Illustration by skypixil / Dreamstime
Dr. Jeffrey Warren remembers the first time a pharmaceutical salesman came to his office, offering a new medication called Oxycontin. “It must have been about 20 years ago. They told me how much better it was, how it was going to make all my pain patients happy, and yet not get them addicted,” says Warren, a family-medicine physician with Regional One Health. “Well, that just didn’t sound right to me.”
Oxycontin and other products like it in the opioid class of medicines (Percocet, Dilaudid, Vicodin, and others) were initially hailed as miracle drugs because they do indeed reduce pain. But patients quickly discovered how addictive opioids can be — and how deadly, leading to heart failure and respiratory arrest when taken in high doses. A chart released by the group TN Together, a Governor Bill Haslam initiative whose stated purpose is “Ending the Opioid Crisis,” shows the increasing number of deaths from patients who overdose on these drugs when they increase the dosage to fatal levels. The dark bars on the chart march across the page like tombstones. In 2012, physicians reported 698 opioid-overdose deaths in Tennessee. By 2016, the most recent year data was available, that number had almost doubled, with 1,186 deaths reported.
As a result, “I can’t even give you Oxycontin anymore,” says Warren. “Here’s the new rule: If you haven’t been my chronic pain patient before the law came in, I can’t write you a prescription for pain medicine.”
Opioid addiction has been making the news lately, with good reason, but Warren’s patients also come to him with other addictive disorders — non-prescription drug abuse, smoking, alcohol problems, and more. As their primary-care physician, he often serves as the first line of treatment as he steers them on the road to recovery.
Dr. Jeff Warren
Photography courtesy Regional One Health
Warren has certainly seen a wide range of patients over a career that spans medicine and local politics. Born in Salisbury, North Carolina, he earned a bachelor’s degree at Yale and studied medicine at Duke. He completed his fellowship at East Tennessee State University in Johnson City, his residency at Long Island Jewish Medical Center, and his internship at the Columbia-Presbyterian Medical Center.
Warren initially began his medical practice in New York, working at Queens Hospital Center and then serving as the medical officer at the Riker’s Island Correctional Center. After relocating to Memphis, in 1992 he established Primary Care Specialists before selling that practice and joining Regional One Health.
“I always liked science,” he says. “And as an athlete [Warren played football at Yale], I experienced a lot of care from doctors growing up, and I saw this as a good way to use science to help people.”
An associate professor of family medicine at the University of Tennessee Health Science Center, Warren is also a member of the University of Memphis Biomedical Engineering advisory board and serves as the medical director for Trezevant Manor and The Parkview assisted living facilities. Along the way, he has served on the Memphis City Schools board as well as other civic organizations.
“You have to let them know you care, and you have to keep reminding them that you are not giving up on them.”
Drug addiction is nothing new, of course. “If you look at the history of medicine, you look at the history of heroin, opium, cocaine, morphine, and all these scourges,” Warren says. “They’ve waxed and waned since the 1800s, when many of them were legal.”
The problem is that even “hard” drugs like heroin and cocaine have a “therapeutic window” — a certain amount of time when they are indeed effective at reducing pain. Depending on the drug, however, that window eventually closes as the patient’s body adapts to the initial dose, the pain relief drops, and the patient requests — even demands — higher doses. This is what, inexorably, leads to addiction and overdose.
Warren says his main responsibility, as their personal physician, is to know his patients as much as possible. “You want your doctor to know you as a whole person,” he says, “and then that makes a difference in how they treat you.”
With a full knowledge of the person’s background and medical history, Warren is able to stay on the lookout for drug-seeking behavior. “You look for someone who is constantly trying to up their dose,” he says. “Or losing their prescriptions two or three months in a row, or wanting it filled earlier.”
Illustration by skypixil / Dreamstime
Once he determines that a patient has a true medical condition that is causing chronic pain, which can be the result of any number of conditions, from cancer to nerve disorders, then he is faced with a challenge.
The “new rules” Warren mentioned earlier refer to a series of bills enacted by the Tennessee legislature in 2018. As he explains it, the first step is “you really have to tell people what each one of these drugs can do for them, but also what it can do to them.”
If you have been a longtime patient, then Warren can write a prescription for, let’s say, Oxycontin — “but for no more than three days at a time, and only twice a month.” Even then, the patient has to return to the office for a full battery of tests before that prescription can be refilled a second time. After that, Warren is required by law to refer the person to a specialized pain clinic, where their medications are closely monitored.
Insurance companies are also paying close attention. “I get a printout from Blue Cross Blue Shield that shows every provider in the state who’s a family practitioner, and where they are regarding how many narcotics they write,” he says. Because he also serves as the medical director for Trezevant Manor, where elderly patients often have chronic pain problems, “I’m somewhere in the middle. I’d probably be lower, but I have a lot of patients with hip fractures, cancer patients, and things like that.”
Such careful monitoring has made many doctors nervous. “It’s complicated because now you have people who won’t write [these prescriptions] at all because they don’t want to get into it [with the various agencies.],” he says. “There was a recent case in California where a doctor was sued, and lost, for not writing a pain prescription for a patient who was actually in pain.”
