Archive for the ‘methadone’ Category

Choices

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Today’s blog is more a ramble of my recent musings than a march toward a specific point.

Over the last few weeks I’ve been working out of town, covering an opioid treatment program for a doctor who is out on sick leave. At my usual work sites, about half of the patients who come for admission at these OTPs specifically request to be started on buprenorphine (better known as Suboxone, Subutex). At these new sites, many patients are opposed to buprenorphine, and want to start on methadone.

That’s fine with me. Methadone has been around for fifty years now, and we have reams of data to show it works. I have no problems starting these patients on methadone, but I’m curious about the resistance opioid addicts have towards buprenorphine in this area of the state, as opposed to my “home” opioid treatment program.

Some addicts bought Suboxone or Subutex illicitly, and when they took it, they got sick. Because of their bad experiences, they are much opposed to trying buprenorphine again. I try to explain that because buprenorphine is a partial opioid with a higher affinity for opioid receptors than their usual opioids of abuse, their prior experience probably occurred because they took the buprenorphine too soon. If they took it before they were in withdrawal, it caused precipitated withdrawal. I try to explain that I can help them start buprenorphine at the right time, to avoid precipitated withdrawal.

Other patients entering opioid treatment programs say they want methadone because they also suffer from chronic pain. I used to go along with that, and agree with them, because I believed methadone would also treat their pain in addition to their addiction, and do it more effectively than buprenorphine. But recent studies call that into question, and show that patients with both addition and chronic pain got as much pain relief with buprenorphine as with methadone. Also, there’s some evidence that full opioids like methadone actually increase chronic pain in some patients, due to hyperalgesia.

A few patients said they still felt a little bit of euphoria from methadone, and preferred it over buprenorphine for that reason. I appreciate the honesty of those patients, and I think that is true to some extent, but in most cases, the euphoria subsides as tolerance for methadone increases. It is rare for patients on methadone to continue to feel euphoria from it if they are on maintenance for more than a few months.

I’m proud to work for a company that has pushed for its opioid treatment programs nationwide to incorporate treatment options other than methadone, even though there’s less of a profit margin for OTPs who prescribe buprenorphine. That’s because methadone, which has been around for years, costs pennies to dose, but buprenorphine costs much more.

Also, as a regional manager for this company pointed out to me, buprenorphine patients spend less time in treatment and come in & out of treatment more than methadone patients. Treatment retention isn’t as good for buprenorphine patients.

Is that a bad thing? Probably, yes. Studies show better outcomes with better treatment retention. It’s certainly worse for the bottom line of the opioid treatment program, which makes it even more admirable for OTPs to offer buprenorphine.

In my usual neck of the woods, I see patients come into treatment for buprenorphine who say they would never consider methadone, due to the stigma. Those are patients who would not enter treatment if we didn’t offer buprenorphine, and I’m happy we can reach them.

Buprenorphine is much safer than methadone, and has fewer side effects with other medications. And if patients do well in treatment, they can get take home doses much more quickly than with methadone, because of the increased safety.

Most patients on buprenorphine don’t feel the intense withdrawal that patients on methadone feel, if they miss days of treatment. This quality of buprenorphine is probably why patients on buprenorphine leave treatment more frequently than patients on methadone. They don’t feel as bad if they miss treatment for days at a time.

Many addicts at my new OTP site ask for methadone because of recommendations from their friends. I don’t hear as much talk about buprenorphine at the new OTP, so maybe addicts haven’t heard of some of the specific benefits.

I’m just happy their friends recommend treatment in any form.

Readers, why do you think patients starting treatment on medication-assisted treatment prefer methadone to buprenorphine?

Who Should NOT Be in Medication-Assisted Therapy with either Methadone or Buprenorphine?

addiction cartoon

I spend much time and effort explaining how medication-assisted treatment for opioid addiction works for many addicts. It occurred to me that I should explain who isn’t a good candidate for such treatment.

