I have been kicking these observations around for the past year, and have been unable to find a big fish willing to ‘bite’.  I truly believe that the observations below have the potential to dramatically change the approach to opioid treatment of chronic pain.  Since I have a blog, I have a soapbox– so I’ll share the idea, and welcome comments in return.  I do ask that proper attribution be provided if this article is shared.

Introduction:

Long-term opioid analgesia without tolerance, respiratory depression, or euphoria?  Introducing the Holy Grail for chronic pain treatment!

Premise:

The miracle of opioid pain relief is fatally limited by tolerance, addiction and respiratory depression. Buprenorphine, when combined with a mu agonist, results in game-changing effects. Patients experience potent, dose-related analgesia from the agonist, but have NO euphoria. The therapeutic window is widened. Patients unable to control their use of a mu agonist alone gain that control when on buprenorphine. And most exciting, buprenorphine indefinitely anchors tolerance, maintaining analgesia WITHOUT DOSE ESCALATION. This finding offers huge implications for pain management.

Discussion:

Use of opioids for chronic pain has severe limitations. Tolerance removes the benefits of opioid analgesics over time. Worse, tolerance is associated with dependence and withdrawal. Many patients use additional doses of their prescription early in the month, then suffer through withdrawal while awaiting refills. Others find opioids through less-reliable, non-clinical sources.

At the same time, addiction to mu opioids is a nationwide epidemic. Reformulation Oxycontin has pushed many opioid users toward diacetylmorphine—brand name Heroin. Some physicians recommend avoiding mu opioids altogether for chronic pain (e.g. Physicians for Responsible Opioid Prescribing), while pain treatment advocates argue to ease narcotic restrictions.

Over the past six years I have treated over 500 patients using buprenorphine, mostly for opioid dependence. Buprenorphine, a partial mu agonist, is the active ingredient in Suboxone, a medication used for treating opioid dependence. The majority of my patients began their addictions with narcotics prescribed by doctors for back pain, knee pain, shoulder pain, fibromyalgia, chronic headaches, and other conditions.

Many of my patients found their pain reduced or gone after stopping mu agonists and substituting buprenorphine. Buprenorphine has the mu activity of 40 mg of daily methadone, but this activity is unlikely responsible for significant analgesia, since patients rapidly become tolerant to the agonist actions of buprenorphine. Instead, their pain while on mu agonists was likely maintained by psychological forces.

Patients on buprenorphine occasionally need opioid analgesia, just like other patients. My patients have had knees replaced, gallbladders removed, hysterectomies and c-sections, rotator cuff repairs, and in two cases, cardiac surgery. In all cases, sufficient analgesia was provided by maintaining daily buprenorphine at 4-8 mg per day, and using potent mu agonists, usually oxycodone, in doses ranging from 15-45 mg every 4-6 hours as needed.

Several patients have severe chronic pain from avulsion of the brachial plexus, failed spinal fusion, or other conditions, where prior opioid use resulted in rapid tolerance that prevented effective analgesia. These patients are now successfully maintained on combinations of buprenorphine plus mu agonists.

The combination of buprenorphine plus mu agonists has provided perioperative analgesia for patients on buprenorphine. Patients universally describe adequate pain relief, even after major surgeries. They also described the absence of euphoria, and to their surprise, the ability to control their use of pain medication—something impossible before taking buprenorphine.

But it is the effects on chronic pain that suggest a ‘game-changer’ for pain treatment. Even after over a year on combination buprenorphine/oxycodone, my patients 1. have no euphoria; 2. are often able to manage their own narcotic medication; and most important, 3. describe stable analgesia WITHOUT agonist dose escalation.

The ability to treat pain long-term without tolerance or dose-escalation is as exciting a development as was the initial discovery of opioids for pain relief!

Properties of a combination agent

Buprenorphine is administered sublingually, and could be prescribed as a separate medication, and use verified through urine monitoring. But greater safety benefits would come through regulations requiring buprenorphine (or a similar partial agonist) to be an inseparable part of every opioid prescription. Such a policy would dramatically lower the addictiveness and reduce the respiratory depression of mu agonists WITHOUT removing efficacy. The most obvious formulation would be a transdermal system that delivers buprenorphine and fentanyl, since both are already available in separate transdermal systems.

There may be situations, for example hospice care, where euphoria would be a desirable part of opioid treatment. But for other cases, analgesia without euphoria has obvious benefits.

