Addiction and Physicians - Why Having an MD Doesn't Make You Special

Haven't posted much lately, though not necessarily by intention. Life's been very crazy lately, but in a very good way.

Wanted to touch on a story that's rightfully making the rounds on social media, of a Canadian physician talking about his addiction to Fentanyl. Fentanyl is the new addict drug of choice in much of Canada, particularly in southern Ontario. It's been building for a few years. Every conversation I have with those in addictions or drug enforcement says that this is where we're seeing a big focus. It's a very powerful narcotic, one that's definitely overprescribed, and it has numerous routes of absorption. In many ways, it's the most recent culmination of the wider opioid crisis that's been growing for decades now.

Dr Gebien's tale is worth reading for its account of the devastating effects of opioid addiction, and the hubris of physicians who think they're immune to such common human failings. On the former point, there's enough written by more knowledgeable people than me that I won't say much besides a reiteration that I want my practice to be very opioid-averse. As far as I'm concerned, unless something's going to cure your pain very soon (usually by an operation of some sort), or we expect you to die at some point in the near future, I have trouble seeing the role of opioids. They don't work well long term, they're addictive, and they come with tons of side-effects. They're not really a treatment for pain, they're a way to stall it in the short-term.

On the second point, it can't be emphasized enough - doctors are human and we fall victim to all the things humans fall victim to, including addiction. One particular point to mention about this story is the hazards of self-prescribing. Physicians are not supposed to treat anyone who isn't their patient, including themselves. That means no treating family or friends except in very unique circumstances. That means no treating co-workers. That means no treating fellow physicians unless they're in your office for a valid reason. I can't say how often I've seen a physician write off a prescription to one of their colleagues based on that colleague's word alone. No history. No physical. No investigations. Just "I need this script, can you help me out?", and bam, done. In one instance, a physician asked a colleague for a medication for their child, effectively treating their own kid with the help of a fellow physician who never even laid eyes on that child! Don't do this. Yes, it sucks to have to go to your GP to get a simple script. Yes, you know exactly what needs to be done. You know who else it sucks for to have to do that? EVERYONE! Being a physician should not get you a fast track to basic medical care, nor should it allow you to skip the basic components of treatment, such as a proper evaluation. Please, colleagues, supervisors, and anyone coming afterwards, just don't do this, and don't help others do this. It's unethical and can lead to some very dark outcomes.

There's a few other elements to this story that deserve a quick mention, since they probably contributed to his situation and are much more common traps for physicians to fall into then addiction. First is proper money management. He was making $300k a year and needed parental assistance to cover two rehab-related bills of $10k and $80k, in addition to needing to put $35k on a line-of-credit. Everyone, regardless of profession, should have an Emergency fund of at least 6 months of living expenses, ideally 1 year's worth. In his case, it doesn't sound like he had anywhere close to that. I don't doubt that a fair bit of money was going to feed or hide is addiction. Yet, there are other clear missteps. Buying a large house, luxury cars, and a boat weren't necessary and probably weren't affordable. Even if your means are great, you still need to live within them.

Secondly, this story highlights the need for a robust support system. Here we see only one side of the story, so it's hard to draw conclusions, but I don't get the sense of a reliable base of support from Dr Gebien's wife or parents. Their relationships seem dysfunctional and his mother, who looked to be dealing with her own problems of opioid use, was an enabler in his addiction. Building connections with reliable people before, during, and after medical training is important. Equally important is picking the right partner - they're the one family member you get to choose.

Overall, Dr Gebien's story serves as an excellent case study in the hazards of being a physician, and the failings too many of us assume we'll avoid just by having an MD after our names. He doesn't come across well in telling his own story, and there are numerous areas to find fault in beyond just his addiction. Yet, that makes his story all the more valuable to share. Being a doctor doesn't make anyone special, better, or more capable at handling the challenges of life. When physicians start to think that it does, they start engaging in behaviours that are destructive to their own lives or, as Dr Gebien's story briefly mentions, the lives of loved ones and colleagues. Staying grounded, staying humble, and remaining self-critical of our own behaviours is critical for physicians.