I enthusiastically support medication-assisted treatment (MAT) of opioid addiction, but no treatment works for everyone. MAT doesn’t work for every opioid addict. Here are some reasons a patient may not be suitable for MAT:

1. The patient isn’t addicted to opioids. That seems obvious, but occasionally I encounter an addict who wants to be started on methadone even though he’s not addicted to opioids. Rarely, an addict using cocaine, benzodiazepines or other drugs will come to the OTP after they have heard how well it worked for other (opioid) addicts. After I explain that buprenorphine (Suboxone) and methadone only work on opioid addiction, some of these patients have become angry.

One patient accused me of discriminating against her because of the type of drug she used. I said yes, but only because methadone doesn’t treat cocaine addiction. (I tried to refer her for more appropriate treatment.)

2. The patient takes opioids for pain, but has never developed the disease of addiction.
Such a patient may be physically dependent, but lacks the hallmark indicators of addiction, such as misuse of medication, obsession and compulsion regarding opioids.

Opioid treatment programs, (OTPs) have stringent regulations put on them by both federal and state government, because OTPs are designed to treat patients with addiction. These patients have lost the ability to control their intake of opioids, so the OTP regulates a maintenance dose of either methadone or buprenorphine to keep the patient out of withdrawal and able to function normally.

If a patient has only pain and no addiction, there’s no reason to enroll in an opioid treatment program, because patients without addiction are still able to take opioid medication as prescribed. Pain medication can be prescribed by any doctor with a DEA license.

Opioid treatment programs aren’t intended to treat chronic pain, but if a patient with both addiction and chronic pain finds methadone also helps with pain, it’s a nice benefit. Many of these patients do find they have less pain once they’re out of the miserable cycle of intoxication and withdrawal. So less pain is a happy side effect of addiction treatment.

3. The opioid addict presenting for treatment has been physically dependent for less than one year.
Methadone is difficult to get off of, and federal and state regulations say it cannot be prescribed for opioid addicts with less than one year of addiction (daily use or near daily use). This is a somewhat arbitrary cut off, and the OTP physician can ask for an exception to this regulation if needed. Even if the OTP wants to treat the patient with buprenorphine (Suboxone), which is usually much easier to taper off of than methadone, permission must be sought from state and federal authorities before enrolling a patient who has used opioids less than one year.

If buprenorphine is prescribed in the office setting, the prescribing physician can use her best judgment about who is appropriate for treatment, without needing government approval.

4. The opioid addict has the ability to go to a prolonged inpatient residential treatment program for his addiction.
This is controversial, because some doctors think medication-assisted treatment should be given to everyone because of its success rate compared to abstinence-only treatments.

But who gets the best of medical treatment in our country? Possibly it is medical professionals like doctors and dentists, airline pilots, politicians, and celebrities. They usually get the gold standard of treatment for whatever disease ails them.

If such people have opioid addiction, they are treated with inpatient medical detox, using buprenorphine to ease withdrawal, followed immediately with prolonged inpatient residential drug addiction treatment. I know doctors and dentists who spent six to nine months in treatment. After treatment, they must sign monitoring contracts with their licensing boards in able to go back to work. These contracts usually involve a mandated number of group sessions per week and random drug testing. With this kind of support and accountability, these medical professionals have excellent outcomes. Studies show that more than 80% are still off all drugs and alcohol at five years after entering treatment.

If only everyone could get that kind of treatment!

If this kind of treatment is available to the addict…take advantage of it. But most opioid addicts can’t access this kind of treatment, with post-treatment accountability. Insurance companies might pay for a one-week stay in detox, which won’t help. Even if the addict gets a few weeks of inpatient treatment, it’s usually not enough. What I’m talking about is months of quality inpatient treatment.

5. An opioid addict who is also physically addicted to alcohol, benzodiazepines or other sedatives. These drugs can be deadly when mixed with methadone or buprenorphine. I prefer such patients enter a medical detox unit to get off these sedatives prior to entering treatment in an OTP.

