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Are You Afraid to Help?
The headlines were impressive. Maintenance man successful in daring river rescue! Valor and selflessness are not dead!
During the summer of 1989 I experienced the life of a hero in my small town after I saved a drowning woman. The experience contributed to my eventual desire to attend medical school, and supported me during times in my life when I’ve let myself down. The experience helped me remember that I have the guts to step up to help a person in need, a trait that all good doctors should have.
After the rescue, reporters asked how I decided to go into the cold, deep water for a person I didn’t know. I remember saying in reply that I didn’t have a choice, because I couldn’t imagine standing on the shore and watching a person drown.
I worked as an anesthesiologist between 10 and 20 years ago, a job that I (along with many other anesthesiologists) would characterize as 99 percent boredom, and 1 percent sheer terror. When attending to the respiratory failure of a morbidly obese patient, for example, I could tilt the odds in my favor by preparing a variety of laryngoscope blades, opening a crico-thyroidotomy kit, and having an ENT surgeon on standby. But when the time came to perform the intubation, no amount of preparation removed all of the risk. The same could be said for anesthetizing a newborn or placing a cervical epidural. All of those procedures cost me restful sleep, but there was something about the attendant fear that fit my personality. I’m open to the possibility that the fear contributed to my eventual opioid dependence, but that’s another story for another time.
…I didn’t have a choice, because I couldn’t imagine standing on the shore and watching a person drown.-Jeffrey T. Junig
The practice of addiction medicine stirs a different fear, and I can’t imagine any personality that would find the fear a good fit. As an anesthesiologist I feared being placed in the position where even my best efforts would be stymied by an impossible situation. As an addiction doctor, I fear that the best option for one of my patients will run counter to the prevailing winds of drug prevention, placing me in the crossfire of regulators or causing me to appear guilty by association. I’ll provide one example—the situation when a patient runs out of medication early. But there are many situations that create the same conflict, such as deciding when to discharge a relapsing patient or whether to make accommodations for a patient with severe financial hardship.
Every doc who prescribes buprenorphine is familiar with the scenario that occurs relatively often, despite our best efforts, when otherwise- stable patients take too much buprenorphine. And every doc with good knowledge of pharmacology and neurochemistry knows that such patients do not take extra medication to get high, and do not, in fact, get ‘high’ from the medication. They take extra medication because they were conditioned, through years of addiction, to do exactly that. Active opioid addicts learn to use opioids when they feel good, or when they feel bad. And even while stable on buprenorphine treatment, the brains of opioid addicts retain the neural substrates for that conditioning – despite years of AODA therapy (I suspect even after a lifetime of therapy!).
Such patients will do great on buprenorphine, going days, weeks, or months without any desire to take any opioid beyond their morning dose of buprenorphine. But then life happens, as it has happened many times before. And just like on those many other days, the patient experiences an emotion in response to whatever happened. And for reasons beyond the full grasp of neuroscience, this time around, the patient has the unconscious desire to take something that blocks those emotions, and decides, half unconsciously, that there is no harm in an extra dose of buprenorphine.
On some level the person feels comforted by that extra dose of buprenorphine, but if challenged to quantify the experience most patients admit that nothing of substance was gained.-Jeffrey T. Junig
On some level the person feels comforted by that extra dose of buprenorphine, but if challenged to quantify the experience most patients admit that nothing of substance was gained. There was no mood elevation, no true calming of the nerves, and no real reduction in cravings. The extra dose is just that – the extra experience of taking something, and placing trust in whatever is being taken. For the buprenorphine patient, I suspect that part of the comfort derived from an extra dose comes from replicating the placement of trust in one’s caretaker – nothing more sinister than that.
But extra doses of buprenorphine create a significant problem at the end of the dosing interval, when patients request early refills. All of the focus on buprenorphine diversion seems to have convinced most pharmacists that even the most innocent-looking patients are part of a massive buprenorphine diversion ring! Nobody has the real numbers, but my years of working with such patients convinces me that far more early refills are caused by an occasional extra dose of medication, rather than an effort to set aside medication to sell and augment one’s income.
What is the ethical choice for doctors when such patients call the office to say that they are two or three days short of medication? Should the doctor say, “I’m sorry, but I never allow early refills,” knowing that such a decision will result in either several days of illness that may trigger efforts to replace the medication with illicit buprenorphine – or something much worse? Is it ethical to refuse the early refill to prevent a theoretical risk to society, in the face of very real risks to a specific patient?
For the record, like most doctors, I tell such patients that I cannot provide early refills, in part hoping that I’ll motivate them to avoid the same situation next month. But in all honesty, the other reason I refuse early refills is out of fear that if I don’t, I’ll be viewed as part of the problem: a pushover doctor who panders to drug addicts, allowing extra buprenorphine to reach the street. That last half-sentence sounds pretty important to most people, and I keep telling it to myself as my patient calls to tell me that he’s too sick to go to his son’s baseball game. I repeat it to myself when I think of the profound misery of opioid withdrawal, as I try to forget that almost nobody dies from diverted buprenorphine.
…the other reason I refuse early refills is out of fear that if I don’t, I’ll be viewed as part of the problem: a pushover doctor who panders to drug addicts, allowing extra buprenorphine to reach the street.-Jeffrey T. Junig
Still, every time I tell a patient that I don’t do early refills, I have a little sense of what it would have felt like to stay warm and dry on the riverbank, 30 years ago.
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