The resulting legislation, while well-meaning, had unintended consequences that could have been predicted by addiction specialists. However, physicians were not invited to the table to discuss solutions to this burgeoning epidemic, because we were seen as part of the problem. In Kentucky, the governor formed a task force, which did not include a single physician, to develop solutions, thus leading to Kentucky House Bill 1 (HB 1).
As a result of HB 1, physician attitudes transitioned from fear of undertreating pain to fear of overprescribing pain medications, sanctions from the medical board and potential loss of license. Many physicians, who received almost zero training on the disease of addiction, abruptly stopped prescribing opioids, discharged chronic pain patients from their practice, and/or referred to pain specialists who would later discharge patients for positive drug screens positive for marijuana. Other physicians pre-screened patients by using prescription drug monitoring programs (PDMPs) and simply refused to accept any patients suspected of having dependence and/or addiction to opioids.
RELATED BLOG: America's self-inflicted opioid crisis
During this phase, patients, including Jamie, turned to pain pills on the black market and eventually, cheaper heroin in order to find relief from withdrawal symptoms caused by abrupt cessation of prescribed pain meds. Jamie was unlucky enough to be susceptible to addiction genetically and also due to her environment as a child. When she started using heroin, her addiction escalated quickly and she eventually injected the drug. Fortunately, she did get help several years ago and entered a methadone treatment program. She remained in recovery on methadone for four years, working, taking care of her kids and owning a car, until she was arrested on an old warrant. Methadone was not allowed in jail, so she endured a very painful detox. Maybe she deserved to be incarcerated for her crime that undoubtedly occurred when she was in active addiction, but did she deserve to remain on a medication that saved her life or did she deserve to suffer excruciating withdrawal symptoms? Jamie was sober while incarcerated, but addiction is a chronic brain disease, and she relapsed after her release.
Jamie has Medicaid, managed by a managed care organization (MCO) in Kentucky that does not cover methadone treatment and requires an onerous 10-page prior authorization for buprenorphine/naloxone and very specific, frequent counseling that interferes with a person’s ability to remain employed.
Last month, Jamie was hospitalized for endocarditis involving three heart valves. She received antibiotic treatment while hospitalized, costing her Medicaid MCO hundreds of thousands of dollars. Her cardiothoracic surgeon refused to replace her valves until she got treatment for her addiction. When I saw Jamie today, she feared for her life. She knows she needs treatment for her hepatitis C and replacement of her valves in order to survive. Today, she also has an infection on her right leg where she injected heroin. She says she has not shared needles in years, but she does use one needle several times in a row. She does not have a primary care provider. My inclination, as a primary care provider, was to treat her infection, but my contract with this highly regulated methadone clinic dictates that I only treat her addiction with methadone.