Of course this is a complex issue, and there may be times when starting methadone or buprenorphine can be done, perhaps keeping the patient at a relatively low dose, while the patient undergoes a gradual taper from benzos. The OTP physician should be free to use her best judgment about how to treat these complex and high-risk patients.

6. The opioid addict also has acute, severe mental illness. An actively suicidal patient is too sick for an outpatient opioid treatment program. So is an acutely psychotic patient who is having hallucinations and delusions. These patients often can’t to understand what is real and what isn’t. Ideally these patients need inpatient treatment at a facility that will treat both mental illness and addiction. Sadly, it’s getting ever harder to find such facilities for patients who need them.

7. A patient has behavior that interferes with treatment.
OTPs have an obligation to all their patients to maintain a safe and orderly treatment environment. Patients who start physical fights, threaten staff or other patients, or sell drugs shouldn’t be kept in treatment. I know that sounds harsh, but OTPs have a hard enough time maintaining good standing in their communities without having to face accusations about illegal behavior on premises.

Patients need to be emotionally stable enough to conduct themselves in a non-threatening manner to be able to remain in treatment. Some patients, after being counseled about acceptable behavior, are able to comply with requests for behavioral changes. Some patients have erratic behavior due to mental illness, and shouldn’t be blamed, but their behavior still may be too disruptive for the OTP setting.

8. The patient has serious co-existing physical health problems.
Actually, I can’t think of any physical health problem that would make the treatment of opioid addiction with methadone riskier to the patient than untreated opioid addiction. We know for sure that untreated opioid addiction produces high risk of death and disability.

Issues like severe lung disease and specific heart rhythm problems do increase the risk of medication-assisted treatment, especially with methadone. I try to contact the patient’s other doctors and consult with them before the patient goes above a low dose of methadone.

Ideally, I’d like to talk to the other doctors on the day of admission, before methadone is started, but that can’t always be done. With the time pressures doctors are under, it’s getting ever harder to claim some of their time for a patient consultation.

Some of these patients could be started on buprenorphine instead of methadone, which is safer with these health conditions, and has fewer medication interactions.

9. The patient has transportation difficulties.
Some patients can’t get a ride to their treatment program every day, which interferes with delivery of quality treatment. With buprenorphine, federal requirements for daily dosing were lifted, but states still have varying regulations. With methadone, the patient must come for treatment daily. During the first two weeks of stabilization, it’s important for medical personnel to be able to evaluate the patient every day, to assess the effects of dose increases.

10. A patient who enters treatment expecting to be completely drug free in the near future.
I try to make sure patients entering treatment with methadone or buprenorphine understand that I am not switching them from illicit opioids to these medications because tapering off of them is easier. Particularly with methadone, it is not. But both methadone and buprenorphine are so long-acting, they can be dosed once per day, giving the patient a steady level of opioids. This allows the addict to function normally, without withdrawal or impairment, once the dose has stabilized.

Both medications give the opioid addict time to regain physical and mental health. Once on a stable dose, the recovering addict can make changes in his life, with the help of counselors and other OTP workers. The addict can get back to work, stop a life of crime, form better relationships with his family and himself, and recover a better quality of life.

Will that addict ever do well off methadone? There’s no way to be sure about this. Some patients can taper off methadone, as long as they address all of their issues prior to the taper, and if they bring the dose down slowly enough that they don’t feel intolerable withdrawal. Some, perhaps most, recovering addicts find they will do better if they stay on methadone.

All this is to say that the goal of entering an opioid treatment program isn’t necessarily to
get off the treatment medication.

So if a patient seeks to enter methadone treatment but also expresses a desire to be off buprenorphine or methadone within weeks to months, I tell them their expectations aren’t realistic. These medications don’t work like that. If the patient wants to get off all medications quickly, they need referral to an inpatient program. This way, patients can’t later say they were mislead, and they feel like they have liquid handcuffs, chained forever to methadone, with its many regulations for treatment.

