Opiate Dependence or Addiction?

As we close out Recovery Awareness month (September) the need for recovery and addiction treatment persist. Unfortunately, a great deal of stigma remains. Many people complain of “being judged” when presenting prescriptions to pharmacist. This is known to happen when patients present prescriptions for opiates used for pain management and also when being treated with medically assisted therapy for Opiate addiction.

This “judgment” is unfortunate and aided by confusion between Opiate dependence and addiction. Dependence denotes the patient is requiring opiates and “dependent” on those opiates. It does not indicate the patient is “addicted”. Dependence indicates a physical component including the possibility of tolerance and withdrawal. Addiction is neurological and describes behavior. Addictive behaviors include: being unable to control drug use, destructive behaviors and cravings. Another confusing factor is that one can have addictive behavior without addiction and one may also have dependence without addiction.

What is not needed is judgment or misuse of terms that deter people from seeking treatment or obtaining prescriptions. Physicians treating patients with opiates monitor for signs of addictive behavior and monitor physical dependence and medication efficacy. It is not within the scope of practice for pharmacist or other non physicians to judge patients or fill prescriptions based solely on a diagnosis. Two different patients may have the same diagnosis but have very different clinical needs. It is the job and clinical assessment of physicians that should be the determining factor in a patient’s medication needs.

What physicians do need to account for is the availability of other means to treat pain and addiction. At our Opioid Treatment Center in Marietta, GA. We use acupuncture and physiotherapy to avoid the need for opiates. We also treat addiction with (Buprenorphine) in addition to counseling.

As recovery awareness month closes we should ALL remember to be nonjudgmental and use alternatives to opiates whenever possible. Here at Acupuncture and Injury, our goal is to have our patients “pain free without pills“^TM.

Can your doctor lead you to recovery from Opiate addiction?

Medically assisted therapy for opiate addiction has many critics. Some value only specific counseling treatment programs for opiate addiction. Many will criticize medically assisted therapy as simply “substituting one drug for another”. The fact of the matter is, there is no one therapy that works for every patient. One must understand that the term “medically assisted” implies there is more than just the medication being used to help the patient in recovery.

On the medical side, some facilities will not differentiate between one opiate treatment modality and offer a number of different medications for the treatment of addiction. Unfortunately, the modality chosen is often done for monetary reasons and not the benefit of the patient. As one patient recently lamented: “When I started at the Methadone clinic, another patient told me ‘say goodbye to the next five years of your life’. That was 5 years ago.” The statement depicts the actions of some Opioid Treatment Centers keeping patients on medication for the sake of repeat visits and monetary gain without consideration for weaning the patient off or down from medication. This IS NOT the way we treat patients at our Opioid Treatment Center.

We have discussed the use of Suboxone (Buprenorphine) as a Methadone alternative in a previous blog. Methadone has a higher risk profile and usually requires more frequent visits. Many patients are prescribed Methadone and kept on it for long periods of time. This is done despite the alternative of Suboxone treatment being available. A Suboxone Treatment Center like our office can provide Suboxone treatment and appropriate referrals to counselors as part of a treatment plan to eventually have the patient completely “opiate free”. As a Subxone treatment doctor, I often tell my patients that: 80% of treating addiction is counseling the other 20% is monitoring and adjusting the medication dosage.

What often isn’t discussed is: How do patients get into treatment? I have described elsewhere how so few primary care doctors screen for or make referrals for opiate addiction. The more complex part of the problem is how quickly some doctors will prescribe opiates. For example: I once had a patient referred for pain management stating she had Rheumatoid arthritis in her hands. She stated that her primary care doctor told her he could no longer treat her pain and that she had to go to pain management. Strangely, she had no laboratory or X-ray studies done to confirm the Rheumatoid arthritis diagnosis. When X ray studies were performed they only revealed “mild osteoarthritis”. Lab studies were also negative for Rheumatoid arthritis but the patient had already developed addictive behavior! When doctors are cavalier with the prescribing of opiates and neglect to screen for opiate or other addiction, the results are not in the patient’s best interest.

So the question remains: “Can your doctor lead you to recovery from opiate addiction?” That question should not be confused with “Can a doctor lead you to recovery?” The difference of course is how YOUR doctor handles opiates and addiction. You can simply ask your doctor if they regularly refer patients for addiction treatment. If so, where to? Keep in mind that about one in ten patients in a given primary care waiting room uses opiates. Is YOUR doctor quick to prescribe opiates? Does YOUR doctor routinely refer patients for non opiate-based pain treatment like acupuncture, physical therapy or chiropractic? If not your doctor maybe leading patients toward addiction which is opposite to the road to recovery! In addition, does YOUR doctor advocate for insurance companies providing non opiate based coverage for pain management when it’s denied?

You can learn about your doctors referral habits by asking a few simple questions:

• • Where does he/she refer patient for Addiction Treatment in Georgia?
• • What methadone alternatives does your doctor recommend? Does he/she have a referral relationship with a local Suboxone Treatment Doctor?
• • Knowing your doctors referral habits can give you insight as to whether or not they can lead you or a loved one to recovery from opiate addiction.