I have written to several pharmaceutical companies with this idea, and have heard back that while the idea is interesting and scientifically sound, the generic nature of the component medications reduce the potential for profit that would motivate development. But given the potential value of this approach for multiple problems– addiction and chronic pain among them—I have to think that there is money to be made—not to mention the advances in treatment that the approach offers.

Reference:

Some supporting background information can be found in: Alford, D., P Compton, and J Samet, Acute Pain Management for Patients Receiving Maintenance Methadone or Buprenorphine Therapy. Ann Intern Med. 2006 January 17; 144(2): 127–134.

I also discuss this approach to pain treatment in my ‘Users Guide to Suboxone’, sold on Amazon and at bupeguide.com

Jeffrey T Junig MD PhD

Please do not reproduce without attribution.

I’ve been blogging for PsychCentral.com for the past couple months– which is one reason that I’ve blogged less here.  The Psych Central spot is a great opportunity;  the site is very highly read, and I hope to have a larger audience for my message– which at Psych Central will mainly be related to opioid depenence, and the need to accept a new treatment paradigm– since the old paradigm is usually a waste of time and money.

Please consider visiting the blog there and becoming a subscriber… but don’t run off too far!  I’m hoping to keep some readers HERE as well!

Thanks–

Jeff J

A reader wrote that her son, an opioid addict, developed a new addiction to alprazolam—a medication prescribed by his physician to treat opioid withdrawal while starting buprenorphine. Without getting too detailed about buprenorphine, I will note that the opioid withdrawal that occurs when starting buprenorphine is short-lived, and does not generally warrant treatment with an addictive substance like alprazolam.  Those who are interested in learning more about buprenorphine (brand name Suboxone) are invited to check out my blog and forum.

I did not, of course, witness her son’s anxiety, and I know nothing about the details of the case. But her remarks reflect a common phenomenon that deserves examination.

I sometimes get frustrated by patients struggling with addiction who also complain of ‘anxiety.’  By my understanding—according to impressions I have developed through my own experiences with addiction — the core problem in those of us with addictions is that we struggle to tolerate the normal pains and stresses of life.

We make the mistake of labeling normal and appropriate feelings of fear, guilt, or shame as ‘anxiety.’ Somewhere along the line we developed the incorrect impression that everyone is happy except us, and that WE have a right to happiness as well. The mistaken impression that ‘everyone is happy’ is one of the cognitive distortions corrected during recovery, in part through reflection and through cultivating insight.

But addicts who cling to a diagnosis of ‘anxiety’ seem unable or unwilling to develop that insight. I admit to having two opposing sets of feelings about addicts in such a position. As a physician, I see anxiety as a condition that warrants a sympathetic approach.  But I dislike the way that we addicts become ‘big babies’ who view our own misery as more severe, more important, and more deserving of ‘treatment’ than the feelings of others.

I like to remind myself of a phrase often repeated in 12 step meetings, about the need, in recovery, to ‘face life on life’s terms.’  The subject of this post asked the question “is there nothing for recovering addicts to treat anxiety?”

I have learned that in order to remain free of addictive substances, I must abandon seeing feelings that are the normal ‘part and parcel’ of life to be ‘anxiety.’ There are, of course, such things as anxiety disorders; people who suffer from panic attacks or from debilitating symptoms of obsessive compulsive disorder deserve treatment for those conditions, and should not feel guilty for seeking such treatment. But self-diagnosing an anxiety disorder, or even accepting such a diagnosis, is treading on dangerous ground for those of us with addictions.

Before considering myself to have anxiety I must ask myself, “Am I willing to tolerate the normal ups and downs of human existence?”

Am I saying, then, that addicts have a tougher road to follow— that they are less entitled to treatment of anxiety than ‘normal’ people?  Yes, I suppose that is one way to view things—if one chooses to measure the fairness of the world, rather than simply accept the realities of one’s condition. But that is always the case; people with non-psychiatric illness must make sacrifices to accommodate their illnesses, and so must those of us with addictions.

I remember the days before buprenorphine, when one taste of an opioid could eliminate insight for good, precipitating relapse that literally had no effective treatment. When I had opioid addicts as patients in the operating room, some begged me to avoid giving opioids, instead relying on a combination of regional anesthesia and grit to tolerate breakthrough pain.  And of course from a ‘feelings’ perspective, a person new in recovery should expect to have a greater load; the behaviors we engaged in during active using usually resulted in a great amount of anger and distrust, and we should not expect a ‘pass’ on experiencing the consequences of those behaviors. Working through shameful feelings is necessary for developing self-respect and humility—traits that are key to maintaining sobriety.

