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  • Dr. John Tanner, Medical Director, Florida Intervention Project for Nurses
  • Dr. Alan Schwartzstein, family practitioner and Vice Speaker, American Academy of Family Physicians

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Can Primary Care Doctors End The Opioid Epidemic?

Reed Pence: The opioid epidemic has reached into nearly every community in America. Surveys show around a third of people know someone who has abused or been addicted to prescription pain-killers and not quite 20% of us know someone who’s died of an overdose – a proportion that is likely to increase.

Dr. John Tanner: Recently the CDC said that in the past 5 years there’s been an increase in the death rate by 33% from opioid related deaths so that is a horrifying statistics, this is an increasing problem – we don’t seem to getting a good hand on it.
Pence: That’s Dr. John Tanner, Medical Director of the Florida Intervention Project for Nurses and an addition medication specialist for more than 30 years.

Tanner: 1 in 7 Americans, or nearly 21 million people, have suffered some sort of addiction. We know that 2.4 million people are addicted specifically to opiates and 1.9 million of those are related to prescription opiates and about a half million people and rising are addicted to heroin now.
Pence: Addiction often starts innocently, with an injury or surgery and a patient in severe pain. Doctors may prescribe a painkiller such as Vicodin or Norco, trying to alleviate the pain. But they may have been doing it a little too freely and letting the patient stay on those medications too long.

Dr. Alan Schwartzstein: Opioids are a medication that’s been used for pain going back to the 1800’s and several years ago the FDA, based on limited data, approved some of the extended release opioids and physicians, not just family physicians, but others have a false sense of security that these were effective and safe to us.

Pence: Dr. Alan Schwartzstein is a family practitioner in the Madison, WI area and Vice Speaker of the American Academy of Family Physicians.
Schwartzstein: We’ve realized over the last several years, not just the academy but the national organizations, that perhaps these medications are not appropriate used for chronic pain. Perhaps we should be using other medication, including non-opioids.
Pence: Opioid pain-killers are powerfully addictive, about 5% of people who use painkillers exactly as directed become addicted anyway within a year. Experts know who’s most at risk.

Tanner: The people who are most vulnerable are people who have a family history of addicted. It could be alcohol – which they themselves use as substance that they may misuse, or they may be a smoker and abusing the nicotine or even if they use marijuana – something like that, it kind of lays the groundwork for the brain to learn to escape and learn to deal with the everyday stresses in life. And then when they have an opiate they discover that it’s very potent, very powerful in relieving that. Some people feel that they have increased energy so they very quickly can become addicted. The other thing that makes people vulnerable to addiction is having had a experience of trauma sometimes in their life – this can be sexual abuse, physical abuse, emotional abuse – they’re more prone to learning to escape some of the pain of that by using substances like opiates.
Pence: Addicts on prescription pain medications often don’t look like what many people expect – It may be your neighbor or a coworker. Tanner says for them, substance abuse is typically a progressive disease, starting slowly and becoming more and more severe.
Tanner: We don’t realize these people, they can be very functional sometimes up until the point where they’re so sick that they wind up overdosing and dying or having severe global hypoxia or something like that – so their brain and they have some severe brain damage. Many people can appear to be very functional, they keep this very secretive, part of the problem is there’s stigma associated witht his and because of this stigma many people don’t seek help, they don’t tell anyone about this disease that they suffer from and it’s tragic because they get sicker and sicker and try and cover the bases more and more until something tragic happens.

Pence: The hidden nature of opioid addiction means that it often takes someone who knows a person to spot the trouble they’re in or to have a chance they’ll ask for help. That’s why Schwartzstein and Tanner, along with many other experts, believe that primary care doctors such as internists and family physicians may be in a better position than addiction specialists to provide medical help.

Schwartzstein: We provide ongoing, complete care, for patients and so we get to know them personally – we get to know their businesses, their families, who they are in the community and so it makes it easier sometimes to recognize that possibility. We also have patients that come in and say, “Doctor, I’m just having trouble with these medications. I’m feeling like I have to use them. I’d like some help so I don’t have to use them all the time.”

Tanner: You know with all the stigma, many people are afraid to ask their doctor and if the doctor just prompts and just says, “well are there any issues with any drugs, be they illicit or non-illicit that you feel have become a problem?” and just asking that simple question can relieve a patient to know that they’re free to talk about that.
Pence: Until changes in legislation about 15 years ago, doctors pretty much had to refer patients with substance abuse problems to addiction treatment centers or 12 step programs. Many doctors still do but now primary care doctors who’ve received special training have the means to treat drug addiction in their own offices. One key is the use of a drug called, Buprenorphine.

