Neonatal Abstinence Syndrome: Genetically Influenced

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As you can see from my blog post of July 27th of this year, we know genetics influences the risk of developing opioid addiction. Now, according to a 2013 study, we know that certain genes are associated with less severe neonatal abstinence syndrome. [1]

Neonatal abstinence syndrome, called NAS, occurs in about 50% of babies born to mothers maintained on methadone or buprenorphine. Of course, NAS also occurs in babies born to mothers using other opioids, prescribed or illicit, but this study only included mothers in addiction treatment on methadone or buprenorphine.

The withdrawal signs seen in infants are gastrointestinal: diarrhea, poor feeding, and vomiting; central nervous system: tremor, increased muscle tone, increased startle response, and poor sleep; and other symptoms like sneezing, yawning, increased respiratory rate, fever, sweating, and nasal stuffiness. For infants, NAS is a serious medical problem that can cause seizures and even death if untreated, so it is important for doctors to know if an infant has been exposed to any opioids during the pregnancy. With longer-acting opioids like buprenorphine and methadone, the withdrawal can be delayed for up to a week. With short-acting opioids like heroin, withdrawal can occur quickly in the infant.

Thankfully, NAS is treatable, and most hospitals use a standardized protocol to check babies for serious withdrawal signs. If the baby has more than mild signs, an infant-sized dose of opioid is administered in tapering doses, to gradually reduce physical withdrawal.

Aside from treating the baby with tapering doses of opioid medication, we know other things can help reduce the severity of NAS. Reducing or even better quitting smoking before or during pregnancy reduces the chances of neonatal withdrawal, as can breastfeeding. Contrary to popular belief, it isn’t methadone or buprenorphine in the breast milk that helps withdrawal; it’s the warmth and comfort of being at the mother’s breast that soothes the baby. Similarly, babies are calmed when their environment is quiet and dark, and swaddling (wrapping the baby closely in a blanket) also helps.

Most people assume that the higher the mom’s dose of methadone or buprenorphine, the more likely it the infant will have withdrawal, but repeated studies show no clear relationship between maternal dose and the likelihood of NAS.

But now, this study shows we may become able to predict which babies will have more severe withdrawal based on genetic profile.

This prospective cohort study, conducted in Maine and Massachusetts from July 2011 to July 2012, looked at eighty-six pairs of mothers and infants. The study looked at length of hospital stay for the infants and the need for medical treatment for NAS in those infants. The study found that babies with certain genetic variants of the OPRM1 gene and the COMT gene had significantly shorter hospital stays and needed significantly less medication to treat withdrawal symptoms.

Of course, we can’t change genetic makeup, but we may be able to use this information someday to help predict which babies need longer hospital stays and more medication for their NAS. Ultimately, these studies may help us better understand NAS and how to treat it.

With the recent increase in incidence of opioid addiction, more women are getting pregnant while addicted to opioids. Most hospitals have seen an increase in the percentage of babies born with NAS, so this is an important area of research.

1. Wachman et al, “Association of OPRM1 and COMT Single-Nucleotide Polymorphisms With Hospital Length of Stay and Treatment of Neonatal Abstinence Syndrome.” Journal of the American Medical Association, May 1, 2013, Vol. 309(17).

We are More Than Our Disease

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Imagine you are a diabetic, complaining to your doctor’s office manager about poor treatment you’ve received by the doctor’s staff. How would you feel if the office manager said something like this?

“That’s just your disease talking. Your perceptions are wrong because your diabetes wants you to feel resentment and self-pity. Your diabetes wants to give you an excuse to go back out there and eat a bunch of sweets. Your diabetes has you confused. You really weren’t mistreated. Your thoughts and feelings aren’t real.”

Sounds kind of nutty, doesn’t it? Yet people with addiction are sometimes told similar things by their treatment programs.

While it is true that addiction can damage the structure and function of the brain, patients don’t lose all their higher brain functions and often have very accurate perceptions.

