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I train for the second DEA number for buprenorphine, to treat opioid addiction in 2010. I inherit close to 30 patients the next month, when another provider is attacked by the DEA.

Treating addiction is hard, but treating chronic pain with addiction is harder.

Why?

A heroin user does not say that they are not tied to the drug. If they come see me, they genuinely are trying to get off it, get legal, get help. Stop withdrawing. The pain receptors go insane, like a stereo turned way above tolerable volume, to screaming pain.

The heroin users do not always succeed in treatment. Some disappear, relapse, I hear later that they are dead. They may disappear to jail and overdose when they are released.

The chronic pain patients are not a little harder. They are WAY harder. Because they say that they need the medicine for pain, they are not abusing it, they just are not being given enough. And yet, their behavior screams overuse, though it's not always opioids.

People say that they cannot be overusing opioids because they don't take them to party. "I take it for pain." Um, but wait. Tobacco. Do people take tobacco to party? Why do people start tobacco? It seems to be for the cool factor and to be grown up. And they get hooked, addicted. Why would anyone think that an addictive drug would need to make you high to addict you? I don't understand that argument at all and never did. Of course, the pharmaceutical companies pushed the message which then got pushed by pain specialists to primary care providers: opioid addiction is rare if the patient takes opioids as directed. This is not true.

We are still fighting about what percentage fall in to opioid overuse in the medical community. And really now it's moot since it's been renamed opioid overuse, the spectrum from dependency to full on addictive behavior, all under one DSM-V code. Mild, moderate, or severe.

I am still struggling with how to talk to the chronic pain substance overuse folks. The ones using illegal substances or legal but dangerous ones with their opioids are a bit easier. "I am stopping the opioids because the combination of opioids with (alcohol, benzodiazepines, soma, kratom, heroin, methamphetamines, cocaine, krokodil, whatever) is dangerous, you could stop breathing and die." I can offer them inpatient treatment. The real difference between a chronic pain patient and a chronic pain and substance overuse patient is denial/lying to themselves and me. I can offer frequent visits and frequent urine drug screens and intensive outpatient drug treatment or the mindful drug treatment or various versions, but they make the decision. A frequent response is "I've done this for years and it hasn't killed me yet!" Yes, well, the most recent CDC report about women and opioids, here, says the overdose death rate in women has risen 260% from 1999 to 2017.

There are success stories. I have a patient who has worked with me to wean her methadone. She is down from 60mg to 10mg. She didn't understand that methadone is a logarithmic drug compared to morphine. That is, on the morphine dose equivalent calculator, 60mg of methadone is 600mg of morphine. As people wean, 30 of methadone is approximately 40mg of morphine, 20mg methadone is about 80mg morphine and 10 mg methadone is 40mg of methadone. So a drop from 600mg morphine to 40mg morphine is huge. She is now weaning on her own, but I think she is going too fast. Slow it down as the numbers get lower so the brain can adjust. That is a huge jump down. She is an absolute star.

But then there are others. I was looking at my list of patients presented to UW Telepain in 2010 -2011. Of the first ten, six are dead that I know of. The other four are gone and I do not know. It was the most difficult cases that I presented initially. These were inherited patients, high risk, but still. And half of them died under age 50.

I don't think we really have our heads wrapped around addiction yet as a culture or a world. Addictive drugs are addictive and it can happen to anyone. Not me, people say, I'm sensible, I know what I am doing, I am careful. And the interview of Charlie Sheen being asked about a woman who said she was afraid she would die when at a party where they were doing cocaine. "If she doesn't know what she's doing," he says, "she shouldn't be there!" He boasts about banging seven gram rocks of cocaine. "I'm too smart." he says. "There are certain combinations I won't do!"

I have heard that before. Enough people recognize his behavior that you could place a bet on line, bet on the date that he would overdose and die. That should be a teaching interview, the fourth stage in my monitoring patients on opioids or buprenorphine: where the person's denial is obvious and makes no sense at all and the addictive drug is fully in charge. I have seen a subsequent interview where he is off cocaine and clean, well, only tobacco and alcohol.