Guinevere Gets Sober

Recovery news, reviews and stories, by Jennifer Matesa.

Tag: opiates (page 1 of 2)

I’m Not A Unicorn.

It’s been a long time, dudes!! The New York Post is running a story today about middle-aged women and addiction to prescription painkillers. The reporter was looking for a middle-aged middle-class white chick to talk about this, and guess who she found.

The online headline says I was a “perfect mom and wife,” but I was not a perfect mom and wife inside my addiction. I was a lot less than that.

And as always with newspaper stories, some things didn’t make it in:

  • That my son (who is now 18) knows about my addiction, is my biggest supporter in recovery, and has always had my back (read here, and here, and here, where I told him about my addiction)
  • That both my parents were addicted to legal substances and died because of their abuses of those substances.
  • That I do not hold my doctor responsible for my addiction, but I do hold her responsible for failing to screen me for risk of addiction before giving me drugs like pure hydrocodone and morphine and fentanyl, and for failing to recognize my addiction and respond with compassion and treatment, not judgment and punishment.

The biggest thing that didn’t make it in is my main reason for talking to the Post. (I mean, the Post is famous for Page Six, right? but if it had been the New York Times or Pro Publica or the Kalamazoo Gazette, my motive would have been the same.)

I talked to this reporter because there are other reporters out there (here is one example; there are many others) saying that once you’re addicted to opioids, you may as well resign yourself to taking drugs for the rest of your life.

black-unicorn-tattoo-design

(It’s hard to find an edgy unicorn image. They’re usually pink and lavender and sparkly. This black tattoo-design is cool. I’ve been thinking about getting a tattoo—maybe I’ll ask Cara to put this somewhere on my skin)

I am, however, not a unicorn. I know so many people, including many many women, who no longer cop heroin or snort Oxy. And they don’t take methadone or Suboxone, either.

But in some public health circles, it is said that there is no “proof” that we can actually do this. Nobody (except the tens of thousands of people who live opiate-free today) has “proven” that abstinence from opioids is possible—that human beings can choose to live drug-free and actually for-real carry out that choice.

There does exist, however, some evidence that people who are addicted to painkillers or heroin stay off street drugs and stop injecting if they take other opioids. (A lot of the research is driven by the desire to find a way to control the spread of HIV infection through needles.) So indefinite maintenance with these drugs—possibly for a lifetime—is now touted as the “evidence-based standard of treatment” for illnesses like the one I have, no matter what your circumstances.

I’m very cool with anyone who chooses to take drugs for life. If you WANT to drink methadone or suck on bupe films forever to keep from shooting or copping, it doesn’t matter to me. I considered it myself at one point. I have no problem with it, and I will not bristle at you in comments sections.

It’s unfortunate that a lot of people who choose maintenance say the way I do recovery—and the way so many other people I know who have long-term abstinence from opiates do recovery—is not “evidence-based” and therefore is sentimental, stupid, unscientific, or dangerous.

I will bristle at that. (I will still not judge you, but I will bristle, because you are judging me.)

It’s the people who DON’T WANT to drink methadone or eat bupe that I hear from.

I write and speak to places like the New York Post because I have heard from so many people who want to quit their maintenance meds and can’t find anyone to help them. Including, probably, many people who stand in grocery store lines reading the New York Post.

Let me restate in words of one syllable: they want help and can’t find help. Think about that. They are paying, per month, maybe $400 cash to the “Sub doc” plus whatever it costs them to buy bupe, or they are buying bupe on the street, and they want to quit, and they can’t find help.

I want to demonstrate that help is available. In order to demonstrate this, I’m willing to do hard stuff.

It’s kind of a little bit hard to talk to a total stranger from a newspaper with a circulation of half a million and admit that you took oxy just so you could, like, make breakfast for your family. And that you changed dates on scripts, and that you let people down, including the people you loved and who loved you most, and made super-problematic moral decisions inside your addiction.

But anyone who has been inside addiction and who hopes to get out will know what I’m talking about when they hear these stories. And hopefully they’ll see a light at the end of the long dark tunnel.

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The stigma of addiction (part n): Doctors and addiction

In Addiction and Art (a book I swear to G-d I’m going to review very very soon) the authors, professors of psychiatry and behavioral biology at the Johns Hopkins University School of Medicine, write that compared to other medical illnesses, addiction receives little attention from the medical and public health communities. The reasons: the perception that it’s primarily a law enforcement problem, not a public health problem; skepticism about treatment; and “poorly funded research, weak leadership, stigma, and stereotypes.”

The authors go on to add, “Many of these obstacles to appropriate action, however, are caused more by indifference and prejudice.”

We can see this in the kind of outburst registered last week on the comments section of the New York Times story about a piece of Washington state legislation that would require physicians to refer pain patients on increasing doses of opioids to specialists if their symptoms were not improving.

Note well, reader: not cut off the patients, but refer them for further consultation if symptoms were not improving.