This week I encountered a patient who said workers at his opioid treatment program discounted his legitimate complaints about problems he saw at his program. He said he felt like personnel at this program thought because he was an addict, he didn’t know what he was talking about and had no right to complain.

I listened to him, and what he said resonated with me.

I outed myself a few months ago on this blog as a person in recovery. I’ve been abstinent from drugs and alcohol for over sixteen years, and my recovery is one of the most precious possessions I have. And yet, I do remember similar frustrations with my treatment program.

I went to an intensive outpatient treatment program many years ago. It was highly recommended by other doctors in recovery, so I hadn’t shopped around for treatment programs. Besides, who has any idea what to look for in a drug addiction treatment program? I just followed the recommendations of my state’s physicians’ health program.

I do admit that my brain had been damaged by drugs and by withdrawal. I knew my perceptions were not completely reliable, and yet, sometimes I heard my counselors say things that I knew were not OK, and that were offensive to me. I can’t remember exact words after so many years, but the essence of their remarks was I wasn’t able to think clearly, all my perceptions were wrong, and I had no right to be angry about anything, including disagreements with treatment staff.

Which is a rather convenient position to take if you are treatment staff. Essentially, you win any argument with patients, because you can say the patient’s brain is damaged, yours isn’t, so therefore you are right and the patient is wrong.

I remember when I was in aftercare, I overhead a comment made by my counselor to another counselor about another patient who frequently relapsed: “She can’t come to aftercare because she keeps getting drunk.”

His breach of her confidentiality was bad enough, but when I heard him I thought, “Aha! All this talk of disease, but he doesn’t really believe it or he wouldn’t blame her like this.”

Yes, maybe my brains were still scrambled, but I got that one right.

Now I’m on the other side of the treatment fence, and things look different. I think there is a temptation to take the easy way out when faced with a patient complaint, and dismiss the complaint as being irrelevant.

I’m not rising up on a self-righteous scold of all treatment staff; I’m writing this blog as much for me as other staff.

We must always be able to look honestly at our actions and attitudes as addiction treatment professionals. If a patient complains, we need seriously to evaluate our behavior.

For me, it helps to have a good treatment team around me, who are willing to tell me if I’m off the mark with my thinking. I also do my own mini-inventory at the end of each day (OK most days). Did I treat people the way I’d like to be treated? Did I try to do the best thing for them? Sometimes this means making a decision that angers patients or angers treatment staff.

Most importantly, when I’m with a patient, I want to remember he may have drug addiction, but that’s only one small part of who he is. He’s also other important things. For example, this person may also be a son, father, husband, artist, good provider for his family, have a great sense of humor, etc. Treating the addiction should help him get back to being himself. He is so much more than just an addict. Sadly, many of our patients have family who have written them off as “Just an addict,” and are no longer able to appreciate their wonderful qualities and talents.

Addiction treatment personnel: Let’s not make the same mistake.

Bibliotherapy: Women and Addiction

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I’m sorry to post another re-run this week, but i just moved, and my time and energy have been taken up with unpacking. I haven’t made time to write a fresh blog entry this week. Meanwhile, here’s an entry from a few years ago:

If you’ve looked at my blog before, you’ve likely seen that I like to recommend books. I prescribe books as medicine. Looking over my sagging bookshelves, I saw a number of my favorite titles that are specific for women and addiction. While some are a bit dated by now, even those contain information that’s helped me better understand how women, especially pregnant women, have unique needs in their recovery from addiction.

For example, in the past, when I talked to a pregnant patient who was still using drugs, I would tell her every awful thing her drug use could possibly be doing to the fetus. I thought I could scare her into sobriety.

Studies show this approach is associated with a worse outcome for baby and mother than a compassionate and hopeful approach. Pregnant addicts carry a tremendous burden of shame and guilt, as arguably the most stigmatized people in our society. Even other addicts look down on pregnant addicts. So when physicians add to their shame, they tend to run. They leave treatment (physically or mentally), and everyone suffers. With a gentler approach, these women tend to participate in their own treatment.