Schwartzstein: It’s a very unique molecule that has some very interesting properties; one of those properties is what we call a “partial opioid agonist,” that means that it binds to the receptors in the brain and it has some activity but only a mid-level, so to speak, activity and because of that it has a ‘feeling’ effect. The ‘feeling’ effect means that if somebody is on a stable steady dose for several weeks, if they go ahead and – most any good addict will go ahead and do; they’ll try and get extra – if they try and get extra it has no additional effect. They can’t get high on it, they cannot get euphoric and it frees up the craving and desires to use opiates so that now people function at a high level and they are able to learn to cope with things in healthier ways. So it in a way tricks the brain into thinking that it has that medication of addiction when it actually doesn’t. Buprenorphine does not provide the type of high that medicines that fully connect to the opioid receptor would do, so it’s easier for the patient to control their tendency to abuse a medication. And it also prevents them, importantly, from getting withdrawal symptoms.

Pence: Some critics claim that treatment with Buprenorphine simply substitutes one addiction for another, which Schwartzstein says, that’s not true.
Schwartzstein: Not at all. Now, Buprenorphine has such a small possibility for providing any kind of high that it is very much not something addicts will go looking for. Often we’ll start prescribing in the office with a combination of Buprenorphine and a medicine called Naloxone, that’s the brand name Suboxone, and Naloxone is a medication that if given will actually completely block the receptor so if the person decided to use an opioid they were addicted to they would automatically go into withdrawal.

Pence: Now those benefits don’t mean that a doctor can simply prescribe Buprenorphine and send the patient on his way, that’s part of the reason doctors need training and why not every patient is successful.
Schwartzstein: The patient has to be motivated for the treatment to control their addiction, if you don’t have a motivated patient who is willing to follow through with doctors instructions, who’s willing to get counseling, who’s willing to go to support groups and other therapies beyond the Buprenorphine, the chance of success with them are much less.

Pence: However Schwartzstein says that the chances of success at your family doctors office may be much greater in the first place simply because patients are much more likely to seek help there.

Schwartzstein: Patients are much more likely to follow through with their treatments if they can see me in the office to get treated, rather than having to go to an opioid addiction center. There are not enough of them around in the country, most of them are located in cities and they’re often an hour or two away from where the patient is. And yes, the stigma for all mental health issues has been gradually decreasing over the years that I’ve been in medicine and patients are much more willing to come into the office to get treated for this than to go to one of those centers.
Pence: But Tanner says stigma effects doctors too. He says its one reason so few primary care doctors are trained to use Buprenorphine to treat addicted patients.

Tanner: Only about 3% of physicians actually do this, again, I think part of it comes down to stigma – I have been a trainer of physicians for this way back before the medicine was even approved way back in 2001. We started training trainers and we went out and trained people to prescribe this before it was actually even released and there seems to be this stigma that physicians sometimes say, “well we don’t want those kind of patients in our practice” and they don’t realize that they’re treating multiple people that are too afraid to approach them about their problem. So, that’s part of the problem, fortunately I think there’s more and more interest among physicians in addiction medicine now.
Pence: Schwartzstein says the American Academy of Family Physicians has trained 55,000 doctors to use Buprenorphine and is encouraging its members to get on board. But Tanner says some 12-step programs balk at its inclusion, it can create conflict in 12-step programs when some members are using a medication to recover and others are not.

Tanner: Many of the treatment programs are opposed to this type of medication, sadly that flies in the face of what research show and I know in my local area I have witnessed many times over the years where people go through treatment, they get detoxed, they may even have some good rehab that addresses all the psycho-social aspects, but because people are discharged without a medicine that can help get them on track, especially when they’re early in recovery and vulnerable, these people go out and quickly relapse and they overdose and die or wind up long-term incarcerated.

Pence: A couple of years ago the federal government started a push to double the number of doctors who can prescribe Buprenorphine and treat substance abuse from their offices. Schwartzstein says the results can be extremely successful.

Schwartzstein: We very much want the public to see opioid addicted and other mental health problems in the same continuums they see other physical problems with people. People think of diabetes and high blood pressure as being chronic disease that needs to be treated for their life and some patients are very good about taking their medications, about controlling their diet, about having activity and those people often get good control of their blood pressure of their diabetes. Opioid addiction really is no different, the person needs to follow through with the treatment recommendations, needs to take the medications that are necessary, needs to follow through with the lifestyle changes. There’s a study that shows that those motivated patients who have addictions can be as successfully treated as those with diabetes or hypertension – so really talking about illness that same as any other chronic illness.

Pence: However Tanner notes that we need to pay attention to history and the fact that addiction doesn’t go away, just the substance that we’re worried about. Just a few years ago the concern was all about meth, he fears that once we turn the corner on opiates and start prescribing and treating addiction to them more rationally, then we’ll forget our due diligence on some other classes of drugs, maybe stimulants and we’ll start all over again. You can find physicians in your area qualified to treat addiction medically through the Substance Abuse and Mental Health Services Administration, they’re only at: Samhsa.gov. You can find out more about all of our guests through our website, RadionHealthJournal.net. I’m Reed Pence.

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