An “opioid prescribing culture” fuelled by doctors who doled out “crazy amounts” of ineffective narcotics, and the pharmaceutical companies that sell the drugs, bear a share of the blame for Nova Scotia’s drug epidemic, according to physicians quoted in a new study.
The Saint Mary’s University research project – funded by the Nova Scotia Health Authority — examines the perceptions and experiences of 20 local primary care physicians surrounding methadone treatment.
The aim of the study was to probe factors physicians take into account when considering prescribing methadone to opiate addicts.
Physicians involved in the study practice in Halifax or within a two-hour drive of the city.
“Opiates… don’t work”
Methadone, which is used to treat people with opioid addictions, doesn’t have the “euphoric effects” of most opioids, James Livingston, the study’s principle author, told the Halifax Examiner. Livingston is an assistant professor of criminology at Saint Mary’s who works in the area of mental health and the criminal justice system.
“What [methadone] does is it relieves the cravings,” he said.
In Nova Scotia, most people with opioid use disorders are using prescribed medication, Livingston said.
“For instance, they were prescribed an opioid for pain and then they become dependent on that. So the idea is that to move away from their dependency on one opioid, to handling their dependency on methadone.
“So you’re still dependent on some sort of drug. So people become dependent on methadone rather than being dependent on another opioid.”
The situation is “complicated because physicians are increasingly being told not to prescribe opioids because you’re contributing to the opioid problem,” Livingston said.
“At the same time, they’re being encouraged to prescribe methadone, which is an opioid. So there’s a bit of a mixed message there.
That mixed message is articulated by physicians interviewed for the study.
“Participants reflected on the fact that the current need for (methadone maintenance treatment) to treat (opioid use disorder) was being partially fuelled by inappropriate opioid prescribing practices to manage people with chronic non-cancer pain: ‘It is sad to see that people have to go to methadone treatment because they were put on narcotics in the first place for no justifiable reason,’ (says one doctor),” according to a first draft of the study.
“Early career physicians, who had been trained to prescribe opioids judiciously, spoke about their discomfort with inheriting patients who had been prescribed (what another physician described as) ‘crazy amounts’ of narcotics from doctors who were now retired.”
Many of the docs interviewed for the study “had serious concerns about today’s narcotic-seeking and opioid-prescribing culture in primary care,” it says.
“Why are we using opiates?” says yet another doctor quoted in the study. “They don’t work. The only reason why we use them is because (drug companies) keep giving us free suppers … those guys have infiltrated the whole medical system.”
“Not very good people”
One of the province’s goals is to provide access to care in every Nova Scotia community for “people who struggle with opioid issues, and methadone is one of the effective ways to do that,” Livingston said.
One of the few ways a person can access methadone in the community is if their family doctor prescribes it.
“But some are reluctant to do that,” continued Livingston. “Sometimes there are some physicians out there who are really onboard and are currently prescribing it,” he said, but a smaller group of physicians were dead set against prescribing methadone “because they thought it introduced a whole host of problems (and problematic people) into their practice.
“They didn’t want to scare away what they called their normal patients.”
General practitioners “are kind of like independent contractors or freelancers,” he said.
“For their own businesses, their own practices, they can kind of do whatever they choose to do,” Livingston said.
“So if they choose not to serve a certain patient population, they can do that.”
Several doctors interviewed for the study described people who need methadone as riskier than their other patients.
“Some participants perceived people with substance use disorders, including those on (methadone maintenance treatment), as a problematic group to manage in a primary care,” says the study.
“It’s probably one of the more challenging patients that can walk into your door and I think a lot of primary care doctors would agree with me,” says one physician.
Problems coping with “adverse life circumstances,” substance use problems, and the related “disarray in their lives,” are common among those seeking methadone, says the study.
“Many of them [methadone maintenance treatment patients] are not very good people,” says one doc. “They’ve become very street wise and they’re survivors of a pretty rough world, and you’re going to deal with these people.”
Physicians interviewed for the study “routinely attributed manipulative and deceptive characteristics” to opioid use disorder and methadone maintenance treatment patients.
