Nora, we adore ya!

On September 20, 2024, NIDA Director, Dr. Nora Volkow, gave the keynote address at UofL’s Research!Louisville awards ceremony. Here’s some of what our nation’s top addiction researcher had to say…

The opioid crisis started more than two decades ago, and we have not solved it.

It has caused more people dying than COVID itself.

The people that have died from the opioid crisis, all of them could have been prevented. Every single one of them could have been prevented.

We know how to prevent an overdose.

Overdoses are happening throughout all of the ages, throughout the whole life span.

The rise in overdose crisis…they went up to 117,000 in one year, those numbers were driven predominantly by fentanyl

We are seeing the decreases in fentanyl overdoses…the latest numbers are twelve percent (decrease).

Pain medications started the overdose crisis. It basically stabilized and it’s going down.

Similarly, heroin basically is accounting for a very very limited amount of overdoses. And this reflects the fact that the drug dealers actually don’t see any benefit for them, incentive for them, selling heroin. They sell fentanyl.

What has created the turn down of the curve (in overdoses)?

This is what’s likely to be accounting for it… In the field of opioid use disorder, which is different from actually any other field in the substance use disorders, we have extremely effective medications.

To start with, we have an incredible drug, naloxone. Naloxone is an opioid receptor antagonist.

When you give it (naloxone) to someone that overdoses, you reverse that overdose if they overdosed with an opioid…Whether it is fentanyl or heroin or an opioid medication, you need to give the naloxone, for it to be effective, rapidly and at the correct dose.

We are very lucky to have naloxone.

And then we have three different classes of medications, all targeting the opioid receptor system, but with different pharmacological effects, that are very effective in treating opioid use disorders.

Methadone…It has been in existence for, I think, sixty years.

Buprenorphine was approved at the beginning of the 2000s.

And then we have naltrexone, that was approved for opioid use disorder more recently.

Methadone – full agonist at the opioid receptor.

Buprenorphine – partial agonist.

These medications (methadone and buprenorphine) are effective in reducing drug taking, in reducing craving, in reducing withdrawal.

Except for naltrexone.  Naltrexone does not, per se, reduce withdrawal, it reduces craving, and it improves mood.

They are very effective in preventing overdose.

So the challenge is, you say, if you have these medications that are being so effective, why are we having so many people dying of overdoses? And the answer is because we do have the medications, but they are not being given to those that need them.  

Why are they not being used?

There are  multiple issues.

A key one is the stigma and discrimination against addiction.

The healthcare system providers don’t want to treat people with a substance use disorder.

We have generated a specialized system for the treating of substance use disorders that is independent of the healthcare system. Which is a totally lost opportunity.

Across the continuum, how can we improve access to these medications for people that need them?

There’s no evidence, to my knowledge, that any of the harm reduction practices exacerbate or increase the rate of overdose. I don’t know of any evidence. On the other hand, there’s ample evidence to show that harm reduction practices significantly reduces mortality.

There was so much expectation that the removal of the (DEA) waiver would increase the number of practitioners prescribing buprenorphine, but it hasn’t happened. What the research has shown is that the number of prescribers giving buprenorphine has not increased very much…Restrictive practices don’t help…The issue to me, this is discrimination. There is discrimination also in the way that we set up the reimbursement of taking care of someone with a very complex and potentially fatal disease.

Thank you, Dr. Volkow. You knocked it out of the park!

And this statement by our NIDA Director bears repeating, because it is a call to action: “If you have these medication that are being so effective, why are we having so many people dying of overdoses? And the answer is because we do have the medications, but they are not being given to those that need them.

Dear Governor Beshear

On September 19, 2024, I did two things via the Kentucky Governor’s official website: (1) I requested a meeting, and (2) I sent him an email via https://governor.ky.gov/contact.

Hint: Anyone can do this.

Here’s my email to Governor Andy Beshear.

Dear Governor Beshear,

This could be the most important message you get today. I appreciate you for taking the time to read it. And first of all, let me thank you for your amazing support of patients, families, and caregivers struggling to battle the disease of addiction and its tragic effects on the lives of Kentuckians. 

