How a small minority of Kentucky doctors can ruin medication-assisted treatment.

Last May the DEA conducted Operation Pilluted, the largest pharmaceutical drug investigation of all time, where across four southern states over 140 people, mostly doctors and pharmacists, were arrested for their participation in dispensing narcotics without a legitimate medical purpose.

This practice is referred to as a pill mill. It involves “clinics” that house a couple of prescribing physicians who churn out obscene quantities of hydrocodone, oxycodone, and benzodiazepine to “patients” who pay cash money, usually around $300 per visit, in a mutually beneficial doctor-addict relationship. (Depending on how you view things, of course.)

One Kentucky doctor caught himself a life sentence back in 2012 for prescribing 3.3 million pain pills throughout his career working at a pill mill. At his peak, he was the largest buyer of oxycodone in the country.

These pharmaceuticals eventually find their way to the black market, often sold by drug users who have a habit of their own to tend to.

Such busts may look like progress to some. But the pill mill battle is proving far too complex a problem, where, once again, DEA raids (such as Operation Pilluted which involved over 1,000 agents) appear to be a fruitless effort. As clinics dishing out oxycodone and hydrocodone are being dismantled, new ones continue to sprout up.

But the newest pill mill, pill drug du jour isn’t oxycodone. Buprenorphine, branded under Suboxone or Subutex, is the latest narcotic being churned out by networks of shady clinics. It also happens to be the very drug that is supposed to help opiate users kick their habit.

Once again, the problem is most visible in Kentucky, where “a lot of the [former] pill mills morphed into facilities that dispense these prescriptions,” for Suboxone, Dr. John Langefeld, medical director for the state’s Medicaid program, told Mary Meehan of theLexington Herald-Leader.

After the passing of House Bill 1, which helped dismantle pain-management clinics by penalizing pill-pushing doctors and requiring prescribers to use an electronic prescription drug-monitoring system, the problem was thought to have been, if not conquered, at least dampened.

To an extent, it has been. But still, small minorities of doctors in Kentucky who operate under the pill mill method tarnish the name of the often useful detox and maintenance drug. Nearly 80% of the prescriptions for Suboxone in Kentucky were written by 20% of the state’s 470 prescribers, Dr. Allen Brenzel, medical director of the state’s department of behavioral health, told Meehan.

Kentucky state officials also found the use of buprenorphine increased 241% since 2012—the same year a lot of pill mills churning out oxycodone met their demise. That same report found one user who was doctor shopping, obtaining prescriptions from nine different prescribers.

What we’re seeing in Kentucky, and all over the world, is not a problem with drugs and chemicals, but how humans live with them, or in this case, dispense them.

Recent academic investigations demonstrate the many clinical benefits associated with using buprenorphine as a form of medication-assisted treatment for opioid abuse, such as less illicit drug use among users, above average retention rates, and because of its ceiling effect with respect to respiratory depression, fewer fatal intoxications occur in buprenorphine users than with methadone users.

So how is it that this medication can be at once a solid method of treatment and a much sought after dope?

Unfortunately, House Bill 1 did not address buprenorphine, as its primary concerns were street drugs such as hydrocodone and oxycodone. Buprenorphine came on to a scene where a cash-for-pills market was already set, where practices like doctor shopping through networks of dirty (or sympathetic?) doctors were in full swing.

Once the DEA began to crackdown on unscrupulous prescribers who handed out oxycodone prescriptions for cash, Suboxone was next in line, where it was inserted into a system that’s always already rigged for unprincipled, licensed greed.

Evidenced by their prescribing habits, pill mill doctors show no interest in best practices. This minority of Kentucky doctors were prescribing the ceiling dose of Suboxone, roughly 32 milligrams daily and indefinitely, to nearly all of their patients. For reference, when I was treated with Suboxone to kick a $100 per day heroin habit, I was given 8 milligrams daily, which was enough to starve off some of the nastiest withdrawal symptoms. When it was time to wean myself off, it was a collaborative effort between my doctor and I.

Without any recommendation for therapy, some form of supervision, and other social support to promote the lifestyle changes necessary for one to kick an addiction, someone on Suboxone may not see its many benefits.

According to Kentucky’s state report, some of the doctors were also prescribing Suboxone along with other opiates, which makes little sense given that buprenorphine has an extremely high affinity for mu-receptors, meaning if one ingests Suboxone, a drug like oxycodone wouldn’t have much of an effect, let alone the high one is chasing.

