I am a constituent in Blacksburg, Virginia. I am calling to urge Senator Edwards to vote no on House Bill 2163. While I appreciate the attempt of public officials to address the opioid crisis in Virginia, HB 2163 would endanger those with opioid use disorder and further strain our systems providing them care. Health care professionals have determined that some people with opioid use disorder must take buprenorphine alone as Subutex and cannot take Suboxone for medical reasons. The law will require men and non-pregnant women on Subutex to switch to Suboxone, which may be medically contraindicated. HB 2163 legislates potential malpractice and must be opposed. I so hope Senator Edwards will take my views into consideration.”

State Senator: John S. Edwards (Democratic)
Capitol phone: (804) 698-7521
District phone: (540) 985-8690

. . . . .

*We were unable to find verifiable sources for the number of methadone clinics in the Commonwealth of Virginia. This source lists 3 methadone clinics in Western Virginia and this source lists 5 in Southwest Virginia. We verified that a clinic is operational in Pulaski, VA, and is listed in the second source but not the first. Many people, particularly in rural areas, will be unable to make daily commutes to a distant methadone clinic, whether due to conflicting responsibilities (i.e., dependent care, work) or due to a lack of or limited transportation.

Disclosure and disclaimer: The opinions expressed here are mine alone and do not necessarily reflect the positions of my employers, co-workers, family members or friends.  This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

Last updated 2/17/17

How Might We Work Together on This?

If I want to feel close to people, I’ve learned to listen for the essence of what they’re trying to express, which may or may not be directly conveyed by their words, the topic under discussion, or the position taken.

Since the 2016 election, and more acutely since the January 20, 2017 inauguration of President Donald Trump, I have been listening through the news, social media, and personal interactions, trying to hear what Trump’s supporters are expressing. I listened to several supporters on February 1, 2017, when NPR reporter Susan Davis interviewed Republicans on their views about Trump’s executive orders on immigration policies.

Seeking understanding

When I’m listening to adults, I assume they have reasons for what they’re saying that make sense to them. I assume they’ve learned through bitter experience to protect their feelings and to state reasons for feelings rather than the feelings themselves. I assume humanity, i.e. people will feel better or worse on some days, express themselves more or less clearly at some times, and simply make mistakes. I assume thinking fluctuates, evolves and regresses. I assume good intentions.

What I think I’m hearing is that Trump’s supporters want to feel safe geographically (immigration), financially (jobs), and morally (religion, abortion). They don’t feel safe – in fact, they feel threatened – they’ve tried individually and collectively to do something about it (Republicans vs. Democrats), that hasn’t worked, so now they want someone in power to make it happen. Regrettable means may be necessary, but they’re justified by the end in mind, i.e. safety and security.

I’ve learned that, if I want to have a working or close relationship with someone else – and I’ve discerned that the person is capable of it – after I listen, I need to try to understand. Internally, I discover and acknowledge my own position which may differ significantly from the other’s – in this case, until the election, I felt geographically, financially and morally safe in America – but I try to use my mind and heart to think and feel as the other person might. So, wanting and needing safety makes sense to me. Feeling threatened triggers my own survival instinct, the fight-flight-freeze response, an acute and destabilizing state of stress. I understand how alarm leaves no room for nuance and negotiation and any-means-necessary can kick in as an imperative.

Then I ask the person, Have I understood what you’re thinking? Is that what you’re feeling? I listen to the answers and refine until I receive confirmation that I do understand.

Then I seek common ground.

In her report for NPR, Susan Davis states, “[W]hen it comes to Trump, Democrats and Republicans are often living in parallel universes.”

In his article on how Chavez came to power in Venezuela, Andrés Miguel Rondón writes, “Don’t feed polarization, disarm it.”

In seeking common ground with adults, I assume at 58 something I could not fathom at 28: Opposing sides may both be true. Or truth may exist on a continuum. Or we may be in the wrong universe not even talking about what’s really the problem. And I, individually, never know enough or understand enough to make a perfect choice. I am limited to making the best choice I can with what I know at the time. Similarly limited are my paradoxically tough and fragile fellow human beings.

Fear may be the mind-killer. But judgment is the killer of connection.

To seek common ground, here is the question I ask:

How might we work together on this?

Asking the question requires vulnerability. Asking the question requires risk because the response may evoke shaming, rejecting, belittling. Asking the question asks all parties to suspend connection-killing judgment, at least for a moment. The answer may not be one we want to hear. The answer may alarm us, triggering a fight-flight-freeze reaction, or the more weighty, strategic decision to go to battle.

But not asking the question keeps us polarized, separated, disconnected.

What we want, we don’t have. We are not safe when we are not together.

How might we work together on this?

. . . . .

Photo by Zane Queijo