It is apparent to me that my desire (or need, depending on perspective) to treat uncomfortable feelings fluctuates over time. Some days, particularly when I am experiencing anger, resentments, or hurt feelings, my tolerance for an ‘untreated existence’ is low (understand that WANTING to treat one’s feelings is different from actually TREATING one’s feelings!). On other days I have less desire to ‘treat’ my feelings.

I am convinced that my own ability to tolerate ‘existence’ is higher when I have some awareness that life has an ultimate purpose, and that our existence lies beneath the realm of a Higher Power. (I am amazed by the way that the founders of AA discovered this principle, and included awareness of a Higher Power among the steps that have been used to bring life to so many suffering addicts!) The logical conclusion of this line of reasoning suggests that ‘anxiety,’ for some, may be a consequence of a lack of connection to something deep in life—a Higher Power, Faith, a reason to be alive—something.

To answer, then, the question of whether there is anything for addicts for ‘anxiety,’ I would say yes — but not in the form of a substance. The treatment for anxiety, by my reckoning, is first to take an honest look at whether one’s anxiety is truly worse than the feelings tolerated by our fellow beings. We addicts are bound to feel guilt, shame, and fear, especially in early recovery. Considering those normal feelings to be ‘anxiety’ only feeds into the core misunderstanding about life that led to our addiction in the first place!

And the most effective ‘treatment’ for the uncomfortable feelings of shame, guilt, and fear is to increase our awareness of whatever life is all about–an answer that will be different for each one of us.

The other day I met a new patient who described a long history of anxiety and depression that recently became severe.  She had been to two other psychiatrists in the past year, and was seeing me because she was not getting any better; in fact if anything she was getting worse.  She described symptoms that changed from anxiety and mild depression to severe panic attacks and social withdrawal; symptoms that were almost certainly the consequence of her being prescribed large doses of alprazolam (Xanax).  She described a pattern that I have seen very often;  a person has relatively mild, manageable anxiety, and is prescribed a benzodiazepine.  After a few weeks the ‘benzo’ is no longer effective because of a process called ‘tolerance,’ and worse, if the person misses a dose, the discontinuation symptoms FEEL like severe anxiety and panic– leading the person to take more of the benzo.  The dose must be increased to get a response, and then the discontinuation symptoms become even greater… leading to a spiral of increasing anxiety and medication use.  This is a difficult pattern to break, because the patient must reduce and taper off the medication that once was providing relief– all the while tolerating a certain amount of anxiety and insomnia. 

I feel bad for patients in this situation, because they would be better off had they never gone to a doctor for their anxiety in the first place.  But the situation in my new patient was even worse– and what had happened to her was not uncommon.  As her ‘anxiety’ worsened, the psychiatrist treating her piled on more and more medications.  She was prescribed Depakote without relief.  Then whe was prescribed risperidone.  Then lamotrigine.  These medications are all somewhat sedating, and when she complained of being too drowsy she  was prescribed the stimulant Adderall, and then modafanil.  The stimulants made her shaky, and so the original benzo was increased.

Medications like Depakote, lamotrigine, and risperidone have a place in psychiatry;  all three are mood stabilizers, and are used to treat bipolar disorder among a few other conditions.  In order to qualify for a diagnosis of bipolar I (the more serious form of bipolar disorder) a person must have a history of ‘mania’– a period of 7 days (shorter if the person is hospitalized) when the person is ‘revved up,’ with less need for sleep, increased risk-taking, racing thoughts, and other specific criteria.  There is some credible evidence that the diagnosis of bipolar has been overdone in recent years, particularly in children.  Over-diagnosis of depression would not be a horrible thing, given that the medications primarily used to  treat depression, a class of medication called ‘SSRIs’, are relatively benign.  But the same cannot be said of over-diagnosis of bipolar disorder; medications used to treat bipolar have a number of significant side effects ranging from sedation and tremor to weight gain and diabetes!

When I asked the patient about her diagnosis, she was confused.  She was not told that she had bipolar disorder, and so she was not certain why she was taking so many medications.  She had no idea that some of the medications were prescribed only to treat side effects from other medications.  And she had no idea that the medications had the potential to cause a wide range of systemic illnesses and conditions.

