Dana Corriel wrote in KevinMD, “The doctors who did this should be hanged.”It’s a statement the came at her with a bang. It stood out in its thread, in the accusatory way of old courtroom scenes of black and white movies, where the heroine dramatically screams out at the jury, seated wide-eyed in their box nearby.

But it was merely a response to a Facebook post on the topic of the opioid epidemic, typed in nonchalantly, by an otherwise peaceful-looking individual, who had clearly had their buttons pushed and was subsequently irate. She didn’t think she meant harm by it, but it hit her like a ton of bricks. She thought about her accusation long and hard; about all the accusations on the thread.

The doctors who did this? Have we honestly “done this?” Why am I lumped into a collective, and deemed responsible for something grand like an epidemic, when I slave through patient after patient, and do my due diligence of the searches and actions described above? Have I failed at something and not recognized it?

More quotes from the general public on this matter, screaming at me from the computer screen, as if typed in all-caps, below. Under each one, my visceral reaction:

“Doctors like this all over the country are running mills.”(I’m not. But I prescribe pain medications and am now fearful of being labeled and blamed, thanks to accusations like this).

“Yes, the doctors and big pharmaceutical companies fueled the opiate epidemic, and guess who is making billions off of rehab drugs like suboxone? You guessed it those same doctors and big pharmaceuticals.”

(Doctors make billions? How exactly does my prescribing a medication result in money directly in my pocket? I don’t benefit from a prescription monetarily. I do, however, admit to an emotional benefit when my prescriptions result in lowering blood pressure. Or normalizing glucose levels of a diabetic. Or making pain disappear. We’ll leave out cholesterol levels at this time because of the growing trend to suddenly blame doctors for “greed” in prescribing statins to lower patients’ cholesterol levels and heart disease risk. It all seems to be a conspiracy. Except that no one’s filled me in on the plot, and I’m actually one of them).

(Plus, is it just me or do faceless accusations seem to be the biggest “in” thing on social media these days?)

“The opioid problem in this state starts with the doctors overprescribing them.”

(What defines “overprescribing?” Under which scenario would an over-prescription be an accurate description? If Percocet is to be taken every 4 to 6 hours, as is FDA-approved, is it not legitimate that one quite possibly prescribes a larger supply? Should I negotiate the number of tablets, much like the sale price at an auction? If not, does the patient need a return visit for more? Because I know what takes place when this happens. The patient says, “The doctor is only making me come in for a co-pay.” He then subsequently rates me poorly on the mail-home patient survey, which comes back full circle to kick me in the ass, since government ironically plans to change reimbursement based on scores in patient satisfaction, recorded on this very same survey. A catch-22, to say the least.)

“Our society has changed. People are now told they don’t have to deal with any discomfort or problem. We supposedly have a solution for everything. So someone who has pain rather than deal with it goes to the doctor and gets something to make the pain go away. 50 years ago it was deal with it until it’s gone.”

(This actually makes some sense, and I agree with some of it. But the bottom line is that I practice medicine, and, to some degree, am here to serve. If someone stands before me, in pain, asking for an appropriate “next” medication, and that medication is controlled, who am I to tell them to “just deal with it?”)

“Doctors are drug dealers in white coats.” (Drug dealers? Is this also true for antibiotics that make you better? Or for anti-depressants that make you better? Or diabetes medications that make you better? What is it about our line of work that makes us so vulnerable to criticism? What has turned us into dealers in the eyes of the public, especially now, when we’re equipped with a magnifying glass to weed out those who have grown dependent or actually abuse?)

“Doctors all over this country are getting people addicted” and “About time the doctors get the blame for this epidemic.” (Ouch. A collective accusation, once again, and it hits right where it counts.)

What strikes me to the core is the fact that the general public has stopped seeing us as the healers, and started viewing us as the drug dealers. We are now the enemy. It leads me to ask the following:

When did we who practice medicine, and mean no harm, actually start doing exactly what we swore not to do? When did we turn into the bad guys and how do we revert back to the good?

This all happened because we tried to help. I imagine patient X, the first narcotics patient, who stood in front of his doctor, cringing in pain, who was subsequently made to feel better by that little blue paper, signed illegibly (an attempt to infuse some comic relief into this serious post) and traded in at the pharmacy for “pure gold,” the pain reliever. When the patient thanked him for his miracle treatment, the doctor must have thought, Eureka! Boy, was he wrong.