Duh. Don’t we all do better with gentler approaches?

Anyway, here’s a list of books about women and addiction. Some I have mentioned before, like Women Under the Influence, by the National Center on Addiction and Substance Abuse at Columbia. This is maybe the most comprehensive book, full of references, about addiction in women. Happy Hours by Devon Jersild is more conversational, with excerpt from interviews with women addicted to alcohol, but it also contains solid information. One of the most entertaining, because it is a well-written story told by a female alcoholic is Drinking: A Love Story, by the late Caroline Knapp.

Parched, by Heather King, is similar to Ms. Knapp’s writing, and also worth a read. This book is a well-written, entertaining documentation of an intelligent woman’s descent into alcohol addiction. Thankfully, she also describes her recovery. This is a better-than-average addiction memoir, and hasn’t gotten the recognition it deserves.

Using Women: Gender, Drug Policy, and Social Justice, by Nancy Campbell, written in 2000, is an unusual and fascinating book. It describes how society has viewed female addicts throughout history and how they are frequently judged more harshly than male addicts. Throughout the decades, addicted women don’t do what’s expected of them by their society, and society’s expectations often shaped U.S. drug policies. The author contends that female addicts cause more outrage because they stray so far from assumed female roles. The book is filled with cool black and white photos of sensationalized news stories from the girl addicts of the 1950’s to the crack moms of the 1990’s.

Women, Sex, and Addiction: A Search for Love and Power, by Charlotte Davis Kasl, PhD, 1989, focuses more on the way the inequities of power in relationships shape female behavior with sex and drug use and addiction. The author discusses all sorts of addiction, not just sex or drug addictions. For many female addicts, codependency and sex are strongly intertwined. The book also has sections of lesbian and bisexual lifestyle and addiction, and male codependency and addiction. Some sections were interesting and helpful, and others…not so much. The author uses older terminology, from the time when codependency was more in vogue.

Women on Heroin, by Marsha Rosenbaum, 1981. This book follows the careers of 100 female addicts in a street study. The author talked with a hundred women of many ages and various races to hear what their lives are like, being addicted to heroin. One theme of the book is that initially, drug use gives the illusion of empowering the women, but eventually the need to support their habit steals their power. Women resort to criminal means to support their habits, and this is more difficult for women caring for small children. Treatment programs often don’t consider children can be a strong motivating factor for a woman to get clean, but not if she loses her kids while she goes off to treatment. Lots of quotes from the women she interviews are scattered through the book.
All counselors working with female patients need to read this book to more fully understand how effectively to engage women into treatment. Besides containing useful information, it’s just a really interesting book.

Crack Mothers: Pregnancy, Drugs, and the Media, by Drew Humphries, 1999. Here’s a book bound to stir controversy. The book describes how the “crack baby” was a media invention, not a medical reality. While some children born to women addicted to cocaine had medical issues, we now know these kids didn’t grow up to be the permanently and hopelessly damaged human beings as conjured by the media. This book talks about the racist prosecution of pregnant minority addicts, and how they tended to be the ones to be jailed, while middle and upper class pregnant addicts were able to use their resources to avoid prosecution. In some cases, pregnant women had asked for treatment but were turned away because it wasn’t financially accessible, and they were jailed instead. I thought this book was very interesting and I read it in just a few days.

Substance and Shadow: Women and Addiction in the United States, by Stephen Kandall, The author is a renowned neonatologist, and this book is scholarly, filled with references. I’m reviewing the book from memory, since I loaned it to a friend and I can’t remember who has it. The author talks about the paternalistic methods of physicians in previous centuries, and how their attitudes increased the risk for female addiction to opioids. Then he traces the history of drug policy in the U.S., paying special attention to how women were treated – or not treated – differently. This book is a bit more intense, and not as light or quick reading as most of the others listed.