“There’s a great deal of fear in primary care around people with addiction, period — especially opiate,” says one doc.
“The few times that I got sucked … (in)to prescribe something and I found out about it; I was pissed.”
Some docs expressed fears for their own safety should they start prescribing methadone.
“There’s kind of an undercurrent with some of them (people on methadone maintenance treatment) of the potential for violent behaviour that isn’t there with my other patient population,” says one doc.
Physicians interviewed for the study who do not prescribe methadone “referred to office staff, colleagues, and family members that expressed worry about” the practice.
“My wife doesn’t want me doing it. She’s afraid. And, we live in a small community and these patients know where we live,” says one doc.
“Safety concerns were most often discussed in the context of untreated substance use problems and opioid prescribing, rather than (methadone maintenance treatment) specifically — a distinction made by this methadone prescriber: ‘Usually those instances where the patient is threatening or you’re worried about them stealing a prescription pad or threatening violence … that’s usually the patient that should be on the methadone or suboxone that hasn’t had the help yet.’”
One doc worried out loud that people on methadone might “scare away their normal patients” with foul language, sloppy dress, or strange behaviour.
“I don’t think is appropriate in a primary care setting when we have two-, three-year-old kids here,” says one physician.
Others challenged that view, according to the study, “by suggesting that people stabilized on methadone were (according to one doc), ‘a pretty straight forward, stress- free encounter usually.’”
A threat to the doctors’ careers
Besides fear of the patient, Livingston’s research points to other factors that affect the readiness and willingness of general practitioners to prescribe methadone to treat opiate use disorders.
“Some of those factors are really big things like the fact that substance use problems aren’t really a key part of medical training,” he said.
“When someone goes to med school, addictions is kind of a niche area,” Livingston said.
“They don’t get very much training on what it is and how to treat it and what their role is. And so when they leave med school, doctors sometimes feel like it’s not in their purview to treat people with substance use disorders.”
Livingston recommends medical students get more addiction treatment training “so they don’t walk out of medical school thinking it’s someone else’s job,” he said. “That’s what happens currently.”
Many of general practitioners interviewed for the study felt “there were threats to their career if they were starting to take on people with opiate use disorders, like the College of Physicians and Surgeons would be on their back about things,” he said.
“Methadone prescribing was perceived by most participants as a risky practice,” reads the study. “They worried that (opioid use disorder) patients and methadone would bring them to the attention of governing bodies and threaten their careers, with one methadone prescriber describing it as the ‘almighty fear of all physicians’ that their medical license would be compromised by ‘addicts.’”
Doctors interviewed for the study saw “the elevated scrutiny associated with methadone prescribing and the potential damage to one’s career … as major deterrents,” to integrating it into primary care.
“Why would you want the hassle?” says one doc. “Why would you want to have to look over your shoulder?”
A related issue is treating people with methadone doesn’t bring in much money — those patients generally take up more of their doctor’s time, says the study.
“People on (methadone maintenance treatment) were perceived as constantly missing their appointments, resulting in loss of income for non-salaried physicians,” it says.
“Many participants wanted fairer remuneration for delivering quality care to people on methadone, which was identified as key for attracting and retaining methadone prescribing physicians.”
Policing the patient
Nor did some of the physicians interviewed for the study enjoy the idea of looking over their patients’ shoulders.
“The surveillance duties associated with (methadone maintenance treatment) were uncomfortable for several participants,” it says.
“There’s something weird about being the policeman that I never really liked,” says one doc.
General practitioners who prescribe methadone send their patients to a clinic, such as Direction 180 in Halifax, or The Nova Scotia Hospital in Dartmouth, to be initiated on methadone, Livingston said.
Then the patient would be referred back to their family doctor for continued management, he said.
“For instance, they have to have someone come in to do urine screens to make sure that they’re not abusing it and not using other substances,” Livingston said.
“And some physicians felt like by taking on methadone, they’d be taking on policing duties that they didn’t want. Some of the physicians, especially in the smaller communities, were more comfortable trusting their patients … and they thought by introducing methadone into their practice, their practice would change to somewhat of a policing role. So they’d be surveilling their patients and not trusting what they say. Some of them were quite uncomfortable with that because that’s not how they were trained.”