I don’t know what to make of THAT kind of psychiatry.  I talk often on my radio show about the need for patients and psychiatrists to spend TIME with each other;  time to get the diagnosis right, or in this case to at least come to SOME diagnosis!  Too often, medications seem to be prescribed out of desperation; an overly-busy, short-on-time prescriber adding medication not according to a sound treatment plan for a careful diagnosis, but rather using medications to blunt symptoms like firefighters in a helicopter dropping water on a fire.

Not all psychiatric conditions require medications, but sometimes, medications are useful and even necessary.  When medications ARE used, I encourage all patients to demand to know the diagnosis that is being treated, the options in medication and non-medication treatments, and the effects and side effects of anything that is prescribed.  That understanding will probably take some time– but that time should be a basic part of every psychiatric relationship.

A recent study out of Philadelphia and published in the American Journal of Psychiatry found a general trend toward the use of psychiatric medication without psychotherapy.  The authors of the study note that this is not particularly good news for patients, as research tells us that people do best when treated with a combination of medication and psychotherapy.

The specific data:  The percentage of persons using outpatient psychotherapy was 3.37% in 1998 and 3.18% in 2007.  Among individuals receiving outpatient mental health care, use of only psychotherapy (15.9% and 10.5% in 1998 and 2007, respectively) as well as psychotherapy and psychotropic medication together (40.0% and 32.1%) declined while use of only psychotropic medication increased (44.1% and 57.4%). Declines occurred in annual psychotherapy visits per psychotherapy patient (mean values, 9.7 and 7.9), mean expenditure per psychotherapy visit ($122.80 and $94.59), and total national psychotherapy expenditures ($10.94 and $7.17 billion).

At first blush the numbers are not all that dramatic.  For example, the percentage of persons using psychotherapydropping from 3.37% to 3.18% is not a huge issue.  But the numbers become more significant when you look only at the people receiving mental health care.  In that group, the percentage treated with psychotherapy alone dropped by over a third (another way to phrase that outcome is that a greater percentage of people who get help for mental illness use medication).  I believe that the numbers reflect a larger, insidious pattern of discouraging psychotherapy by insurers, and of dismissal of psychotherapy by patients as not useful.  This belief is supported by the other data– that even those who recieve psychotherapy are having less of it, the data showing fewer visits by such patients.  And despite the well-known increases in health care expenditures over the past ten years, money spent on psychotherapy has actually dropped over the past ten years– dramatically.

This article is only the tip of the iceberg.  People generally think of psychotherapy as an hour-long session with a therapist.  But psychotherapy can take many forms.  A psychiatrist can provide ‘supportive psychotherapy’ during a 30-minute medication check with a patient.  Internists and family practice physicians commonly provide such supportive psychotherapy as part of a wellness check or any doctor visit.  Supportive psychotherapy generally attempts to do exactly as the title suggests;  to support the person as he/she faces challenges in life.  It is easy to feel alone in today’s world, despite (or because of?) all of the electronic means of communication.  A supportive word or a calm voice can be a Godsend during times of emotional upheaval.

The primary reason for the movement away from psychotherapy is likely financial considerations.  Psychotherapy is labor-intensive and relatively inefficient.  On the other hand, efficiency determinations depend on the outcome measures that are used.  If nobody is getting better from medication alone– and a recent study in JAMA showed exactly that fact, that medication is not all that effective for mild depression–then psychotherapy deserves a place in modern psychiatry, no matter how few patients can be ‘cranked out!’

I have written about the nature of my practice a number of times.  I see at most two patients per hour, and more and more, I am providing longer psychotherapy sessions for people who have not done well historically using medication alone.  I hear stories that are simply shocking– and disappointing.   I’ve had patients tell me that they have not seen a psychiatrist for an appointment lasting longer than 10 minutes!  I recently saw a person with side effects from haloperidol, an old antipsychotic medication;  she could not sit in place for more than a few minutes before rising to her feet and pacing, apologizing for feeling so ‘restless.’  I explained the relatively common side effect to her called ‘akathesia’, and put her on a new medication without that side effect;  she now sits comfortably through her 30-minute appointments.  I wonder if her past psychiatrist saw the side effect as a blessing– as a chance to move her from his office more quickly!  More likely, though, he never even made the diagnosis;  the patient said that she never sat in his office long enough for the symptoms to cause her trouble!

I cannot speak for other practices, but I see a huge benefit for patients in having a psychiatrist who ‘gets’ them;  someone who can provide insight into their feelings and behaviors, who can help them know that their feelings are not unique from the human experience;  someone who helps them realize that they ‘matter.’    These are much more important parts of treatment than the benefit of an SSRI in most cases.  I hope that insurance companies realize that the goal is not to ‘medicate’ patients, but to help people and ease suffering.  I myself have decided to leave insurance companies behind for now, until they get things figure out.  They want psychiatrists to push people through, one after the other– and that, most of the time, is pure folly.