A Woman’s Way Through the Twelve Steps, and A Woman’s Way Through the Twelve Steps Workbook, by Stephanie Covington, 2000. Compared to the method of working the twelve steps outlined in either AA’s Big Book, or NA’s Step Working Guide, this workbook is a little “fluffy.” It’s a softer way of looking at the steps, and may be quite beneficial for women who have been traumatized by abuse in the past. For some women, harsh rhetoric occasionally heard in 12-step meetings can triggers memories of abuse, verbal or physical. For women who are turned off by more traditional steps guides, this book and workbook offer an alternative. I liked the book better than the workbook. For some people, this could be a great resource.

Benzodiazepines Associated with Increased Risk of Death

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Adults who use sleeping pills are more than three times more likely to die prematurely compared to matched controls that don’t use sleeping pills, according to a recent study. [1]

I’ve never been a fan of sleeping pills, even the newer, first-line “Z” medications: zolpidem (Ambien), zaleplon (Sonata), and eszopiclone (Lunesta). I’ve seen all of them cause more harm than good in my patients, but that’s not surprising, since I treat patients with addictions.
These newer sleeping medications are touted by many as being safer and less addictive than older medication like temazepam (Restoril), triazolam (Halcion) or clonazepam (Klonopin). However, all of the “Z” medications are Schedule IV controlled substances, just like their benzodiazepine predecessors. This means they all have roughly the same potential to cause addiction, despite some enthusiastic and misleading marketing done by some drug companies.

I know many people, without a history of addiction, can take sleeping pills without apparent problems, so I was surprised to read about this recent study. This relatively large study looked at the medical records of over 10,000 patients who were prescribed hypnotics for sleep, and compared their outcomes to over 23,000 matched control patients, similar except the controls weren’t taking sleeping pills.
The sleeping pills, also called “hypnotics” were associated with significant increases in mortality and significant increases in cancer incidence.

The patients’ average age was 54, and they were followed for an average of 2.5 years. All were members of a large U.S. healthcare system in Pennsylvania. The data from the two groups were adjusted for age, gender, smoking status, prior cancer diagnoses, body mass index, ethnicity, and alcohol use.

Patients in the group taking prescribed hypnotics most frequently, defined as more than 132 doses per year, had over five times increased risk of dying than patients not taking hypnotics. Even the group of patients taking hypnotics relatively infrequently (up to 18 doses per year) had a three times higher risk of death. These differences were statistically significant. The medications in the study included all of the “Z” medications, as well as temazepam (Restoril), barbiturates, and the sedating antihistamines, such as diphenhydramine (Benadryl).

Of note, eszopiclone (Lunesta) was associated with the highest risk of death. (This pill’s advertisement has a beautiful butterfly wafting in through an open window, and landing gently by a woman in bed, presumably helping her sleep. I guess the butterfly seemed like a better commercial symbol that the grim reaper.)

The use of hypnotic medications was also associated with an increased risk of cancer, and reached statistical significance in patients taking the most hypnotics. Lung, colon, and prostate cancers were significantly more likely to occur in these hypnotic medication users, as well as lymphoma.
The author estimated that hypnotic medications are associated with 320,000 to 507,000 deaths in the U.S. over the year 2010.

This study raises some important questions, since hypnotic drugs are the most commonly prescribed drugs in the U.S., with an estimated 6 to 10% of the population being prescribed these medications.

Then in early 2014, a study done in the United Kingdom showed similarly increased mortality for patients prescribed anxiolytic and hypnotic medications. [2]

This second study was a retrospective matched control study, looking at all-cause mortality in patients prescribed these medications as compared to patients with no such prescriptions. Patients in the group prescribed benzodiazepines were more than three times more likely to die than matched controls. There was also a dose-response association; the higher the dose, the more likely the patient was to die. This study shows a correlation, but not necessarily causation. Perhaps sicker patients were prescribed the benzodiazepines in the first place.

We know benzodiazepines are associated with increased risk of auto accidents, increased risk of completed suicide, worsening of mood disorders like depression, increased risk of drug-induced dementia, and increased risk of daytime fatigue. Benzodiazepines are also associated with increased risk of cancer, falls, and pneumonia.