Watching patients pee for urine tests and interacting with them in “mistrusting” ways was unpleasant for some docs.
“The interaction requires a degree of paternalism that physicians try hard not to engage in with their patients, because it’s a society that doesn’t perceive paternalistic physicians as being appropriate,” says one physician.
“There was an age of paternalism in medicine but that’s gone.”
A bridge to other help
Still, some of the physicians interviewed for the study saw prescribing methadone as a way to provide other help for their patients.
They “referred to poverty, unemployment, crime and incarceration, poor access to transportation, housing instability, traumatic experiences, and negative relationships as they spoke about” people on methadone maintenance treatment.
“Their lives are very chaotic,” says one doc. “Like, they might not always have a phone that’s active … they might not have transportation … sometimes they’re in and out of jail too, which makes things challenging.”
Physicians interviewed for the study “also discussed co-occurring health problems (e.g., chronic pain) as they spoke about people on (methadone maintenance treatment), and emphasized the challenge of managing peoples’ serious, untreated mental health needs in primary care. Several methadone prescribers framed their (methadone maintenance treatment) appointments as opportunities to address these unmet needs: ‘They will come for their methadone, so that’s when I have them in my hands — when I can expose them to other things,’ (says one doc). ‘Methadone is actually the entry—that’s the entrance to a new life.’”
Many methadone prescribers enjoy the practice, according to the study.
“It’s the most rewarding thing I’ve ever experienced in my life,” says one doc, “to watch that (recovery) happen is a miracle.”
Some of the physicians involved in the research talked about patients “who were able to get their lives back together and get back with their families and get jobs, and lead sort of ordinary lives while they were on methadone,” Livingston told the Halifax Examiner.
Frustrating delays
But “there were stories where methadone didn’t work for a person, so they ended up with more negative outcomes,” said Livingston.
Some docs voiced dissatisfaction with methadone’s inability to resolve underlying mental health and social issues, says the study.
“I’m prescribing methadone just to treat their chemical dependence,” says one physician.
“These people are mentally ill so you’re not going to fix them with methadone.”
Some opiate addicts are unwilling to acknowledge their need for treatment, while others can’t get it due to long wait times, says the report.
“I’ve had a couple patients that were quite keen on making change in their life and getting onto [the] methadone program and this entire process took months,” says one doc, “which makes it challenging.”
Opiate addicts “prepared to move forward with treatment faced barriers, such as travel and cost, preventing them from accessing to other necessary services, such as psychiatry or substance use counseling, to support their recovery,” says the study.
Some physicians described having patients who finally recognize they have an addiction problem, Livingston said in an interview.
“So they’re finally at that place and the GP goes to refer them to services and there’s a two-month wait to get them into a methadone program,” he said. “So that causes humungous barriers. People’s readiness to change fluctuates and if you don’t get them when they’re really ready, then you kind of lose that opportunity.”
The doctors interviewed for the study “were very, very frustrated with that,” said Livingston.
Assisting doctors
Doctors stressed the need to be able to reach out to colleagues with expertise in prescribing methadone and managing patients with an addiction to and dependence upon opioids.
“Having easy access to people who do this all the time … that I can pick up the phone and call. I think it’s probably one of the most important things,” says one physician.
Researchers who conducted the in-depth interviews heard specialized methadone clinics that help stabilize patients on methadone also play an important role.
“Physicians without such connections described feeling alone, isolated, and unsupported,” says the study. “‘I’m with two other partners, but they don’t prescribe methadone so there’s no point in talking to them,’ (says one doc). Poor access to methadone expertise also manifested in the lack of coverage for vacation time and other leaves (e.g., parental), especially in smaller communities.”
Livingston interviewed “quite a few young doctors who were just fresh out of med school and starting up their practices.”
They had “some unique concerns” around methadone and opioids generally, he said.
“It’s really hard to start a new practice when you’re … just getting your feet wet,” Livingston said.
“Methadone can be kind of complex to handle and they felt that they were just too new to navigate that particular system.”
