Consult-Liaison Education Medicine Observations Policy Systems

Buprenorphine and Other Controlled Substances.

I recently completed the buprenorphine waiver training. Buprenorphine, itself a partial opiate, is a medication that can be prescribed to patients who have opiate use disorders (e.g., taking Oxycontins or injecting heroin to get high). A physician must complete an eight-hour training and take an exam to become eligible to prescribe this medication. The physician must then apply for a specific “X license” through the DEA to prescribe it.

In some ways treatment of substance use disorders is the most evidence-based practice in psychiatry. When talking about opiate use disorders, for example, we can talk about specific mu-opioid receptors and their roles in pain and intoxication. We can discuss how drugs—both illicit and licit—work on these receptors and why certain medications can reduce or eliminate illegal drug use. This logic satisfies the analytical mind.

Since completing this training I have wondered: Why must one undergo a specific training and obtain a separate DEA license to prescribe buprenorphine?

With my current licenses I could prescribe all forms of pharmaceutical morphine (e.g., Oxycontin and Dilaudid), which can lead to severe physical and psychological dependence. Which could then result in the intervention of buprenorphine.

As a psychiatrist I would likely arouse the suspicions of the DEA if I prescribed opiate medications. That’s outside the scope of a psychiatrist’s practice.

However, it is not outside of the scope of a psychiatrist’s practice to prescribe benzodiazepines (e.g., Valium and Xanax), which are Schedule IV drugs (“a low potential for abuse relative to substances in Schedule III”).[1. You can learn more about controlled drug “schedules” on the DEA website.] I can also prescribe Schedule II drugs (“high potential for abuse which may lead to severe psychological or physical dependence”), such as Adderall and Ritalin. Physicians are not required to go through any special training or obtain separate licenses to prescribe those medications. Once I got my DEA license, I was free to prescribe these without anyone looking at me askance.

And, get this: buprenorphine is a schedule III drug!

The training offered the Harrison Narcotics Tax Act of 1914 as one reason behind the training requirement: This law suggests physicians can prescribe opiates as part of “normal” treatment, but not for treatment for addiction. Addiction was not considered a disease in 1914. Thus, if addiction is not a disease, no intervention is indicated.

That explanation, however, doesn’t make sense. There is growing consensus that substance use disorders are diseases. Nothing, other than my good judgment, prevents me from cranking out prescriptions for stimulants and benzodiazepines. Use of either medication can lead to addiction. What makes opiates so special?

The consequences of the buprenorphine training are not slight: The eight-hour training alone likely deters some physicians from pursuing it. The extra licensure is also an obstacle, as well as the consequences of using the license: No one wants regular, but unannounced, DEA audits (which, just to be clear, doesn’t happen with when one prescribes benzodiazepines or stimulants). No one is eager to maintain the documentation that is required when one prescribes buprenorphine.

It just makes me wonder what the actual story is….

Nonfiction Observations Reflection


Shortly after my mother died, a coworker asked me about grief: “What does it feel like?”

I remember looking at her and feeling confused. What does it feel like…?

Words like “terrible”, “awful”, “really sad”, and “numb” didn’t seem quite right. Elements of all those adjectives were true, but none of them captured the fine texture of grief.

“It feels like… a really bad breakup,” I finally said. As the words came out of my mouth I realized that wasn’t quite right. It was also an inane comparison.

“Huh,” she answered.

Nine months later, I found words to describe my grief: It feels like my heart is falling.

During moments of stillness, those spaces between exhalations and inhalations, I feel my heart physically dropping. It is an endless fall; there is no bottom.

I remain surprised with how close to the surface the grief lives. I don’t cry when I talk about my mother’s death. Yet, when people ask me about her, I feel my face scrunching up the way faces do when people are about to cry. The sensations in my face remind me of that week she was in the hospital, when I smiled during the day and wept at night, asking God and the Universe questions that nobody could answer.

Though the tears do not come, my face suggests they will. And I know that the person listening to me sees it. It’s like when you blush: You feel your cheeks flash with heat and hope that the other person won’t make fun of you for it.

Emotions always shift, though: Sometimes, in my mind’s eye, I set an imaginary table and place a pot of steaming tea and two cups on it. I invite Grief to sit down and have tea with me. Grief never declines. I ask Grief how it is doing. Grief never says anything in response, but we sit in silence and enjoy our tea together. When Grief is ready, it leaves.

And then I notice that my heart is no longer falling.

Almost 11 months have passed since my mother died. Since I found words for my grief, my heart doesn’t feel like it is dropping as often. Maybe the time I needed has elapsed; maybe the sensation of my heart falling doesn’t overwhelm me as much as it used to.

Maybe by showing Grief some kindness and acceptance with imaginary tea it has also shown kindness to me.

Medicine Observations Policy Reflection Systems

On “Mental Illness”.

I’ve been invited to speak to a group of attorneys who work at the interface of psychiatry and the law. The topic of my talk? “Psychiatry 101.”

A psychiatrist who gave this talk to a similar group a few years ago advised me: “You should assume that lawyers are laymen. It’s surprising how little they know, given the work that they do.”

This teaching opportunity to teach has given me pause: What is mental illness?

