From the front lines of the opioid epidemic, two very different NY Times articles:

First, a New Jersey ER striving to come up with alternatives to reliance on opioids.

Nobody is pretending that an ER can do without opioids. The goal is simply to reduce dependence on these medications. This ER has had evident success with some of the most common ailments (migraines, kidney stones, fractures) that drive ER traffic. Some of the approaches mentioned are not science-based. Others represent options available to any ER physician, if he or she cares to use them.

This caught my eye: “At discharge, patients are often given opioid prescriptions…. E.R.s have been identified as a starting point on a patient’s path to opioid and even heroin addiction.” Outpatient clinics and physicians often continue and expand the practice. One survey found that 99% of physicians exceeded the recommended 3 day dose limit, while a quarter regularly prescribed the full 30 day supply.

It all makes sense in the context of a nation that annually consumes 80% of the world’s opioids.

The second article, an opinion piece by a practicing psychiatrist, told of using the opioid medication buprenorphine to treat depression.

It’s an off-label use, of course, that the physician justifies based on lack of success from other treatments. The patient has been off heroin 5 years, and happens to comment during a session that “… the only time in her adult life when she had been able to socialize easily and function at work was when she had been hooked on heroin.” It’s something therapists often hear from their addicted patients, whether it’s about alcohol, cocaine, heroin, whatever.

What caught my eye was the opening sentence:  “One of the most painful experiences of being a psychiatrist is having a patient for whom none of the available therapies or medications work.”

In my experience, most physicians are helpers by nature as well as training. It’s no accident they choose this often challenging work, and it genuinely bothers them when they can’t relieve a patient’s discomfort. That discomfort is often in the form of patient complaint. And a complaining patient can be difficult to resist.

I shared the piece with some colleagues, who came up with the usual diverse views.

  • One said he’d consider buprenorphine if other legit attempts had failed.He’d require the patient commit to continued therapy (“otherwise there’s too much potential for misuse.”)
  • Another wondered about a future time  when the patient, now doing well, wanted to taper off. That could trigger a heroin relapse — return to heroin post-maintenance being a common occurrence. “Frankly, I might try to talk her into staying on it,” she admitted.
  • A counselor, in recovery himself, had a very different view. He wondered if the patient’s goal hadn’t been to find a doctor willing to put her back on opioids. “If that was the case,” he noted, “I suppose it was a resounding success.”