Doctors indicate that giving them access to social workers, mental health workers and addiction workers in smaller communities would help them navigate the social problems their patients are experiencing, Livingston said.
“So people are not just receiving methadone, but are having their problems taken care of in a more holistic way,” he said.
Kicking the addiction
Some doctors interviewed for the study, especially those who don’t prescribe methadone, worried about the drug’s adverse effects with long-term use. “Being on methadone itself has its risk and complications and long term effects,” says one doc.
“Several non-prescribers also questioned the logic and usefulness of prescribing methadone indefinitely,” says the study.
“If it’s just substituting one drug for another forever then I wonder what’s the point?” one says.
“But methadone also has a regime where you can wean people off and lower the doses, which some physicians were doing,” reads the study.
Many of the doctors Livingston interviewed, however, didn’t have much information on whether methadone was something an opioid addict could be weaned off eventually, or it was a drug that they would need to continually take.
“One school of thought is that a substance use disorder is just like any other chronic illness and that the treatment for it is often lifelong,” he said.
“Others felt that that was unsatisfactory and really wanted to see the weaning off process.”
But the latter “wasn’t really the ultimate goal for a lot of physicians who are currently prescribing methadone,” Livingston said.
“Their main goal was to help people pick up their lives in sort of safe, satisfying way. And if they were to be on methadone for the remainder of their life, that was fine with them.”
A survey of 20 physicians’ opinions is a very limited survey. It is hardly a study. On what criteria were these 20 doctors selected? Certaintly not for their experience with treating chronic pain or opiate abuse disorder (based on the fact many of them state reasons why they prefer not to treat such patients). That one doctor is quoted describing persons with addictions as “not good people” and that this quote is included in the survey is appalling, to say the least. The article does not mention that special licenses and training are required to prescribe methadone and that it is actually quite effective in treatment of chronic pain, with fewer side effects than opioids. Many patients suffering with chronic pain and being managed by their family physicians were put on high doses of opioids by the Pain Clinic and are sent back to their family doctors to manage. They (the family docs) are then subject to ongoing scrutiny by the College of Physicians and Surgeons, even as they attempt to treat their patient with compassion and professionalism. One thing that neither this article nor the Saint Mary’s research mentions is that Nova Scotia’s Pharmacare program does not cover less harmful and more effective treatments for chronic pain. Because they are marginally less expensive, the province will only pay for opioids. That Lambie’s headline references opioid prescribing practices being influenced by “free dinners” when that is not the thrust of the survey or his article is both inflammatory and ridiculous. Maybe it’s just the way this article reports/summarizes but, this so called study does not look like good scientific research.
I agree with Bill. Opioids can be like a godsend. Yeah, they need to be treated with care and not over-prescribed, and we need to be aware of over-prescribing and dealing with addiction. But to say they don’t work? That’s a bit much. A friend who has suffered severe chronic pain for decades takes them every so often just to get a break. He told me once he would have killed himself long ago if he hadn’t had that option. (And he has tried all kinds of other things for the pain.)
“Why are we using opiates?” says yet another doctor quoted in the study. “They don’t work. The only reason why we use them is because (drug companies) keep giving us free suppers … those guys have infiltrated the whole medical system.”
Well, actually, opiates do work. Try asking people you know who have chronic pain. They might be hard to find because they seem so normal. That’s whole idea of painkillers, including opioids.
I’ll go further: the biggest vector in opioid addition is not physicians, but government. I know a doctor–NOT my GP–who’s limited in what he/she can do for patients accidentally addicted to painkillers because the best treatment is a gradual reduction in dose down to zero. Unfortunately, that results in a prescription profile that catches the attention of government. For a serious MD, which is almost all of them, it means being caught between their regulatory agencies and their duty to their patients.
It would help if we injected some compassion for pain sufferers and addicts into this debate in place of mid-20th-Century moralism. As it stands, the state is driving both to desperation
I hope the study Chris reported on is genuine, rather than the collection of happy-hour quotes it appears to be. Then it might include a coldly clinical full-cost accounting of the cost-benefit to society of untreated chronic pain vs the cost of managing accidental addiction.