News From the World of Addiction Medicine Research

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The latest issue of the Journal of Addiction Medicine, Vol. 7 (2) March/April 2013 had several interesting articles relating to opioid addiction and its treatment. Here’s my quick summary and thoughts on one of them, “Promethazine Misuse among Methadone Maintenance Patients and Community-Based Injection Drug Users,” by Brad Shapiro et al, pp. 96-1001.

This study attempted to get an idea of the prevalence of promethazine (better known under its brand name Phenergan) use in opioid addicts both in and out of treatment.

I was interested in this article because I’ve had methadone patients misuse promethazine. Most of these patients say that Phenergan gives them sedation with methadone, but most say it’s not a true euphoria, so I’m puzzled as to why they mix the two. Since promethazine can be sedating in many people, obviously I worry about overdose deaths when it’s mixed with methadone.

The authors of this study tested for promethazine in the patients enrolled in a county hospital methadone clinic in San Francisco. Twenty-six percent were positive for promethazine and only 15% had a prescription for this medication. Also, promethazine use was associated with benzodiazepine use.

The authors then recruited two hundred intravenous drug users, and discovered that only 139 were opioid addicts. Of those 139 addicts, seventeen percent reported promethazine use in the past month. However, of the addicts who had been on methadone in the past, twenty-four percent reported promethazine use in the past month.

What does this study tell us? The authors’ conclusion was that promethazine needs to be investigated further as a drug of abuse in opioid addicts.

Well, yeah.

My clinical experience gave me some thoughts about the study. For one thing, pregnant addicts were excluded. But in my experience, pregnant patients are the ones most likely to be prescribed Phenergan because of morning sickness during pregnancy. And this study doesn’t tell us much about the overdose risk when methadone and Phenergan are combined. Early in their article, they do provide some data: In Kentucky, over 14% of decedents from methadone toxicity overdose deaths also had promethazine present in their system. In Seattle, 2.5% of fatal overdoses had promethazine present.

Promethazine, along with many other medications, prolongs the QT interval just like methadone does. I haven’t seen any studies of methadone patients comparing QT intervals before and after promethazine, which may be helpful to further assess risk.

Important Factors for Successful Opioid Treatment Centers: Staff Experience

As discussed in my last blog entry, some opioid treatment centers (previously called methadone clinics) are better than others. Last time I blogged about the importance of communication between staff members. This blog is about the importance of hiring experienced, competent staff.

For an opioid treatment center, the worst counselor to hire is one who doesn’t believe in methadone. This should go without saying, but sometimes clinics hire people who are conflicted about methadone (or Suboxone), and either verbally or non-verbally communicate their uncertainty or negative attitudes about methadone. The effects on patients can be devastating. Fortunately most of these employees don’t remain at opioid treatment programs, either because they must be terminated for the welfare of patients, or because they quit on their own.

Some patients say they’d rather have a counselor who has personal experience with addiction and recovery, because he understands addiction at a deep level. Such a counselor can be valuable, but it’s not enough. A counselor also needs knowledge of counseling techniques and the skill to apply them appropriately. If recovery from addiction is the only attribute of your counselor, why pay for treatment? You can get the same thing for free at any 12-step meeting.

The factor most correlated with patient success in counseling is the relationship with their counselor. A warm and accepting, non-judgmental attitude is most successful. In short, compassion is important. While it’s true that another recovering addict can understand the pain of still-suffering addicts, non-addicts can be just as compassionate, and may have fewer preconceptions about what recovery must be.

The Substance Abuse and Mental Health Services Administration, often called SAMHSA (SAM-sah) for short, produces many publications to serve as guidelines for substance abuse and mental health treatment facilities. They’ve published “Technical Assistance Publication Series, Number 21: Addiction Counseling Competencies.” This document outlines all the necessary skills and knowledge that an addictions counselor should have to work in any drug addiction treatment program.

Counselors must understand addiction. They need to have education about drugs of abuse and how they affect the body and how withdrawal from various drugs affects the body. Counselors should know about all forms of drug addiction treatment, and know which treatment is most appropriate for their client. They should be able to apply helping strategies to best meet the needs of their clients.