What makes the matter evemore challenging is how subjectivepain can be; there is no specific test for it. “For a certain period, the Joint Commission on Hospital Accreditation decided they were going to make pain the fifth vital sign,” says Warren. “Along with blood pressure, pulse, temperature, and respiratory rate, they would add pain.”
A doctor can tell if a patient has too much pain medication because they act over-sedated. “Their respiratory rate goes down, they start to slur their speech, that sort of thing,” says Warren. And a patient is clearly in some level of pain if their blood pressure increases upon exertion. “If it goes up 50 points because it hurts to walk, then they are in pain,” says Warren. “But a lot of it is still subjective.”
Anyone ever admitted to the hospital remembers being asked to rate their pain on a scale of 1 to 10, with 10 being “like you’ve been hit by a train.” As subjective as that is (how does it feel to be hit by a train?), doctors are often required to use that number to monitor the dosage of painkillers. “You know how I write pain medicine in the hospital?” asks Warren. “I have to say, ‘Give this guy a pain scale of 1 to 3. Give this one a pain scale of 4 to 7.’ And then we dose it based on that.”
Treatment of pain requires a balancing act, because a doctor doesn’t want to keep effective medications away from people who truly need them. “I think we’re heading in the right direction,” he says, referring to the new regulations. “We may have overstepped how we’re doing it, but I think we can bring it back a bit, and not hurt people who truly need their drugs, and at the same time treat people who are addicted to them, and are actually hurting themselves with their medication.”
Even though Warren shares concerns about the opioid crisis, he sometimes wonders if our priorities are skewed. “The opioid addiction is grabbing headlines,” he says, “but look at how many people died from lung cancer or heart disease because they were smokers.” According to the Tennessee Department of health, more than 11,000 people die yearly in this state from the effects of cigarette smoking.
“Smoking is probably more addictive than most things you can do,” says Warren, “so it’s really hard to get off of smoking.”
Not only does a patient’s body develop a physical addiction to the nicotine in cigarettes, the act of smoking itself becomes a habit: “It’s what you do when you take a break. It’s what you do when you get in the car. It’s what you do when you finish eating. It’s what you do when you have a beer.”
Warren sees patients who have been in the hospital, where they weren’t allowed to smoke while they had surgery or other procedures. “When they get out, I tell them, ‘You’re not a smoker now. All that nicotine is out of your system. You haven’t smoked for three days, or five days, or seven days. So all you have to do to remain a non-smoker is this: Don’t smoke that first one.’”
But that’s what makes it so hard, and as a former smoker, Warren recognizes this challenge in his patients. “Something good will happen, and you decide to celebrate with a cigarette. And you tell yourself, ‘Hey, I was able to smoke just one cigarette.’ But then you smoke another the next day, and then work up to two, and you still say, ‘Okay, I’ll go up to two but not any after that.’”
Well, pretty soon that “non-smoker” is a smoker again. As their personal physician, Warren monitors his patients with X-rays and even such observations as the color of their teeth, or the smell of cigarette smoke on their clothing. He warns them of the danger: that there is no acceptable level of smoking.
“There’s an interesting new study that just came out of England, which shows that one pack a day increases your risk of heart attack or stroke 200 percent over non-smokers. Just five cigarettes a day increases your risk 80 percent.”
Warren helps his patients by prescribing drugs like Chantix, which reduces the body’s craving for nicotine; or nicotine patches, which allow patients to gradually reduce the dose of that drug, as it is absorbed through the skin, instead of being breathed into the lungs. Warren often suggests substitutes, such as chewing lots of sugar-free gum, and he points out the American Lung Association has a step-by-step quit-smoking program that patients can use online.
But he doesn’t feel comfortable with other options. “We initially thought that vaping [electronic tobacco-free cigarettes] might be a good idea — to have patients switch from smoking to vaping,” he says. “There’s no nicotine in those, but there are other chemicals in vaping, and there are no controlled studies that show what might happen 20 or 30 years down the road. It makes you less stinky, but it probably isn’t any safer.”
As a primary-care physician, Warren also treats patients with other addictive disorders. If the issue is alcoholism, he can prescribe medications that help with withdrawal, put them in contact with local Alcoholics Anonymous groups, or get them admitted into full-scale treatment centers.
“With alcohol, we’ve made some progress because it’s now recognized as a disease, and not a character flaw,” he says. “Even so, treatment is not just one person. The family needs to be involved, their church needs to be involved, their whole social network needs to be involved. It’s not a one-stop shop for treatment.”
For eating disorders, he may initially monitor diet and medications, but often refers those patients to psychiatrists, therapists, and other mental-health professionals. The same applies to patients addicted to non-prescription drugs, such as tranquilizers and anti-depressants, which can have brutal side effects from withdrawal if a patient has taken them long-term. He can monitor their dosage and help them reduce it over a long period or time, or send them to a psychiatrist or treatment center.
In short, a primary-care physician can help with problems that patients cannot treat on their own. “What you have to do is be their champion,” says Warren. “You have to let them know you care, and you have to keep reminding them that you are not giving up on them.”