I was standing in that bright sun on the front row just to your right on Monday’s inspirational Recovery Month event.  After attending, I am more certain than ever that KY in general, and you in particular, are truly dedicated to defeating KY’s opioid crisis — the most deadly public health emergency in our lifetime. 

As I heard you speak, along with the distinguished people to your left and right, and later as I walked along that road between the Capitol and the Annex, meeting the numerous groups representing KY’s amazing response to the crisis, I really felt that united we were standing against this disease, and that we are making some progress.

And as a physician who follows scientific evidence, I’m happy I get to inform you that there is still something you can do. There’s something standing between you and your goal, but it’s fixable. 

That’s good news, Governor! 

I’m referring to KY’s buprenorphine regulation 201 KAR 9:270. It’s outdated and is harming the people it was intended to help. It gets in the way of KY physicians’ willingness and ability to prescribe this lifesaving medication. Something needs to be done about it. It needs to go.

I’m not a politician, not a lawyer, not a regulator. I’m a doctor. I speak for my patients, my colleagues, and the thousands of Kentuckians who could be saved by universal access to buprenorphine. 

But you don’t have to take my word for it. I am certain you know of NIDA Director, Dr. Nora Volkow. I’m equally certain you trust her. Well, she has recently stated that the overdose rate in our country could be cut in half if everyone who needs buprenorphine could find access to it. Dr. Volkow has the research data to back up that claim. And, by the way, I’m meeting her at UofL tomorrow at the Louisville!Research event. Yes, I’m having a really good week!

Governor Beshear, I know in your heart and in your mind you want to do everything you can to save lives. I know it is personal to you. And I promise, if you can find some way to get rid of this outdated, unnecessary, and harmful regulation, my colleagues at KYSAM and ASAM and I will do everything we can to make certain your action in this matter will result in tremendous success — and by “success” I mean, thousands of lives saved. 

Just ask yourself, is there anything else you can think of that is (a) so supported by science, (b) so supported by experts, and (c) so simple to do? You and your administration have already done so much. And you’ve had some success for sure. That’s commendable and something to celebrate.  And how great would it be to stand up to the podium on the south lawn next year and be able to say that KY’s overdose deaths have been cut by 50%

This is not just hopeful, this is do-able! Trust the science.  

Governor Beshear, you work so hard, you put your heart and soul into this cause every day. You deserve to get a better return on your investment. KY needs to get a better return on your investment. And we can!  

Please find some way to suspend or get rid of this buprenorphine regulation, and you will get a return on investment quantified by lives saved.  I’ve already requested to meet with you along with my colleague and KYSAM President, Dr. Colleen Ryan. I hope we can make that happen soon. We’ll help you. I promise.

With gratitude, admiration, and respect for all you do,

James Patrick Murphy, MD, DFASAM

Director, Kentucky Harm Reduction Coalition

Region X Director, American Society of Addiction Medicine

Immediate Past President, Kentucky Society of Addiction Medicine

Assistant Clinical Professor, University of Louisville School of Medicine

Representing ASAM on the AMA Substance Use and Pain Care Task Force

A CAPITOL idea! Governor Beshear proclaims September as Recovery Month in Kentucky!

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On Monday 9/16/2024, under a brilliant baking sun, from the south lawn of the state Capitol, Governor Andy Beshear proclaimed September to be Recovery Month in Kentucky. To his left and to his right sat about twelve sun-drenched dignitaries, most wearing business attire meant for air-conditioned offices.  As I stood there in the front row, myself baking in the sun, I realized two things early on: (1) I had made the right decision to come, and (2) my game time decision to wear my UofL Med School polo shirt instead of a coat and tie was the right move (Can you find me in the pic below?).

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I’d never heard Governor Beshear speak in person, and I found him to be as charming, personable, likable, and relatable as he always appears to be on TV. The governor said all the right things that needed to be said. He was inspirational as he recounted the work that had been done by Kentucky’s government over the past year battling the opioid crisis in our state. He touted KY’s 9.8% drop in overdose deaths from a year ago. He also said “There is a lot of work left to do.”