Most of my work has been with people with few resources (no home, no job, etc.) or with people who are experiencing symptoms that cause significant distress (they won’t eat because they think all food is composed of their internal organs; they often try to kill themselves due to hearing voices telling them to do so; etc.). Most people would agree that these individuals have “mental illnesses”, whether “caused” by their circumstances (imagine people trying to set you on fire or rape you because you are sleeping outside) or by apparent biological events (imagine a freshman in college with an unremarkable history who, over the course of months, begins to believe that the government inserted a chip into his brain).

I have also worked in settings where:

  • a wealthy man’s wife felt overwhelmed with anxiety about which of their three homes they should remodel first
  • a aerospace engineer with no symptoms wanted to try an antidepressant because his girlfriend started taking one and she now seemed to have greater clarity of mind; “maybe that will happen to me, too”
  • a college student felt depressed because his parents wanted him to pursue a professional degree, but he didn’t want to do that

Do those individuals have mental illnesses? Does psychological suffering equate to mental illness? Even if they are able to get on with the necessary details and difficulties of life?[1. Do not misunderstand: People with means can and do have mental illnesses. Take the software developer who was certain that public surfaces were contaminated with exotic diseases; he couldn’t get himself to go to work or spend time with friends due to fears that he would get sick and die. Or the accountant who, if she doesn’t sleep enough, would believe that she is the mother of God; she went to hospitals insisting that she was in labor with Jesus when, in fact, she was not pregnant.]

My mind then spins to recent events, such as the Germanwings place crash. Many people have argued that, because the co-pilot killed people, he was mentally ill. He apparently had a diagnosis of depression, but I agree with Dr. Anne Skomorowsky that a diagnosis of depression alone does not explain why he committed mass murder.

But if he was mentally ill, what diagnosis would best describe his condition? What do we call it when people kill other people? Is that behavior alone sufficient to say that someone is mentally ill? If so, what do we make of:

  • soldiers killing other people during war
  • gang members who, without provocation, shoot police officers or other gang members
  • suicide bombers
  • parents who kill their newborn infants because the babies aren’t the parents’ desired sex

Does a person’s intentions affect the definition of “mental illness”? (How good are we at reading the minds of others? We often assume intention when observing behavior. And those assumptions can be way off.) Does the situational context also affect what a “mental illness” is? (When in Rome, do you do as the Romans do? What if you don’t know what Romans do?)

People have surmised that people who kill other people may have conditions such as antisocial or narcissistic personality disorder. However, these designations are still problematic: Not everyone with those personality disorders kill people.

Perhaps this is why I prefer to work with people who demonstrate behaviors that undoubtedly impair their function.[2. It is easier for me to work with people who demonstrate clear evidence of “impairment in function”. Part of this is due to the greater ease and clarity in diagnosis: If someone’s symptoms are within the spectrum of normal human experience, then diagnosis is unnecessary. Part of this is also due to treatment: Some interventions in psychiatry—specifically medications—are not benign. Furthermore, it is unclear how some—many?—psychotropic medications work. We first must do no harm.] I am reluctant to describe most people as “mentally ill” because some behaviors that people find bizarre have helped the person cope with their circumstances. The people who always wear masks or scream on the street? Those behaviors may have somehow protected them in the past—even if it means that the general public derides them for being “weird”. It seems unfair to say someone is “ill” when what they have done before in the past has given them some degree of protection. (To be clear, I don’t necessarily apply this formulation to people who have committed murder. For example, I can’t think of how flying a plane into a mountain could ever be an adaptive coping skill.)

Words matter. I’m not sure that I have more clarity yet about what I should teach, though it is clear that I should focus on how I phrase the information I present.


What Goes Around Comes Around.

As my father and I stepped out of the crosswalk onto the curb, I looked up and saw John Doe. I didn’t realize who he was until we had already passed each other.

A baseball cap was on John’s head and a colorful satchel was slung across his torso. He had rolled up the cuffs of his jeans with care and his unbuttoned jacket revealed the bright sweater he wore underneath. He was looking down at the street.

My dad continued to talk to me; he didn’t hear me exhale with relief when John kept walking.

John had asked me to step closer to the door of his cell so he didn’t have to speak as loud.

“I didn’t break her windows, I didn’t set any fires, I didn’t kill her dog, I never said anything scary to her,” John said, his eyes fixed on mine. He smiled at me through the cell window. “You believe me, right?”

The police report stated that several witnesses had seen John smash her windows, set a small fire after he broke down her door, and attack her dog.

I said nothing.

“It doesn’t matter what she said,” he continued. “She lied. What goes around comes around.”

I followed my dad up the small set of stairs that led to the glass doors of the restaurant. When I glanced up, I saw John’s reflection in the glass: He was standing near the base of the stairs, his eyes fixed on me.

My dad looked over his shoulder at me as he approached one of the glass doors. “The food here is supposed to be good.”

“Uh huh,” I replied, my eyes still looking at the reflection in the glass. I placed a hand on my father’s back and gave him a gentle push. Go faster, go faster. John lingered for a few moments before he turned back to the sidewalk.

My dad opened a door and smiled at me. I smiled back. He didn’t hear me exhale with relief when John walked away.