Sleep medicine doctors say that correlation doesn’t mean causation, and we shouldn’t jump to conclusions. One sleep specialist pointed out that the study didn’t control for psychiatric illness, which could be a significant factor. Additionally, patients who are prescribed sleeping medications may be sicker overall, in ways the study didn’t control, and therefore a generally less healthy group. This could distort study findings.

Other scientists say that sleeping pills could make sleep apnea worse, and cause deaths in that way. Obesity increases the risk of sleep apnea, and with more adults becoming obese, perhaps sleeping pills make apnea worse and these people die in their sleep. Other scientists say sleeping pills slow reflexes, and perhaps patients taking these medications are more likely to be involved in car accidents and other accidents, increasing their death rates.

As for my patients, many of whom are prescribed methadone or buprenorphine, the risk of drug interaction and overdose with the hypnotics usually outweighs all of the benefits, and I recommend that patients do not mix these two types of medications.

So stay tuned. As time goes on, hopefully we’ll learn more about this correlation between benzodiazepines/hypnotics and death. Both of these studies are helpful because of their large size, and the author points out that 19 other studies have shown a relationship between hypnotics and increased risk for death.

1. BMJ Open2012;2:e000850 doi:10.1136/bmjopen-2012-000850
2. Weich et al, “Effect of anxiolytic and hypnotic drug prescriptions on mortality hazards: retrospective cohort study,” British Medical Journal, 2014

Opioids and Benzodiazepines Prescribed More Frequently in the South

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Last month, the CDC released information comparing rates of opioid and benzodiazepine prescriptions by state and by region. It did not surprise me to learn the South had the highest rates of benzodiazepine and opioid prescribing of the entire nation.

U.S. citizens already receive twice the number of pain pills per capita than our Canadian neighbors. But in addition to that difference, there’s a 2.7-fold difference between the state with the lowest opioid prescribing rate per capita (Hawaii) and the states with the highest rate per capita (Tennessee and Alabama tied for first place). [1]

The same held true for benzodiazepines, with even more difference in prescribing rates. In Hawaii, doctors prescribed benzodiazepines 19.3 times for every 100 people. But in Tennessee, doctors prescribed benzodiazepines 61.4 times for every 100 people. That’s over a three-fold difference between these states.

Alabama, Tennessee, and West Virginia were the top three prescribers for both opioid and benzodiazepines. We already know that higher prescribing rates are associated with higher overdose deaths rates from these medications. Incredibly, these three states were more than two standard deviations away from mean prescribing rates for the entire country.

Even more disturbing, Tennessee doctors prescribed oxymorphone (Opana) at an amount 22 times that of doctors in Minnesota.

That’s just bizarre. It could also explain why so many of the patients I admit to OTPs in the mountains of North Carolina mention Opana as their drug of choice.

The CDC authors of this report admit it’s unlikely there’s much difference in rates of disorders needing treatment with opioids or benzodiazepines. My interpretation of this statement is that it’s an indirect way of saying doctors in the South are overprescribing opioids and benzodiazepines. The authors allude to the problem of overprescribing in the South, mentioning that the South also has higher rates of prescribing for antibiotics, stimulants in children, and medications known to be high risk for the elderly.

How did my state of North Carolina compare to the rest of the nation? Our data isn’t as embarrassing as that for Tennessee, but there’s certainly room for improvement. In NC, doctors prescribed around 97 opioid prescriptions per 100 people, and 45 benzo prescriptions per 100 people.

Benzodiazepine co-addiction complicates induction onto methadone and buprenorphine done by opioid treatment programs for the treatment of opioid addiction, and this co-addiction also predicts poorer treatment outcomes. [2, 3]

This supports what I’ve long suspected: the treatment of opioid addicts with MAT is different in the South than in the West. My colleagues in California, inferring from the CDC’s report, don’t have to deal with benzodiazepine co-addiction as often as I do in the mountains of North Carolina. That co-occurring addiction changes the clinical picture, and makes induction onto methadone particularly more risky.