Listen to the uneducated voices that went ballistic:

I would much rather have some people become addicted to pain medicine than to do anything which restricts people with legitimate pain from obtaining pain medicine. … There is not one bit of evidence to suggest that if pain medicines were not available for misuse that people inclined toward addictions would not just find another drug. That is the history of drug use.

Here we have a guy who would prefer to sentence some people to a deadly disease, rather than consider implementing reasonable regulations that might allow clinicians to distinguish who might not be benefiting from these powerful drugs.

Another:

Patients who use narcotic drugs for real pain relief need them and do not become addicts.

Well, yes, honey, I’m here to tell you that some do! Get yer head out of the sand.

Moreover, patients who use opioids for real pain relief may still be addicts. They might have ruptured discs or spinal stenosis or no cartilage left in their knees. These conditions, which may require pain treatment, don’t exempt them from having addiction as a disease.

There were a very few sane voices:

As 21-year-old who has arthritis (19 years)and fibromyalgia (6 years) and experiences widespread pain every day, I don’t really have a problem with these regulations. If a medication is not working, its use should be reevaluated, especially if the medication could cause further health problems. I’ve been on a variety of different NSAIDs (different than a pain killer, I know) over the years. Whenever the medication stops working or isn’t doing enough for me, I change meds. If a powerful painkiller isn’t making any difference, why would someone keep taking it?

And another:

During my residency I only prescribed OxyContin to terminal cancer patients. … It was abundantly clear that most primary care physicians have very little to no training in managing and prescribing chronic opiates. Many of these patients encountered were physically and or psychologically dependent. Some were addicts.

Even when physicians have training in managing and prescribing opioids for chronic non-malignant (that is, non-cancer) pain, they often do not have the first clue how to recognize addiction inside their offices. And if they can recognize addiction, usually the stigma and stereotypes take over: they see their patients as having become morally corrupt rather than as having an(other) illness.

Pain physicians are trained to get patients ONTO drugs, not OFF drugs. So, largely in fear of DEA reprisals, they kick addicts roughly out of their practices, they refer them to psychiatric hospitals, and the patient is faced not only with negotiating a disruption in continuity of care for their pain problem but also with setting up treatment for their addiction—about which they may be in severe denial—and having to do it in opiate withdrawal, while also having to work, and/or take care of kids, aging parents, etc.

Total nightmare scenario. One that every chronic pain patient who-deep-down-suspects-she’s-an-addict wants to avoid, so this is why she usually stays in denial. She does not know how to get out. She doesn’t need to be kicked out of the practice, she needs help.

I wish this kind of legislation had been around five or six years ago. All I had to do to convince my doctor I was doing well was to go in and say I was doing well. I was taking pain medication for two real, diagnosed, legitimate neurological problems (which I still have), but it had also dimly entered my awareness that it was helping me cope with psychological problems as well. (Of course, the two can’t really be separated. The wellbeing of the body is the wellbeing of the mind.) If my physician, who is diligent, had been required to submit me to a protocol of questions and demonstrations at each visit to determine my actual functionality, it might have been determined, over time, that the opioids weren’t actually helping me improve. But again, I was afraid of being kicked out, cut off, sent to the psychiatric hospital, forced to take care of my child in the interim while enduring opioid withdrawal, etc. It was a conversation I was afraid to have with my physician, because to broach it would be to puncture that can of worms and let escape The Stigma.

In my opinion, and this is just off the top of my head here, I’d really like feedback on this: every pain clinic should have a staff of certified addiction specialists who consider addiction to be a disease and not a moral failing. They would be there to protect the patient population from the risk and to help those who have the disease and who also have chronic pain (because, as above, pain patients can also be addicts).

If you’re going to call pain a disease and you’re going to be in the business of handing out opioids, you need to get real about the disease of addiction. And not in a punitive way.

Kansas doctor accused of causing 68 fatal opiate ODs

A two-month trial of a Kansas doctor accused of contributing to the deaths of 68 patients who overdosed on opiates he prescribed them has gone to a jury today in Wichita.

According to Time magazine, prosecutors allege Dr. Stephen Schneider and his wife, Linda, prescribed large amounts of all manner of opiates—Schneider prescribed hydrocodone, oxycodone, fentanyl, you name it—to patients without enough oversight, and with profit as their primary motive.

The defense, the story says, argues that the Schneiders provided proper and compassionate care for pain patients who couldn’t get it elsewhere, and also:

that the deaths were due to underlying conditions or dangerous choices by addicted patients.

The Time article, and also an Associated Press story, quote a lot of people, including:

pain-patient advocacy organizations who say that “This is really a civil rights issue” because pain patients can’t get their meds and are treated like hell when they go to the drug store or the doctor

bioethics people who say that “most government prosecutions appear to be well-founded” but that if everybody keeps talking about arresting docs for “overprescribing,” it’s gonna have a “chilling effect” on taking care of pain patients

DEA dudes and prosecutors, who say, bottom line, SOMEBODY IS GONNA HAVE TO BE ARRESTED HERE, OK?—so let’s get on with it. Who can we lock up?