Even worse, according to the same report, some doctors gave out buprenorphine and other opioids in combination with benzodiazepines. The combination of opioids and benzodiazepines greatly increases the risk of a fatal overdose. In 2010, the CDC reported out of 16,651 overdose deaths involving an opiate of some kind, 30% of those also had benzodiazepines in their system at the time of death.

For a doctor to hand a drug user a massive prescription for a Schedule III narcotic with a street demand in exchange for a $300 “office visit,” is an all-too-familiar modus operandi. It’s essentially part of what brings us to today, in 2015, where 44 people die from prescription painkiller overdoses each and every day. Over 100 people die every day from heroin overdoses.

The Fix reached out to Dan Bigg, a veteran harm reduction activist who has fought tooth and nail for those with drug addictions to receive the best possible care. On the current pill mill problem, he said, it starts with medical training.

“A better way is requiring physicians to get training in addiction during medical school, and quit pretending a competent MD cannot handle addiction treatment.”

Bigg feels strongly that medication-assisted treatment (MAT) ought to be more accessible for those who need it. “Buprenorphine should be very widely available and much more widely prescribed, just as methadone should be legally prescribed by private physicians.”

“Instead, we systematically alienate people from the simplest and most effective treatments.”

I asked Bigg what a better system might look like. “How about requiring all doctors to treat all people they prescribe opioids to who get into trouble with them?”

Furthermore, he added, “We can take the DEA off the necks of MDs and end their ‘oversight’ of the medical system. This is not helping anyone and making most MDs pretend drug problems do not exist so to avoid scrutiny from DEA policemen.”

When the DEA cracked down on pill mills and other systems of prescription drug abuse, it inadvertently caused users to flock to a ready and waiting supply of cheap heroin. Hence the four-fold increase in heroin-related mortality from 2000-2013, reported by the CDC. It’s worth noting, that most of this mortality spike occurred after 2010, around the time prescription painkillers became more tightly controlled.

Suboxone entering the pill mill system is likely another unintended consequence of a different variety. Under the Affordable Care Act, substance abuse treatment became a mandated service, which expanded addiction health care and Medicaid. In Mary Meehan’s report, Dr. Langefeld said as more people in Kentucky received Medicaid and filed for health insurance, more and more people were being prescribed Suboxone.

This fact is not necessarily good or bad. Many are pleased to see addiction get the same coverage as other ailments. And so it goes, if addiction is indeed a medical problem then shouldn’t it be treated with medicine?

Like Dr. Langefeld’s statement, Suboxone is a chemical formula which in itself does not necessitate a value judgment. The chemicals themselves are not good or bad, just as the people who take them are not good or bad. This revaluation promotes understanding the Suboxone problem outside of the criminal domain.

The current dilemma in Kentucky is not born out of criminality. The problem belongs to the public health policy and the communities they serve. For instance, some of the newest public health legislation in Kentucky, such as bill SB 192, calls for medical schools and graduate programs to offer training and a minimum of 10 hours of coursework dedicated to the study of addiction. This is a positive start, just as Bigg noted.

With respect to pill mill doctors, their ethics are obscured with dollar signs, and as a consequence, are clearly going against all training they have ever received. Many opiate users seek Suboxone to ward off withdrawal symptoms in the event their source runs dry, they run out of money, or are sincerely trying to kick. If these users were offered services to help them, and doctors could prescribe this drug without fear of DEA scrutiny, there would be no demand for pill mills to supply, which, in effect, would negate Suboxone’s street value.

Opioid treatment programs (OTPs), pill mill’s ethical opposite, are becoming more prevalent to meet the needs of opiate addicted individuals. OTPs combine behavioral care and therapy in conjunction with medications like Suboxone to quell the intense cravings one experiences early on.

At most OTPs that dispense Suboxone, there are pill counts and methods to keep people on track and compliant with their dosing. If someone is suspected of abusing the prescription, he or she may be mandated to bring in the prescription to show the staff how much of the medication is left. Prescription drug monitoring systems are also frequently checked to prevent doctor shopping. Essentially, these are all the preventive measures pill mills actively neglect.

And it’s this therapeutic environment where a user seeking help may see the many benefits Suboxone has to offer. Like other mental health, community, and medical issues, a combination of interdisciplinary interventions and resources are needed to make big picture changes, and most of all, help those who have been mangled by their habit gain, or regain, their lives. Read more “the fix”…