Counselors need to be professionals, and conduct themselves in a capable and courteous way. One of my peeves is to hear clinic personnel refer to a urine drug screen positive for drugs as a “dirty” screen. Language matters. Counselors need to have a certain level of self-awareness with good boundaries. This prevents them from being too involved with their clients, or too distant from their clients. They need to follow the profession’s ethical standards. They need to be aware of the need for continued education and be open-minded to new information. This is a rapidly changing field, and counselors shouldn’t continue to work with dated knowledge from the 1980’s.

Once a clinic gets good counselors, they need to keep them. Patients get discouraged when they’re assigned a new counselor every few months. At one clinic where I worked several years ago, a patient told me he’d had six counselors over fifteen months. That’s not OK. Patients get tired of discussing their issues with one person and form a counseling relationship, only to have to start anew a few months later. Staff turnover discourages patients.

Of course, some turnover can’t be avoided in our mobile society, where people switch jobs frequently. But clinic owners need to try to keep good counselors (and nurses and doctors) and retain them to benefit the patients. Clinic owners should be willing to pay staff well, and provide adequate benefits.

Opioid treatment programs need to hire good nurses and doctors, too, with experience and training treating patients with addiction. Doctors should be certified in Addiction Medicine either through the American Board of Addiction Medicine, or through the American Academy of Addiction Psychiatry. And they need to go to continuing education meetings to stay current, since the field of Addiction Medicine changes so rapidly with new research and results.

When I started work at my first methadone clinic, I didn’t know much more than to start the dose low and increase slowly. In retrospect, I should have had more training. If a new doctor has no prior experience working in opioid treatment programs, I’d favor a training course similar to the  course available for doctors who want to prescribe Suboxone.

I love my present opioid treatment program, Stepping Stone of Boone. We’re a new clinic, and relatively small at around 130 patients. We opened in April of 2010, and have had no staff turnover. That’s right – none. All the staff that pioneered the clinic is still there, and all of the new people hired over the last 18 months have stayed. That’s a sign of a good clinic.

It’s a fun place to work because each of us loves what we do, and we believe in what we do. We enjoy not only our patients but also the other staff members. We feel like we are helping people.

My next blog entry will be about the importance of evidence-based dosing of methadone.

Qualities of Good Opioid Treatment Programs

Not all opioid treatment programs are created equal, meaning some are better than others. Over the years, studies have shown which clinic factors are associated with better patient outcomes. Over the next week or so, my blog postings will elaborate on each of the following factors:

  • Good communication between medical, counseling, and administration portions of the clinic
  • Experienced staff with adequate training and low turn-over
  • Low patient to counselor ratios
  • Program follows evidence-based guidelines for dosing
  • Opioid treatment program provide more care than just methadone treatment (also provide primary care, vocational rehabilitation, etc)

Today I’ll blog about communication between staff members. Communication is a good quality in any business, allowing it to run more smoothly. But it’s even more important in healthcare, where patients’ lives and well-being are affected.

In opioid treatment programs, communication happens in many ways, but case staffing is the most formal and efficient. Case staffing is when multiple members of the treatment team gather in one place, usually at a set time, to discuss what’s going on with patients. The treatment team usually includes all of the counselors, the nurses, the doctor, and the program manager. Besides communicating information about patients, case staffing also helps generate creative solutions to problems, and checks for negative emotions among staff. This can also be a forum where concerns about clinic protocols can be raised by staff.

At the program where I work, once or twice per week, after we finish seeing the day’s patients, the nurses, the counselors, nurses, program director and program manager sit in our lobby and discuss patients. First we talk about the new admissions. I tell the staff of any medical concerns I found on my intake assessment. For example, if a patient was found to have an enlarged liver on my exam, I ask the counselor to follow up with the patient later in the week to make sure the patient makes an appointment with his primary care doctor. The counselors raise concerns about new patients. Perhaps one of the counselors noticed symptoms of depression and we decide I should check that patient again the next week, when opioid withdrawal isn’t as severe.