The blame also came about because we have 15-minute slots in which to resolve patient problems, which, when they happen to be pain, can be tough to tackle. Because there aren’t many effective alternatives. Because we haven’t been properly trained in identifying and, more importantly, confronting head-on, the issue of dependence and addiction. Because we don’t enjoy confrontations. Because we want our patients to leave happy. These somehow all combined and turned us into the bad guys.

Betsy McCaughey reported that tragically, myths and misinformation are blocking the path to preventing more deaths. Start with the causes of the opioid crisis. On “Face the Nation,” New Jersey Governor Chris Christie, chair of Trump’s opioid commission, blamed overprescribing doctors. “This crisis started not on a street corner somewhere. This crisis started in the doctor’s offices and hospitals of America.” That’s untrue, Governor.                                                                                                                                               It contradicts scientific evidence and lets drug abusers off the hook. At least three-quarters of opioid pill abusers and almost all heroin addicts got hooked without ever having been prescribed pain medication for an injury or illness, according to the National Survey on Drug Use and Health. Emergency room records show only a fraction – 13 percent — of opioid overdose victims began taking drugs because of pain, according to the medical journal JAMA Internal Medicine. The media feature many stories about patients who needed pain killers and later became addicts, but these are exceptions, not the rule.

Consider also the article in the New York Times this morning reporting on high school and college students experimenting with drugs just as they have done for decades with alcohol and “weed.”                                                                                                           Experimenting with opioids — whether heroin or pills — is almost always a choice., a bad choice. Young adults account for 90 percent of first-time abusers. To protect the next generation from making that mistake, Trump proposes a “massive advertising campaign to get people, especially children, not to want to take drugs in the first place.” The liberal media mock Trump’s proposal as a throwback to the 1980s, but in fact he’s on the mark.

For decades, popular music has glamorized drug use. Late-night host Jimmy Kimmel pays lip service to tackling tough political issues, but his guest lineup this week includes Ty Dolla $ign, whose music videos showcase drug use.

Trump is offering an alternative message. History proves it can work. In 2012 and 2014, the Centers for Disease Control and Prevention ran hard hitting and graphic ads against smoking, with ex-smokers talking about their own lung disease, cancer and other miseries. The ads cut smoking among youth and convinced 400,000 smokers to quit for good. Trump’s campaign should be just as terrifying. Show hospitalized teens with their arms amputated because of infections from heroin needles and brain-damaged overdose victims in nursing homes.

Warning about opioid abuse sounds like a no-brainer. So why do activists like Kassandra Frederique of the Drug Policy Alliance deplore “the persistent stigma of drug use”? As if we’re not supposed to hurt addicts’ feelings. With drug overdose deaths at record highs, that’s misguided.

You no longer see smoking in movies or on television. Stigmatizing cigarettes worked. So why de-stigmatize opioids? We can help those already hooked without doing that.

Christie calls addiction a “disease.” It’s true that some people succumb to it more than others. But new research suggests the disease metaphor could be hurtful. Addicts who believe they have the free will to quit have a much higher success rate than those who think of themselves as diseased, according to new research from the University of Minnesota and Florida State University. Quitting Parkinson Disease or Alzheimer’s isn’t possible, but getting off drugs is.

Harvard professor Gene Heyman insists addicts can choose to stop using drugs once “the penalties for excessive use become overwhelming,” such as losing their job or their kids.

Half of addicts who quit do it without treatment. The drug treatment industry doesn’t want you to know that. The industry is salivating for more public funds, and joining Democrats in bashing Trump for not spending more. But he’s right. Families exhaust their savings and taxpayers foot ever-mounting bills for treatment despite a dismal success rate (under 30 percent) at most rehabs.

To save lives and get better results for the $50 billion already being spent yearly, Washington needs to stop pinning the blame on the medical community, scrap political correctness and turn to the research. And most important, bombard young people with warnings against ever trying drugs.

We also have to consider the long-term effects of this crisis/I.V. drug users. It’s far more than overdoses: IV opioid users’ diseases are overwhelming hospitals.

Jayne O’Donnell and Terry DeMio in the USA Today network reviewed the long term problems even after the addicts are “crured.” Sarah Bolin’s heart infection got so bad last month, the longtime heroin user was passing out by the time she got to Cincinnati’s Christ Hospital. She was relieved the infection — called endocarditis — didn’t require her to get a pacemaker or replacement heart valve like so many other “girls on the streets.”