Does anybody talk to an addict? No.

Addiction is squarely at the center of this story, it is the elephant in the room, and nobody is quoting an addict.

I find this absolutely fascinating.

Quote me:

Guinevere Matheson, a recovering addict and writer experienced in health-policy issues, told the press as the jury went to trial, “What this case highlights is the fact that physicians do not know how to recognize addiction in the doctor’s office. When we hear the term ‘addict,’ we think of a homeless person living under a bridge, jamming a dirty needle into his arm. This is not an enforcement issue, it’s a public-health issue. Physicians are treating more pain, so it’s logical that some chronic pain patients are going to become addicted. Addiction is a disease, just like diabetes, AIDS or cancer—we need to understand how to recognize it and treat it.”

Update: After deliberating seven days, the U.S. District Court jury convicted the Schneiders of 19 criminal counts, including illegally prescribing opioids, laundering money, and defrauding the health-care system. More about the convictions here. The source says the Schneiders prescribed Actiq lollipops to a migraineur who subsequently overdosed… This practice isn’t as rare as the story makes out. Many of us were prescribed Actiq for migraine. What saved those of us who lived remains a mystery.

Tackling the Difficult Problem of Prescription Opiate Misuse

Doctors at Georgetown School of Medicine and Mt. Sinai Hospital in Toronto have published a good editorial in the Annals of Internal Medicine about the need for better strategies to identify and prevent chronic pain patients from abusing opiate drugs.

Two strategies are currently being used:

1. The pain-patient contract, which basically requires patients to agree to consult only with that doctor (preventing doctor-shopping) and to adhere to the dosing schedule set up by the physician (i.e., not buy extra drugs off the street; not steal drugs or forge prescriptions; etc.). As if an addict in the throes of obsession would suddenly remember, “Oh right!—I signed that contract months ago (where did I put it again?), I CAN’T take those extra drugs.” If physicians think this piece of paper would prevent a pain patient from becoming addicted, then physicians do not understand addiction.

2. The urine drug-screen, which I always thought tested for drugs other than those prescribed (my doctor told me so), but maybe it measures for heightened drug-levels? To tell you the truth, I don’t know what the urine drug-screen does.

And the authors don’t know either—they say there’s little evidence that either of these tools does any good, and in fact they may create more stigma for pain patients without addiction problems who need pain treatment and don’t want to prove they’re not addicts by peeing into a cup every month.

One problem is the medical establishment/industry’s inability to define “addiction.” Even the panel rewriting the DSM V can’t figure out how to define it. The doctors write:

To paraphrase Supreme Court Justice Potter Stewart, although drug misuse and addiction are difficult to define, we all assume that we will know them when we see them. This attitude has had a devastating effect on clinical practice and research at the interface of pain and addiction.

They’re talking about that old standard about the meaning of pornography: “I can’t define it, but I know it when I see it.”

They add that a recent review on the safety of the use of opiates to manage chronic non-cancer pain noted the scarcity of addiction-related data and concluded that if there was no data, then addiction must not have been a problem. The editorial argues that addiction is a big problem that has remained hidden because of difficulties in diagnosing it when it intersects with pain management. We all know a junkie when we see her on the street, right?—but it’s harder to recognize the addict in the doctor’s office because she’s, like, not begging for money.

I know my doctor thought I had some kind of “problem” with my drugs. I think she lacked the tools to diagnose and treat me definitively, as an addict. She sends the people she thinks are “real addicts” to the psychiatric hospital. I don’t think she wanted to do that to me, however much I deserved it, and for that I am grateful to her. She was willing to help me taper, but instead I hired a detox doctor. He was what I needed. I could never taper off a full-agonist.

If you were on a panel advising these doctors, what strategies would you give them to identify the addicts in their offices?

Prescription drug addiction taking deadly toll in Montana

Montana is gorgeous big-sky country, and it is also damn isolated and boring. Apparently some of Montana’s kids are now turning to prescription opiates to liven things up a bit.

The Missioulian is covering a two-day conference at the University of Montana bringing together law enforcement and treatment providers to discuss how to address chronic pain and addiction.

According to Montana state crime lab statistics, in 2008, the year for which most recent data are available, at least 320 Montanans died as a result of prescription drug overdoses. The Missoulian reports more people died from prescription drugs in 2008 than from car accidents. In addition,

A federal study ranked Montana third per capita for the number of adolescents abusing prescription drugs, finding that nearly 10 percent of Montana’s youth is abusing prescription opiates.

The state attorney general and 240 treatment providers talked about how to treat both addiction and chronic pain effectively. Which is great: usually there’s a lot of talk about how to lock up all the junkies. The AG said,

I don’t believe that by any measure we are going to arrest and prosecute our way out of this problem. It would be not only naïve but misplaced to believe that is the case. We need effective drug treatment.

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