Opiates and the Flexibility of Practice

Depending on who you ask, opioids are anywhere from the worst drug you could possible prescribe, to a necessary evil, to the best shot at treating a lot of suffering patients.

Opioid addictions are, sadly, quite common. They're also quite dangerous, with opioid-related deaths on the rise. They have some nasty side-effects. They're also becoming a mainstay of low-level criminal activity.

And worst of all, they don't seem to be all that effective. Perhaps there's a selection bias, but I haven't met too many patients who had good pain control on large doses of narcotics - a few who seem to do alright on small amounts, usually low-intensity narcotics like Tramadol. Undoubtedly there's some sampling bias there, plus those with greater pain may require stronger opioids. However, I've yet to really see strong opioids as being a satisfying answer to chronic pain.

At this stage in my career, I've seen a few different attitudes towards narcotic prescription, underlining the fact that there really is no established standard for their use, and highlighting that I may have a lot of leeway to dictate my own prescribing tendencies when I eventually have to make these calls myself. I'm nowhere near a finalized or even satisfying answer to the question "when should I prescribe opioids, and how?", but here are my initial thoughts.

1) Have an exit strategy
I've yet to see a glaring example of someone callously giving a patient an opioid addiction, but plenty of examples of a physician setting a patient to develop one incidentally. Narcotics are insidious in the way they trap patients and providers - a short run of narcotics gets extended, or a small dose gets increased, over and over again, until the patient is on long-term, high-dose opioids. It's far too easy for patients to believe that they need a higher dose and for physicians to see no good alternative to providing it.

Therefore, I think it's essential to have an endgame in mind when starting or increasing narcotics. If there's no timeline to how or when an opioid prescription will be ceased, then the snowball towards higher doses seems to be pretty difficult to avoid. In some cases, the "how and when" narcotic use is ceased will come with the death of the patient. That can absolutely be a valid exit strategy. However, for the large number of individuals who aren't meant to die on these medications, I'd like to have a plan to stop the medications

2) Use concurrent therapy
Opioids aren't a long-term solution to most pain. They certainly don't do anything to cure pain, only to (temporarily) mask it. However, they can relieve it for a time while other factors play out, so they do have a role. In many cases, time itself is a cure. In others, a more active approach is necessary. Even when there aren't treatable physical symptoms, mental health is an important component to address. Pain can practically go away when patients are happy and have a positive attitude. It can become crippling when despair sets in. Mental health issues might not cause pain (with some exceptions...) but it can be a meaningful modifier. At this point, I don't see much value in starting opioids if there aren't other avenues being actively explored.

3) Consider weening patients off opioids
In the simple case of one patient with one provider, opioid prescribing seems very straight-forward. However, medicine's a team sport and that means not everyone plays the same way. It's very common for patients to get started on opioids by a provider they'll never see again, or who will pass on responsibility for pain management before it's properly managed. Presumably, that initiator of the opioid didn't have an exit strategy or sufficient concurrent therapy, but that shouldn't excuse inaction on your part as the now-responsible prescriber.

Opioids don't have a good evidence-base behind their long-term usage. If a patient is on opioids for an extended period already, without sufficient response, doubling-down by increasing or even maintaining their opioid dose isn't likely to help. It's worth a trial ween. It's not going to help their pain - and will increase it in the short term - but it could save them from a number of side-effects and allow the patient (and you) to focus on more effective interventions.

Anyway, opioid use in medicine in a deep, complex problem without an easy solution. You'll find similar opinions from many individuals and groups in medicine. You'll also find many opposing views from individuals and groups in medicine. I don't claim to have any novel insight into this problem. However, these decisions will be my responsibility reasonably soon, so it's time to start forming a practical approach.