Dr. Conrad Murray, personal physician to Michael Jackson, is currently on trial in Los Angeles for involuntary manslaughter, two years after the death of the singer — of “acute propofol intoxication” — was officially ruled a homicide by the L.A. County coroner’s office.
Let me start by saying that administering the anesthetic drug propofol for sleep, as Murray has acknowledged doing for Jackson, even while the doctor feared his patient had developed an addiction to it, is inexcusable. The drug has no medical use outside the operating room and anesthesia isn’t “sleep.” It’s more like a controlled form of coma.
But that being said, giving addicts the drugs they want isn’t always quackery. In fact, it can often be lifesaving. Indeed, “Dr. Feelgood,” a term of disparagement that has long been used to describe doctors who inadvertently or deliberately prescribe psychoactive drugs to addicts, may sometimes do real good.
Increasingly, evidence suggests that maintenance prescribing, as it’s known, may benefit addicts at least as much as direct efforts to get them to quit entirely. Simply giving addicts more drugs sounds like the last thing that could improve health or spur recovery, but the pharmacology of opioids like heroin and OxyContin — the kinds of drugs that contribute to the vast majority of overdose deaths in the U.S. — makes it practical.
Once a person has become dependent on these drugs, a steady, regular, maintenance dose will no longer produce a “high” or any impairment. Rather it will allow addicts to function normally. Studies increasingly support the use of substitute drugs like methadone and buprenorphine (Suboxone, Subutex) for opioid addicts, as well as the use of addicts’ actual drug of choice like heroin. As a handful of studies also suggest, there may be reason to hope that amphetamine could possibly even help methamphetamine and cocaine addicts.
Just like pain patients who can take steady doses of painkillers to function, addicts who are given methadone, heroin, buprenorphine or other opioids aren’t impaired. They don’t have to spend their lives seeking street drugs, a supply that is unpredictable and unlike medical-grade drugs possibly impure, which can only do more harm. When addicts are stabilized and required to see the doctor regularly for prescriptions, their health and lives improve. Research even shows that when addicts are maintained on long-acting drugs like methadone, their stress response is reduced in a way that isn’t seen with abstinence.
Hundreds of studies on methadone and buprenorphine use in opioid addicts support their efficacy. Maintenance prescribing reduces crime, mortality, and HIV and hepatitis rates more than abstinence-based treatment does, and is equally good at improving other outcomes like employment. Research also finds that when methadone clinics are shuttered or when maintenance prescribing is arbitrarily limited, overdose deaths and crime rates go up.
Moreover, for the most intractable cases of addiction, studies have so overwhelmingly supported the prescribing of heroin that countries including Germany, Switzerland, Denmark, the Netherlands and the U.K. now include it among their treatment options.
So, should we be praising our Dr. Feelgoods, rather than putting them in prison? Can we solve the crisis of prescription-drug addiction by legalizing maintenance prescribing of drugs other than methadone or buprenorphine? Can we prevent people from lying or committing crime to get drugs, simply by allowing them get them honestly?
The answers aren’t clear, but here’s one thing that is: the way we’re currently dealing with the misuse of opioids isn’t working. Legitimate pain patients are getting squeezed by measures meant to root out addicts. Overdose deaths are rising. Physicians who discover addicts in their practices tend simply to cut them off, often without even providing a referral to treatment. There’s no evidence that any of this helps.
In fact, a study by Project Lazarus, a comprehensive program aimed at reducing overdose deaths in North Carolina, found that when one physician who was believed to be a Feelgood enabler of addicts had his medical license suspended, his former patients began dying of overdose at a greater rate than when he was practicing.
Other doctors refused to see these abandoned patients: they were viewed as addicts simply because they had been associated with a “bad” doctor. It’s hard to know why they died, however. Did some pain patients commit suicide because of unrelieved agony, as has been known to happen in other cases in which doctors suddenly stopped prescribing (either voluntarily or due to legal issues)? Or were they addicts with a reduced tolerance?
The study’s authors suggest that, whether the people who died were suffering from pain, addiction or both, being cut off abruptly lowered their tolerance and put them at risk for overdose. Project Lazarus has since established a buprenorphine maintenance clinic in an attempt to prevent similar problems in future cases.
Thoughtless prescribing — like giving out propofol — is clearly dangerous. But maintenance should be a widely available option. Expanding the drugs available for maintenance use and the settings in which maintenance is permitted should be studied.