Join us on October 4 for a free panel discussion titled “The State of Opioid Addiction in Vermont: Treatment & Research,” part of Community Medical School at the Larner College of Medicine at UVM. The panel will feature Stephen Leffler, MD, Chief Medical Officer, Charles MacLean, MD, and Patricia Fisher, MD. The event takes place at 6:00-7:30pm at the UVM Given Medical Building – Carpenter Auditorium, 89 Beaumont Avenue, Burlington, VT 05405. Plenty of free parking is available. For more information call 802.847.2886.
I’ve been a family physician for 15 years, mostly here in Vermont taking care of an underserved population at the Community Health Centers of Burlington and now as a hospitalist at the UVM Medical Center.
I have met many people over the course of my time in Burlington addicted to opiates and/or heroin and I’ve seen first-hand the devastating effects it has on people, on their health, their lives, their housing status and their ability to function in society. I’ve had patients go to jail, lose custody of their beautiful children, lose their homes, their spouses, get disowned by their parents, lose their ability to make a living and I’ve had patients die. Usually, they die unintentionally. They take too much or they melt prescription tablets and inject the medication into their veins. Deaths have come at the hands of a medication I was prescribing.
A Familiar Face in the Clinic
Recently, I’ve been treating patients who are addicted to opiates with a drug called buprenorphine or suboxone in a bridge program at the UVM Medical Center. One of my first days at this clinic I noticed a familiar name on my schedule — a name I knew from my former days at the Community Health Centers. But when the patient walked in, I didn’t recognize his face. He was a younger man than the man I was thinking of. But, he remembered me. I had taken care of his dad, with whom he shared his name. I had prescribed opiates to his dad for chronic pain for many years. Opiates that this young man had started taking (and selling with his dad) at the age of 13. I couldn’t believe what I was hearing: I had been the source prescriber for this patient’s 10-year opiate addiction. He switched to heroin and experienced a subsequent series of arrests and incarcerations and eventual placement into treatment. Ten years this guy lost to opiates, and he still looked like a kid.
What are providers doing to address this?
Experiences like these are why I have been working hard to change how my colleagues and I prescribe opiates to treat pain as well as how we treat patients dealing with opiate addiction. According to the Centers for Disease Control (CDC), 165,000 people died in the US between 1999 and 2014 from opiate overdoses alone. And that figure does not include all the other opiate-related deaths from liver failure, hepatitis and infections from IV drug use. Our state and federal governments have been working in conjunction with leading clinicians to change guidance for providers. An example is a recent directive from the CDC: “Opiates should not be considered first-line or routine therapy for chronic pain outside of active cancer, palliative and end of life care.” That statement takes us a long way from the 1990s when doctors were introduced to pain as the “5th vital sign,” meaning that all pain should be treated.
I would be lying if I said this was an insignificant change in how most clinicians will treat patients who are experiencing pain. We’re doctors; we’re trained to ameliorate as many negative symptoms as we can identify – to improve the lives of the patients before us. Telling a patient currently experiencing pain that, in order for them to best manage their pain in the long run and reduce the chances that they will become dependent on opiates (both prescription and illicit), they have to remain in some amount of pain, is not an easy thing. But, there is no doubt now that it is the right thing to do, and at the UVM Medical Center we’re working to integrate this directive into our clinical protocols and training. We’ve already made great strides in changing practice in the Emergency Department, and are focusing on integrating these protocols into other parts of the organization, like our primary care clinics.
Finally, my colleagues and I have come a long way in understanding our role in providing treatment to patients who are addicted to opiates. Through work being done internally at the UVM Medical Center, as well as through collaboration with community agencies like the Howard Center, we are building a system that ensures that people have access to the right level of treatment when they are ready to access it. That means increased capacity at our Hub, and a dramatic increase in the number of primary care providers prescribing buprenorphine in combination with cognitive behavioral therapy and supports right in their practices. We have come a long way in a short period of time, but we still have a long way to go in our community and around our state.
And that young man I spoke of earlier? With treatment, he is doing much better. He is now being seen by a primary care physician, is employed full-time, is in a stable relationship and has two young children that he is raising. He has done amazingly well.
Patti Fisher, MD, a family medicine physician, is the Medical Director for Case Management and Medical Staff Affairs at the University of Vermont Medical Center. She is also an assistant professor at the Larner College of Medicine at the University of Vermont.