Then we discuss established patients, and try to problem-solve. For example, maybe a patient needs to travel out of town for work, and there’s no opioid treatment program nearby where he can guest dose. We talk about the patient’s progress and whether it’s appropriate to ask the state methadone authority for extra take-home doses. We have some leeway to decide about Sunday and holiday take home doses, and discuss who is ready for these take homes.

Counselors may ask about how to approach ongoing drug use. The approach is different for different types of drugs. If a patient has had repeated relapses to opioids, maybe the methadone dose needs to be increased. If benzos are a problem, we must discuss if it’s safe to continue to dose that patient with methadone. For marijuana and cocaine, more intense counseling is indicated, and we discuss the best approaches.

Case staffing also helps us watch each other for negative attitudes. Patients with addiction sometimes behave badly. In active addiction, some addicts have had to lie and deceive to survive, and these tendencies don’t disappear overnight. The whole staff of an opioid treatment program needs to watch each other for negative or pessimistic attitudes developing toward patients.

For example, recently I was in a case staffing where we were talking about the repeated relapses of a patient. I made a comment which was more negative than the situation warranted, and this patient’s counselor appropriately challenged my comment. I’m no different than any other human and can take a skeptical view of a patient when it’s not reasonable. This counselor made me re-consider my opinion, and she was right to do so.

We talk about clinic policies that may need to be changed. For example, when patients can’t pay for treatment, how long do I have to taper their methadone dose? I’ve worked in clinics where if you didn’t have money for that day’s dose, you didn’t get a dose. They had no policy in place to allow a taper. I’ve worked in clinics where the dose was tapered over 4 days. At my present clinic, the dose is tapered over ten days. That’s still too short, and I’d prefer to keep everybody in treatment for free, but that’s not possible. The program would fold. I’ve had the unpleasant experience of working for a methadone program that closed because it ran out of money to operate. So it’s important to include the clinic administrators in some aspects of case staffing.

The best part of case staffing is talking about patient successes. Counselors talk about patients who are participating in counseling, who’ve had negative drug screens, and qualify for take home levels. Unless any staff member has concerns, I sign a form to make it official. We talk about patients who have recently gone through difficult situations without using drugs. We even have an unofficial “patient of the week,” a term for the patient who has worked hard on recovery and had a recent success. Sometimes it’s a patient who got a job promotion. Sometimes it’s a patient who has started going to 12-step meetings. Sometimes it’s a patient who has a negative drug screen for marijuana because he’s stopped smoking pot for the first time in his entire adult life.

Talking about this good stuff is so important for staff. We get to feel like we are at least some small part of the positive changes happening in the lives of our patients. Fortunately, there’s much to celebrate at every case staffing. As I’ve said before, I never saw the kind of positive changes when I worked in primary care that I see working in addiction medicine.

 

Dosing Methadone for Pain versus Addiction

Using methadone for pain is different from using methadone for addiction.

It’s illegal in the United States for a doctor to prescribe methadone for the purposes of treating addiction, unless she is working at an appropriately licensed Opioid Treatment Center. Some doctors don’t know this, and have had grumpy DEA agents pay them a visit. However, it is legal for a doctor to prescribe methadone for pain, as long as she has an appropriate DEA license.

Methadone is prescribed differently when treating pain than when treating addiction. This is because each dose of methadone has an analgesic (anti-pain) effect of about six hours. However, methadone’s opioid blocking effect lasts for twenty-four hours or more. This is why methadone for pain should be dosed multiple times per day, but methadone for addiction can be given once per day.

The dose of methadone often varies, too, depending on the disease being treated. Doses of methadone 10 to 20mg, dosed three to four times per day, are adequate to treat pain for many patients. When treating addiction, studies have shown that patients do better when the doses are high enough to block other opioids. Usually, this occurs at doses 80 – 120mg per day, given as one dose. The patient doesn’t become sleepy or sedated at this dose because the dose is raised gradually, allowing time for tolerance to build to the sedating effect.