This is not the South’s finest hour. We must do more to educate doctors about appropriate prescribing, starting in medical school and continuing throughout the physicians’ professional careers. If doctors don’t start this change, someone else will surely do it for us.

1. http://www.cdc.gov/vitalsigns/opioid-prescribing/index.html
2. Brands et al, 2008, Journal of Addictive Disease
3. Eiroa-orosa et al, 2010, Drug and Alcohol Dependence

Opioid Physical Dependence versus Opioid Addiction: What’s the Difference?

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Many people, including doctors, are confused about the difference between physical opioid dependence and opioid addiction. To further complicate the issue, in the past, psychiatrists used the word “dependence” interchangeably with addiction.

They are not the same.

By physical dependence, I am referring to normal changes human bodies makes when exposed to opioids for longer than several weeks to months.

Our bodies like to keep things level. When we ingest opioids for more than a few days, our bodies compensate, and make changes to help minimize the effects of opioids. Over time, it will take more opioid to have the same effect, which is called tolerance. Then if opioids are suddenly stopped for any reason, we experience a backlash in the other direction, due to the body’s adaptations. We will feel physical withdrawal signs and symptoms: increased heart rate and blood pressure, nausea, vomiting, diarrhea, sweating and chills, goose bumps on our skin, muscle and joint pains, anxiety and insomnia. This happens to human bodies when exposed to opioids for long enough, and then stopped suddenly.

The presence of physical withdrawal symptoms alone is NOT the same thing as opioid addiction.

For addiction to exist, the person taking opioids must have psychological manifestations. Such a person suffers from the obsession and compulsion to use more opioids, even knowing bad things happen with opioid use. A person with addiction neglects other important parts of life in order to focus on the use of opioids. She may use the drug in ways it’s not meant to be use – injecting, snorting, or chewing for faster onset. She may start using opioids to treat negative emotion, and mix them with other drugs for different effects. She may use opioids even when not in pain, for the effect the drug has on her.

Having the brain of an addict is like having a car with the gas pedal stuck all the way down. An addicted brain may be able to see sharp curves ahead, and even recognize that slowing down would be prudent, but still feels powerless to do so.

It’s often a scary ride.

A person with only physical dependence may feel bad if she stops opioids too quickly, but she would be able to taper if done slowly enough, because the mental obsession to keep using more isn’t driving the drug use. She may feel physical pain return as the opioid is tapered, and may have to slow the reduction in dose, but that’s a different issue.

So we see it’s possible to have physical dependence to opioids without actual addiction.

It’s also possible to have addiction to opioids without physical dependence.

For example, if you put an opioid-using addict in jail, she will undergo physical withdrawal. By the time she’s released, she may longer have the physical dependence (Though many opioid addicts have a post-acute opioid withdrawal that can last for days, weeks and even months. These people’s bodies may have lost the ability to manufacture endorphins, our bodies’ natural opioids.). But if nothing has been done to treat her real problem, the obsession and compulsion to use opioids will return, and she will relapse.

Too many family members of addicts, cops, judges, and even doctors have the false expectation that physical detoxification from opioids is the same thing as treatment. Often the addict is judged harshly for failing at treatment, when the addict wasn’t even given effective treatment. Because detox alone is not treatment.

Opioid addiction is treated with talk therapy, consisting of motivational enhancement counseling, cognitive/behavioral counseling, 12-step facilitation counseling, or a mixture of counseling techniques.

Success rates are markedly improved when medication-assisted treatment with buprenorphine, naltrexone, or methadone is added to counseling.

I’m writing this blog after a visit from a new patient at my office. This nice lady had been accused of being a drug addict by her doctor. She’s been on the same dose of opioids for the last three years, never runs out early, doesn’t misuse her medication, and has urine drug screens that show only the medications he prescribes. At her visit with me, she denied shooting, snorting, or chewing her medication for faster onset. She’s never obtained opioids from friends or acquaintances, and doesn’t use any other drugs including alcohol.