It did require surgery to remove lesions from infected valves, a 10-day hospital stay and weeks of IV antibiotics and nursing home care.

As opioid overdoses dominate headlines, more hidden casualties of intravenous drug use are overwhelming the hospitals tasked with treating them. Addiction clouds users’ judgment so much that patients thwart or reject treatment for their infectious and other diseases. And hospitals, taxpayers and people with commercial insurance foot the bill for repeated return visits that can cost from tens to hundreds of thousands of dollars a year per patient.

Hospitalizations for endocarditis increased almost 50% from 2002 to 2012 and average about $50,000 per patient, according to the Department of Health and Human Services. Little known to the public, it is well known to the medical community as a side effect of opioid addiction.

Other related illnesses include:

• Hepatitis C is the most common infectious disease affecting people with opioid use disorder, according to an analysis for USA TODAY by Amino, a health care analytics firm, but what’s less known is that progress treating it is being reversed by the opioid epidemic.  Reported cases of acute HCV infection nearly tripled to about 2,500 from 2010 through 2015.
• The antibiotic-resistant infection MRSA is  the second most common co-occurring condition with opioid use disorder, according to an analysis for USA TODAY by Amino. MRSA costs about $10 billion a year to treat in the U.S. or about $60,000 per patient.

There’s been no shortage of solutions out of Washington recently, including last week’s roundly embraced recommendations by the Trump administration’s opioid commission. The Department of Health and Human Services is advocating more coordinated health care for those addicted to opioids so they get treatment when they show up with related medical problems, as well as needle exchange programs.

Attempts to include addiction treatment with medical care often fail because local options aren’t available fast enough, there’s no in-patient care or patients aren’t willing to quit.

“Now that the opioid epidemic is a public health emergency, it’s supposed to make personnel and/or money more easily mobilized to deal with the problem,” says Leslie Dye, a medical toxicologist who is an addiction medicine physician in Cincinnati. “And the opioid commission made all these recommendations, but where do you get the resources? Where do we get the money?”

Leslie Dye is a medical toxicologist working as an addictive medicine physician in Cincinnati. She is also a vice president and medical editor at the analytics company Elsevier. (Photo: Courtesy of Leslie Dye)

Along with insuring more low-income people, the Affordable Care Act was supposed to lower health care costs by rewarding doctors and hospitals for keeping people healthy and by coordinating care. For opioid addicts, however, those rules often don’t apply, because addicts care for their addiction and not their health.

“Non compliance is probably the biggest risk factor for death in this country,” says Dye, also a vice president and medical editor at the analytics company Elsevier, which has a new opioid resource center.  “Addiction is a disease where their brain is saying, ‘Please, please make me feel better.'”

Cardiac care with heart

There’s no national data on endocarditis costs, but a recent study showed North Carolina’s costs to treat endocarditis in opioid users shot up from $1.1 million to $22.2 million between 2010-2015, an 18-fold increase. One small rural hospital in Waycross, Ga. spent nearly $400,000 to treat one uninsured IV opioid user’s four cases of endocarditis. That doesn’t include her cardiac surgery at another hospital.  And at Miami’s Jackson Memorial hospital, infections overall in IV drug users cost the hospital more than $11 million in one year.

Florida and Georgia have not expanded Medicaid so unless the patients are disabled, hospitals are paying for the care, often using federal funding for indigent patients that is being threatened in Congress. Bolin in Cincinnati is on Medicaid.

“The addiction issue is causing the endocarditis, so if you’re not treating the addiction, they’re going to be coming back,” says Ulas Camsari, a Mayo Clinic addiction psychiatrist who co-authored the Georgia study while working for the Waycross hospital.

 Yale medical school student Max Jordan Nguemeni Tiako, left, is shown with Yale New Haven Hospital cardiologist Arnar Geirsson, who is chief of cardiac surgery. (Photo: Yale)

Cardiologist Arnar Geirsson, Yale New Haven hospital’s director of cardiac surgery, estimates surgeries for endocarditis have quadrupled in the last three to four years. He and Yale medical school student Max Jordan Nguemeni Tiako are working to quantify the exact increase and how much is attributable to IV drug use.