Some patients prefer to stay at a low methadone dose, so they can still feel intoxication from illicit opioids like heroin or oxycodone. For example, one patient told me he liked keeping his dose around 60mg, which was high enough to stave off the worst of his withdrawal symptoms. But it was also low enough to allow him to feel high from an injection of heroin in the evenings. He resisted going up on his dose as recommended by his treatment team.

Doctors have to be very careful prescribing methadone for pain. The very characteristic of the drug that makes it effective to treat addiction, its long duration of action, also makes it dangerous to prescribe. Too many patients, experimenting with methadone for the purpose of getting high, die of a drug overdose. Tolerance to the euphoric effect of methadone develops more quickly than the tolerance to the sedative effects. People consume a fatal dose before feeling high.

Over the last decade, the incidence of overdose deaths from methadone rose sharply. Most of these deaths were from people taking methadone pills, dispensed from local pharmacies, and prescribed by doctors who were treating patients for pain. Along the way, many milligrams were diverted to the black market, with disastrous results. Some methadone was diverted from opioid treatment centers, but appears to be a fraction of the total.

Given the overdose potential of methadone, it should be used cautiously when prescribed by physicians for pain. Soon, doctors may be required to take a training course before they can prescribe the long-acting opioids. This training will educate doctors on how to recognize if a patient is developing the complication of addiction, and to identify evidence of drug diversion.

Best Treatments for Addicts who Snort or Inject Suboxone

Suboxone misuse is much more common than I realized, as I’ve learned from people who write comments to this blog. These opioid addicts have described how they snort, inject, and even anally insert the Suboxone that’s meant to treat their addiction.

Not every addict can be treated with Suboxone from a doctor’s office. For some patients, the addiction is too strong, and they are unable to use the Suboxone as instructed. If a patient is injecting or snorting the medication meant to help them, they aren’t in recovery. These addicts need to be referred for another form of treatment. They aren’t being helped with Suboxone, except that perhaps it’s a little safer then other abused opioids, since at least there’s a ceiling on its opioid effects.

 What are the best options for these addicts? 

Most aren’t willing to go to inpatient detox followed by prolonged (one to six months) residential drug rehabilitation. It’s costly, and no one likes to be away from home for that long. However, this form of treatment can be life saving and gives the best chance of drug-free recovery.

Or they could enroll in an opioid treatment program, called OTP for short. In the past these facilities were called methadone clinics, because that was the only medication offered, but now many clinics also use buprenorphine. I’m glad to see this trend. For many patients, buprenorphine is a better drug. Patients tend to feel less medicated, and are less likely to feel any euphoria from buprenorphine. And the clinic gives patients more structure than I can from my office.

At OTP (opioid treatment programs) the patients are seen every day. Most clinics are open at least six or seven days per week. That way, patients can be given an observed dose each day. They won’t be able to misuse their medication, since a nurse places the tablet or film under the tongue, with buprenorphine. Methadone, dispensed as a red liquid, is swallowed each day in the presence of the nurse. Diversion to another person certainly isn’t impossible, but it’s much less likely to occur.

 So to all of the addicts now using Suboxone in unorthodox ways, snorting, injecting, and other ways, tell your doctor what you are doing. You can get your addiction treated by going to a clinic each day. Counseling is built into the opioid treatment program system. Patients there must see their counselors, and many clinics also make group sessions mandatory.

 I’ve become gradually more selective about who I’m willing to treat with Suboxone in my office. I’m more vigilant about medication misuse, since this blog taught me that it happens much more frequently than I previously thought. I now believe that only very stable opioid addicts should be treated in an office setting. Older addicts with jobs, families, and no other addictions appear to do the best in this type of treatment. From now on, if I have openings for new patients, I’m going to screen more rigorously. Many addicts have an addiction that’s too severe to treat with office-based therapy.

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