Yet she told me that for some reason, her doctor made the comment to her, “If I didn’t prescribe these pills for you, you’d be buying them off the street.” She was appropriately offended, but also worried she might have addiction. She tried to stop her opioids suddenly, but got sick. She took this as evidence she was addicted, so she came to see me for an evaluation.

I assume she’s telling me the truth, because why else would she waste time and money coming to see me? She has no evidence of addiction that I can detect.

I recommended she go back to her doctor, and ask him to taper her dose down, slowly. This should be a gradual process, so that she doesn’t have withdrawal that interferes with her life. Usually, a 15% drop every two to four weeks is a good rate of decrease. I told her that if she develops addiction, I’d be happy to see her again, but for now, she doesn’t need my services. She does need to communicate her desires to taper with her existing doctor.

Drug Testing

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Every so often one of my established office-based buprenorphine (Suboxone) patients gets a little rebellious about being asked to take drug tests. They feel since they’ve been doing so well for so long, they no longer need urine drug tests. They say things like, “Don’t you trust me by now?” But it’s not about them or their character. It’s about the disease of addiction. I tell them some abbreviated form of the following:
• Patients in treatment don’t always tell me when they’ve relapsed. In order for addiction to thrive, lies must be told. Otherwise honest people sometimes tell outrageous lies while they are in the throes of addiction. I see this as part of the disease. It’s not about them. It’s not about me. It’s the addiction.
• It’s good medical practice. Like many chronic illnesses, relapses happen. It’s better to detect these as early as possible, to discuss what happened, and if/how we need to change their treatment. If a patient has relapsed to opioids, it may mean that I need to increase the dose of buprenorphine, if they were still able to feel an opioid high. If the relapse was to other drugs, it usually means we need to increase the “dose” of addiction counseling.
• There’s a gold mine of information in relapses. I ask my patient what happened immediately before the relapse. Was she around people who were using drugs? Did she use drugs to try to get rid of an unpleasant emotion? Did she use drugs because she became complacent? The answers can help decide how best to avoid relapses in the future. If a patient is fortunate enough to live through a relapse, she can get information she can’t get any other way.
• Drug screening benefits the patient by giving them accountability. Some patients are less likely to relapse with accountability. I’ve had patients say that the thought of having to talk about a relapse is enough to keep them from using drugs. This surprised me, but I’m glad.
• Drug screening also shows them I’m serious about their recovery. I’m not just going through the motions of writing a prescription and getting paid for the visit. I really want my patients to recover and get their lives back.
• I’m not a human lie detector. In the past, I smugly thought I could tell if someone had relapsed, so drug screens just confirmed what I already knew. After more experience, I know that’s not true.
• It’s the standard of care. Even if the other reasons aren’t compelling enough to do drug screens, the vaguely increased regulatory oversight of doctors who prescribe buprenorphine should induce them do drug screens. I know if my charts are ever audited by the DEA, my state’s department of health and human services, or my state’s medical board, I can show I’m doing things in the proper manner.
• I don’t want to prescribe medications that will be diverted to the black market. Some doctors say, with some justification, that buprenorphine is a safer drug than most other illicit opioids, and we should look at black market diversion of buprenorphine as a form of harm reduction. However, governmental types don’t see things that way. The DEA certainly doesn’t. I don’t want to prescribe buprenorphine to people with the criminal intent of selling part or all of it. When I do urine drug screening, if there’s no buprenorphine present, that’s a serious matter. If the patient isn’t using what I prescribe, it’s likely they are selling it. Since such diversion of buprenorphine endangers the whole program, it’s essential to stop prescribing for people who sell their medication.

These are my reasons for drug screening. Since I’m not going to stop doing them, addicts who refuse drug testing have to find new doctors. New opioid addicts who come to my office are told, both verbally and in writing, that I do drug screening. They can make their own decision about whether they want to see me as their doctor or go elsewhere. Most established patients comply with requests for testing after I explain the above reasons.

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