“If you get a new valve in the heart and get back to using drugs, it will go back to being infected,” says Geirsson. “It’s an ethical dilemma for surgeons: How many times do you do a life saving operation on a patient who is actively using drugs? One can argue there is a shortage of resources to do these operations.”

Their work comes as Yale’s medical school launches a new addiction medicine program where research will include recognizing substance use disorders in primary care doctors’ offices and hospitals, as well as improving access to treatment.

A ‘girl’ and the street 

Bolin thought she had pneumonia and believed she had fluid around her heart. Still, she didn’t go to the hospital until she could barely breathe.

Addicted to heroin almost since her mother first shot her up when she was 17, Bolin

was relieved that her endocarditis surgery was relatively simple, as other homeless women suffering from addiction she knows have had to endure multiple return trips to emergency rooms because of endocarditis.

Scarlet Hudson, Ministry Director for Women of Alabaster Ministries, prays with Sarah Bolin, 36, as she recovers from endocarditis at Christ Hospital in Cincinnati. (Photo: Liz Dufour, The Enquirer/ Liz Dufour)

Bolin feels lucky she hasn’t contracted HIV, the virus that can cause AIDS. She wasn’t so lucky with “Hep C,” though she’s not being treated for it yet. This inflammation of the liver costs about $84,000 to treat and, if it goes untreated, can lead to liver cancer and death.

During a recent hospital visit, Bolin was prescribed Suboxone, which eliminated her heroin cravings, for the first time. She resolved to get clean.

Bolin said her reluctance to go to a hospital was “a fear of hospitals, a fear of the unknown.” But she said people with addiction avoid hospitals because they are afraid of withdrawal, of being stuck somewhere without heroin. She acknowledged that’s happened to her, too, when she had infected abscesses.

Despite her resolve, Bolin’s addiction won out. She slipped out of the hospital minutes before she was going to be transported to a nursing home for additional care.

She remains on the streets, relapsed on heroin and so are others.

And low and behold a study finds that Docs don’t need to use narcotics for pain control in many cases and as I mentioned in a previous post that I haven’t used narcotics for post-op pain control in 5 years. The article written by Lindsey Tanner reviewed the study that Drugstore pain pills as effective as opioids in ER patients. Emergency rooms are where many patients are first introduced to powerful opioid painkillers, but what if doctors offered over-the-counter pills instead? A new study tested that approach on patients with broken bones and sprains and found pain relievers sold as Tylenol and Motrin worked as well as opioids at reducing severe pain.

The results challenge common ER practice for treating short-term, severe pain and could prompt changes that would help prevent new patients from becoming addicted.

The study has limitations: It only looked at short-term pain relief in the emergency room and researchers didn’t evaluate how patients managed their pain after leaving the hospital.

But given the scope of the U.S. opioid epidemic — more than 2 million Americans are addicted to opioid painkillers or heroin — experts say any dent in the problem could be meaningful.

Results were published Tuesday in the Journal of the American Medical Association. Long-term opioid use often begins with a prescription painkiller for short-term pain, and use of these drugs in the ER has risen in recent years. Previous studies have shown opioids were prescribed in nearly one-third of ER visits and about 1 out of 5 ER patients are sent home with opioid prescriptions.

“Preventing new patients from becoming addicted to opioids may have a greater effect on the opioid epidemic than providing sustained treatment to patients already addicted,” Dr. Demetrios Kyriacou, an emergency medicine specialist at Northwestern University, wrote in an accompanying editorial.

The study involved 411 adults treated in two emergency rooms at Montefiore Medical Center in New York City. Their injuries included leg and arm fractures or sprains. All were given acetaminophen, the main ingredient in Tylenol, plus either ibuprofen, the main ingredient in Motrin, or one of three opioids: oxycodone, hydrocodone or codeine. They were given standard doses and were not told which drug combo they received.

Patients rated their pain levels before taking the medicine and two hours later. On average, pain scores dropped from almost 9 on a 10-point scale to about 5, with negligible differences between the groups.

Ibuprofen and acetaminophen affect different pain receptors in the body so using the two drugs together may be especially potent, said Dr. Andrew Chang, an emergency medicine professor at Albany Medical College in upstate New York, who led the study.

He noted that a pill combining ibuprofen and acetaminophen is available in other countries; his findings echo research from Canada and Australia testing that pill against opioids for pain relief.

Let’s discuss about health care and health care reform next.