family practice issues and general life events

Posts tagged ‘addiction’

Stopping smoking

Let me start this by saying, I have never smoked, so I personally never had to deal with that addiction and the cravings.  However, I do treat many smokers as patients and try to help them conquer that addiction.  The first thing I do know, is that everyone who is having problem stopping smoking has that one friend that just decided one day to stop and laid the pack down.  No problems, no cravings, just pure will power.  And to those friends, I say, stop it.  You are not helping your friend by saying,

“it’s easy, I just decided to quit and did it.”

Because for every one smoker who decides to quit like that, I have seen about 20 of the other kind.  Twenty who suffer from the cravings and the desires to smoke.  Those who have dealt with the stress in their lives by smoking.  Those who now struggle what to do with their emotions and how to deal with stress.  

Recent studies indicate that the average smoker tries 7 times before stopping smoking.  That is six times they were not successful.  Six attempts that frustrate and make them feel like a failure.  Looking at it as a failure is part of the problem.  Some studies indicate that tobacco is more addictive than heroin.   And heroin is the drug that everyone fears being addicted to.  In fact, when in an inpatient setting to deal with other addictions, the one addiction that is never dealt with, tobacco.  Rationale, if you take away the tobacco addiction, chances for relapse for other drugs increase significantly.

There are multiple choices of products that help with cessation, many replace the nicotine through patches, inhalers, gum, etc.  The goal is that by stepping down, you can beat the habit.  Then there is Chantix, which makes tobacco taste bad, and makes people nauseated.  Or Zyban/Wellbutrin which is an anti-depressant thought to help with the urges to smoke.  And the latest, the electronic cigarette.  This also is a tobacco replacement system, that removes most of the other products in a cigarette, but initially has nicotine.  Also with the goal of stepping down.  Also includes vapor to inhale.  I am a little skeptical to the claim that it is 100% safe and that you can do it forever without consequences, but as a means to get off of tobacco products, absolutely the lesser of two evils.

Now I live in a state with one of the highest levels of tobacco use.  While there has been legislation preventing smoking in restaurants and state buildings, we also have drive through smoke shops on tribal lands.  The one just outside my town, has three windows.  No need for waiting or getting out of your car.

The reasons for stopping smoking have been endlessly documented for both the individual and everyone they live with, especially their children.  The cost is also well documented.  But if it were easy, all of these products wouldn’t be needed.  Increasing taxes on cigarettes would stop those who couldn’t afford to stop.  

Maybe we should treat it like an addiction.  And maybe we should look to understand the science of addiction, and look at it as a real medical problem and not just weakness of the individual.  

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Addiction in Family Practice

I had a conversation with a patient yesterday.  Well many of them actually, about 40 different encounters, but this one struck in my mind.  We have recently updated our controlled substance agreement to make it more strongly worded, and emphasize that there will be more random drug testing, and monitoring their activity on the State’s narcotic and dangerous drugs data base, and he, like many others had some questions about it.  I am not really certain why this update inspired so many more discussions than previous updates, but everything from the selecting a pharmacy to how the drug screens will be done and how they had Severe pain this weekend so they found an old Diluadad from a previous provider that they took so it might be in the screen.  Or they smoked a joint, and they are really sorry, but what is going to happen to them.

But back to this particular case.  He was wanting to know what if another patient of mine had a positive drug screen for something else.  Methamphetamine.  He has been worried about her, and would really like her to get help.  The problem with an addiction to something like methamphetamine is that it changes chemistry in the brain, so people appear to be willing to lose everything for that drug.

Unfortunately I see a lot more chronic pain patients in my practice than I would like, I struggle to decide who is truly in pain, and who is not.  I was referring them all to pain management specialists but the one I was using has put up barriers making it almost impossible to refer people there.  The next closest places are 2 and a half hours away making it almost impossible for those that are legitimately in pain to obtain the treatment that they need.

In an attempt to be in compliance with the state drug laws we screen patients, we look them up in the data base and we try to monitor what they take, but we are often left wondering who is truly in pain, and whose pain is due to the narcotics that we are giving them.  We do diagnostic studies to find the cause, but unfortunately unlike blood pressure and temperature, the pain scale is very subjective.  One person’s four is another’s 8.

Drug contracts are necessary and may help provide a means for conversation with the patients that might not have been otherwise.  And yet the next question is what to do when there are medications that are not supposed to be there, or even worse, what happens when the screen is completely negative?

I live in the state that is ranked first in the abuse of prescription medications, and it bothers me that I may be contributing to that number.  We take calls reporting someone selling their medications seriously, and attempt to investigate.

But then there are those that are truly addicted to narcotics of any type?  Those that truly want help.  There are supposed programs around here.  A program that does rapid detox that has turned into a program for a weekend fix.  A methadone clinic that I have never seen decrease the dosage of methadone on a single patient.  That is it.  And honestly, I don’t have the training to treat addiction in my practice.  We look at best practices, but I was trained to treat diabetes, not pain management.

It is estimated by the National Center on Addiction and Substance Abuse that only 10% of alcoholics receive the treatment they need.  I would guess that the number is even less for those substances that are illegal.  In the war on Drugs, we have created a group that cannot find treatment because their addiction is to something illegal, so there is a fear of incarceration.  And yet despite all of the laws we have against drug use, we have not decreased usage at all.

There are a few medications approved for detox and to treat addiction, but I am not trained well enough to deal with such a complex disease.  And while I would be willing to obtain such training, I don’t know that I would have time to treat these patients with all of the other requirements on the disease processes that I am qualified to treat.

So we are at a crossroads in treatment.  What do we do with those that are addicted, but want help?  We need to have an open dialogue with our patients that we can treat them.  It has to be honest.  If I have a patient who is honest about their addiction, I will do what I can to help them, but unfortunately my training is not enough for what they need.

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