Sometimes I envy scientists and physicians from 100 years ago who took credit for the easy discoveries, sometimes even attaching their names to them.  The Bernoulli Principle, for example, describes how the pressure of an inviscid material decreases as the flow of the material increases, and why the disgusting shower drape in cheap motels is pulled toward the person in the shower.  I’m sure that I noticed that effect when I was about six years old, and had it not been already figured out, I know I would have come up with it eventually!   But the days of simply thinking real, real, hard and coming up with a ‘discovery’ are long gone.

Or are they?  I have a good one, I think… and with the right presentation and help from readers I might become famous.  Or not.  Either way, it’s worth a shot…. So I’d like to introduce Junig’s Warm Coat Theory of Psychotropic Prescribing.  (I know—the title needs work)

Back when I was an anesthesiologist, surgeons sometimes used the phrase ‘better is the enemy of good.’  The point was that in some surgeries the best approach was to remove the infected or diseased tissue, stop the bleeding, close up ASAP and get the patient back to the ICU.  Spending another 4 hours picking at the tissue to make everything pretty risked  a drop in the patient’s body temperature, a decrease in clotting and immune function, and an increased stress response, all in turn increasing the odds of a bad surgical outcome.  I have to give credit where credit is due, and note that the warm coat theory is similar in some ways to the ‘enemy of good’ phrase that I have heard recited over the years.  In fact, it is entirely possible that the unconscious parts of my mind stole the phrase and adapted it to psychiatry.  If that is the case, I’m sorry for the actions of my unconscious—and I plead ignorance to the entire affair!

When prescribing medication for psychiatric conditions– for example ADD or anxiety– the patient might note positive effects initially but then at some point ask ‘maybe I’d do better with a higher dose—should we try a little more?’  With any medication for any condition, there is a balance between positive effects of the medication and risks or side effects from the medication.  Serotonin medications work well for depression and anxiety, but as their doses are increased they will eventually cause sexual side effects.  At still higher doses they may cause drowsiness or nausea. The positive effects of a medication go up with dose, but the side effects increase as well.   The goal for the patient and physician is to find the proper balance is between positive effects and negative side effects.  If the patient has no interest in sex (and doesn’t WANT an interest in sex), sexual side effects should not limit the dose.  Nausea or sedation on the other hand may be barriers to dose increases.  Different people have different concerns about risks and side effects, and different people have different needs for higher doses of medication.  These differences, by the way, are why I maintain that psychiatrists should spend more time with patients than they do—but that’s another topic for another day.

A warm coat in Wisconsin

When us Wisconsin folks go outside in January, we take a look at the Weather Channel and dress accordingly.  But we don’t dress for 14 degrees F; we dress for ‘pretty darn cold.’  If I’m going to a Packer game, I’ll put on my long-johns (too much information?), jeans, and the snow-suit from Fleet Farm (that changed my life when I finally bought it, after suffering a few football seasons without it).  I’ll also wear a stocking cap and maybe even a face mask, and of course a thick pair of gloves.   At some point during the game, if the drunken guys squeezed in way-too-close on each side of me take off their shirts so their body heat radiates toward me and warms me up, I’ll take off my face mask and maybe my cap.  By the end of the game I might even have my own shirt off if the sun is out.  Of course the guys next to me might have enough of the game at some point and spend the rest of the game at the bar, just as the sun disappears behind a thick layer of clouds.  Then I’ll put the heavy stuff back on, and maybe rub my hands together or do some jumping around to raise my body heat.  If I get cold enough, I’ll go inside and warm up for a few possessions.  The point is that I don’t bring along a spring jacket to change into when I’m warm, and I don’t bring extra coats for when I’m cold.  Instead I change my activity, my location, or make minor adjustments to my wardrobe.