Pills but no needle is often the road to addiction

The story of Peter

The story of Peter. Peter had the unfortunate circumstance of being injured an automobile accident in Georgia. He was uninsured at the time of his accident. His lawyer was able to settle Peter’s case but after the lawyer took 40% of the gross personal injury settlement and negotiated lower fees for Peter’s doctors, the attorney had pocketed more money than Peter! Matters were made worse when, Peter continued to have chronic pain from his injuries. Peter was still uninsured and when he tried to obtain insurance, his monthly premium quotes were in the excess of $500a month. A cash visit to a Pain Management Doctor was less than $300 and would at least give him pain relief.

During his Pain Management Therapy, Peter wasn’t able to afford injections such as epidurals, he wasn’t offered acupuncture and he had already had chiropractic during his original treatment with his auto accident. He stated:“I want to try something else. The chiropractor helped but I am still in pain.”Peter had a several visits with a physical therapist but became discouraged and angry saying “all they do is charge me to teach me exercises that I can do at home!” He had no primary care doctor due to lack of insurance. The Pain Management Specialist only offered Peter opiate pain pills since Peter couldn’t afford interventional treatments and the pain doctor didn’t perform acupuncture.

Peter was able to continue to work construction and handyman jobs due to the relief provided by the pain pills. However, Peter became more physically dependent on the pain pills. After a while, Peter’s doctor became uncomfortable prescribing Peter higher doses of his medication. Peter then turned to marijuana and CBD oil to make up for the pain relief that the pills no longer provided. As a result, Peter tested positive for a urine drug screen and was discharged by his Pain Management Doctor.

Peter was still unable to get insurance due to the high premiums and out right denials caused by his “preexisting condition” from his auto accident. After being discharged from his pain doctor’s office, Peter tried to enter another pain clinic. He was told things like “it’s a 4- 6 week wait to get in after we review your records” and “we only accept new pain patients by referral from other doctors”. Peter was still having pain and needed to work. He started obtaining pills on the street. He experimented with other forms of opiates and even tried Heroin. Peter’s drug used became more than a dependence he had crossed over into the realm of addiction. He was missing work to seek out drugs, resorting to selling drugs, stealing and other activities he could engage in to get the money to fuel his habit. Eventually, Peter lost his job, was homeless and had alienated his family due to his addiction. He finally hit rock bottom and overdosed on Fentanyl which was manufactured on the street to look like the Oxycodone he had been used to taking.

While In the hospital, Peter was diagnosed with Hepatitis (apparently from his previous intravenous drug use). Upon discharge he was referred to Methadone treatment. Peter asked about Methadone alternatives but was told by his doctor there were none. Peter had heard about and occasionally used Suboxone during his time “on the streets”. Peter remembered Suboxone decreasing his cravings and making him feel“normal” without feeling groggy and short of breath like he did with methadone. Peter looked around and inquired about Opioid Treatment Centers and finally found a Suboxone Treatment Center where he could pay cash at a reasonable price. The Addiction Treatment in Georgia center was able to change Peter from methadone to Suboxone. Peter was also introduced to acupuncture to treat his chronic pain from the auto accident injuries. Peter was shocked at how much better he felt after a course of 10 acupuncture treatments. Peter said, “ I wish I had known about these needles before I took all those pills!”

As Peter continued his Suboxone and Addiction Treatment in Georgia, he was eventually able to find work again. He started and continued counseling at a church nearby (as he couldn’t afford a professional counselor without insurance). Peter learned to cope with life’s ups and downs. He learned coping skills and how to avoid triggers. He even learned to tolerate the judgmental look he received from the pharmacist when he filled his Suboxone prescription. He found it odd and often chuckled to himself at the irony.Peter remembered it was the same look he received when he would get his Oxycodone prescription filled in the past.

Eventually, Peter was old enough to obtain Medicare. He had lost homes, jobs family and had permanent liver damage. When he had his first Medicare exam he was offered opiates for his chronic pain. Peter refused stating he would “pay out of pocket” for acupuncture (which isn’t covered by Medicare). Peter’s Medicare doctor was always surprised by Peter’s insistence that acupuncture was controlling his pain. Despite Peter stating his pain was well controlled, Peters’ doctor continued to offer opiates. One day Peter finally became annoyed and asked: “Pills? Is that all you have? You do know that I have liver damage?, Right? Why do you keep trying to get me to take pills? Don’t you realize that the acupuncture needles have saved me from so much pain? If I had known about those needles I would have probably never taken the pills that got me into so much trouble!! WHAT IS IT THAT YOU DON”T UNDERSTAND ABOUT THAT!!!??

Peter’s doctor said,“well we don’t have studies or insurance approval stating that acupuncture really works.” Peter became more upset and said” DO YOU THINK I NEED A STUDY TO TELL ME THAT MY PAIN IS BETTER? ACUPUNCTURE HAS BEEN AROUND FOR THOUSANDS OF YEARS AND YOU ARE TALKING TO ME ABOUT STUDIES?? REALLY? REALLY? DO YOU EVEN KINOW ANYTHING ABOUT ACUPUNCTURE? Peter’s doctor then said, No I have not studied acupuncture. I am a medical doctor. Peter then said, acupuncture has got me “Pain Free without Pills”^TM you doctors all have something to learn!

Medical Acupuncture, a Promising Solution to the Opioid Crisis

The Opioid Addiction Epidemic

What Is Enabling Behavior? Addiction

A Closer Look at Opioid Medication Treatment

Getting Started with Addiction Treatment