Eric Friedlander, Secretary of KY’s Cabinet for Health and Family Services also spoke and said he is thankful he is working for a Governor who “believes in science.”

And Lisa Lee, Commissioner for the Dept. for Medicaid, said that we’ve made progress, but she won’t be satisfied “until all barriers to treatment are gone.”

Others eloquently spoke, bills were ceremoniously signed, a few people with lived experience offered their compelling stories to the crowd, which dwindled a bit over time as onlookers gradually receded into the few shady spots farther away from the podium. All in all, the message was very positive. And as I stood in the front row to the right of the stage, facing Representative Kim Moser, the only other person besides me wearing red in Frankfort that day, I really wanted to believe the Governor when he said in closing, “I am convinced that we can defeat this epidemic.”

After the speeches, Representative Moser visited with me, offered me some of her views, gave me a little advice, and graciously invited me to come back to Frankfort in October to testify before her colleagues. She also introduced me to Secretary Friedlander, who I chatted with briefly. And before I left the podium area I got to speak with a true KY hero, Van Ingram, Executive Director for the Kentucky Office of Drug Control Policy.

These were all great connections to make. I had travelled to Frankfort thinking my main objective was to meet some of the people who I’ve been emailing regularly about the urgent need for a major overhaul of KY’s outdated and harmful regulation governing how physicians prescribe buprenorphine to treat addiction. I felt that my meet-and-greet mission had been accomplished. I could now report back to my organizations (i.e., KYSAM, ASAM, AMA, KYHRC) that our concerns about the buprenorphine regulation were probably a little closer to getting heard by the people who could bring about the needed change.

What happened next was unexpected.

I walked to the far end of the road between the Capitol and the Annex Building where dozens of addiction treatment, addiction recovery, and addiction support groups had set up tents, tables, and booths. I decided to visit every group represented there. I learned what they did, how they were funded, what role they played in the orchestra of helpers throughout our state. I met some amazing people, and I am definitely going to follow up with as many as I can. We truly have some fantastic advocates and caregivers in our state. 

And maybe providence had a plan for me that day, because as I worked my way along that road from the far end to the beginning, near the humongous, beautiful, and famous floral clock on the Capitol grounds, the last group I visited was comprised of only two women. Out of respect for their privacy, I won’t go into specifics. But suffice it to say, these two amazing individuals were living fulfilling lives in recovery from opioid addiction, both were being treated with buprenorphine, and both told me that treatment with buprenorphine had literally saved each of their lives. 

With this as my send off, I left the Capitol a little more sunburned but tremendously more inspired. It’s clear, there are a lot of wonderful people in our state doing fantastic things to help people with addiction make it to their promised land of recovery. And I’m  more determined than ever to prove myself worthy of inclusion amongst the ranks of these dedicated and compassionate healers, by virtue of my doctoring, my advocacy, and my caring. 

If you’ve read all the way down to this point in my article, then you are likely one of those wonderful people I mentioned in the paragraph above – because I know my writing is nowhere near as compelling as the cause. And you’re probably a person who wants to make a difference – maybe even save a life in the process. If so, then I have an ask of you…

Please help me get the message to our Governor that Kentucky’s outdated buprenorphine regulation needs to be gone. The science, the data, and the lived experience of thousands in recovery confirm that buprenorphine treatment for opioid addiction promotes recovery, prevents overdoses, and saves lives. I made some handouts that I gave to people at the Recovery Month event on the Capitol lawn. Below you will find screen shots of the handouts. 

As I said to one nice young lady, who politely told me that because she was employed by the state there was no way she could advocate for changing a state regulation, “That’s all right. I’m just asking that you read it.”

“Why?” she asked.

“Because, once you read it, you can’t un-read it.”

So, now I humbly ask you to please read the information below. And if you want to help remove a significant barrier to people with addiction receiving the most effective treatment we have to prevent overdoses and promote recovery, then stoke your creativity, ingenuity, determination, and problem-solving skills and help me find a way to get this information to Governor Beshear.

As Secretary Friedlander said, our Governor believes science. 

Once he reads this, he can’t un-read it.

And he will know what to do.

Your grateful colleague,

James Patrick Murphy, MD