According to the warm coat approach, I suggest that patients think of their psychiatric medications in a way similar to how I think of dressing for a Packer game in January.  At the time the person wonders about a higher dose, he/she is getting a good response from the medication, usually with a low amount of side effects.  At this point, ‘better’ may be the enemy of ‘good.’  The person is essentially wearing a warm coat in January.  There is no need to run home and pick up a few more coats; the better action is to change behavior to fine-tune the degree of symptom relief.  If the target symptoms are attention problems and the current dose of stimulant has taken the person 85% of the way, the correct action is to adjust behavior.  Find a quiet location for  studying.  Get enough sleep.  Come up with reminders and plan ahead, to avoid time crunches that interfere with performance.  These are better approaches than increasing the dose of stimulant, which might raise blood pressure or lead to addictive problems.  If the target symptoms are anxiety-related, work on positive self-talk and try to gain insight into why the anxiety is there in the first place.  Learn to relax using deep breaths or by taking a walk to get away from the stressful environment.

The medication should be like a warm coat in January; a way to make symptoms ‘good.’  Use behavioral or therapeutic interventions– approaches that don’t increase risks or side effects– to make things ‘better.’

If Junig’s Warm Coat Approach becomes big, some day you’ll be telling your grandchildren about the day you first read it, before anyone was talking about it.  They’ll look up at you with big eyes and say ‘Wow!’   

Or not.  Either way, I for one think the idea has legs!

A couple months ago the Governor of Oregon, Ted Kulongoski, vetoed a bill that would have allowed psychologists to prescribe medication after completing two years of additional education.  To date only two states, New Mexico and Louisiana, have granted prescribing authority to psychologists despite significant lobbying by psychologists over the past few years.

Proponents of prescribing authority for psychologists point to the shortage of psychiatrists, claiming that granting prescribing power to psychologists would alleviate that shortage and allow greater access to mental health care for patients in need.  They also cite studies that (so far) have not found negative consequences from the granting of such prescribing authority.

I have written a number of times about the problems with the field of psychiatry.  For example I believe that psychiatrists make a mistake when they leave the mind behind, thinking that the symptoms of depression, anxiety, and other disorders can be understood using only the ‘hard sciences’ of physiology, chemistry, and anatomy.  But ‘hard science’ is where the field is going; those without a firm grip on neuroscience blindly follow the leaders on a professional snipe hunt, taking it on faith that there will be answers at the end of their journey.  While much of the training for my PhD in Neuroscience is out of date, I have enough background to know that there is no ‘there’ there.  Understanding the metabolic pathway for paroxetine for specific individuals is NOT going to have profound effects on mental health care. 

Many of the patients who I see tell me horror stories about their prior encounters with psychiatrists.  They talk about appointments lasting several minutes.  They talk about being prescribed medications without any explanation of why they are to take them, what side effects to expect, or what other options are available besides the medications.  Many times they do not even remember their psychiatrist’s name!   All of these issues come down to one thing:  time.  People want more time to explain themselves, more time to hear the options that are available, and more time to learn whether they are ‘normal.’

In a way, I am saying that psychiatrists need to emulate… psychologists.  I find it a bit ironic that psychologists are striving to get the very power that is pulling psychiatrists AWAY from patients!  It will be interesting to see if the psychologists who gain prescribing authority move toward the psychiatry model of the ‘med check’ appointment!

Psychiatrists do not fret over the issue of prescribing authority for psychologists.  Many of them work for health systems on a salary, and if anything they would prefer a lighter load.  So what if a few patients disappear?!  Besides, most psychiatric medications are already prescribed by non-psychiatrists, i.e. family care docs or nurse practitioners.  But I think that such nonchalance is a mistake.  I assume that third party payers are looking forward to the day when the initials ‘M.D.’ no longer command a higher fee schedule than N.P. or even Ph.D.  And I doubt that any leveling of fees will do as much to elevate the fees of non-M.D. practitioners as it will to lower those of M.D. psychiatrists.  There have clearly been efforts to make everyone the same in the eyes of healthcare consumers.  Those efforts are fine and dandy for the person who DIDN’T spend eight years accumulating debt! 

If physicians are ever forced into a position of having to justify their higher fees, they have placed themselves in a bad position in the battle for PR.  If everything else is even close to equal, patients will choose the practitioner who provides TIME over the 7-minute appointment with someone ‘more educated.’  Already, I hear patients talk about ‘Dr. Steve’ or ‘Dr. Betty’ in reference to their APNPs, any difference in training compared to ‘Dr. Thompson’ totally lost on them.

For the sake of the profession, I hope that psychiatrists learn one thing:  slow down.

Another show from the archives.  I should mention that the other person on the show with me is Bob Hoffmaster, who does the morning show at KFIZ Fond du Lac every day.  As you can hear, he makes the show a breeze;  he has a curiosity about everything, and all I have to do is come in and chat with him.  It is always the high point of my week– too bad it has to happen on a Monday!!