Archive for the ‘Overdose deaths’ Category

Project Lazarus in the Huffington Post

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In a nice article in the Huffington Post, Project Lazarus, located in Wilkes County, NC, was highlighted as an example of how a community can take action to prevent drug overdose deaths. Please check it out at: http://www.huffingtonpost.com/2014/03/05/project-lazarus_n_4889620.html?1394071210

Many people think Project Lazarus provides naloxone kits to reverse overdoses, and this is true, but they do much more than that. Project Lazarus has sponsored educational programs for doctors to learn to be more cautious when prescribing opioids, has sponsored medication take back days where old prescription meds can safely be disposed, and has worked with agencies and organizations across North Carolina and the nation to better inform doctors, law enforcement, and elected officials about what works to prevent drug overdose deaths.

Project Lazarus helped pass a Good Samaritan law North Carolina (see my post of April 20, 2013). Under this new law, a person who calls 911 to save another person’s life – or their own – won’t be prosecuted for minor drug possession, since they were trying to do the right thing and save a life by calling 911.

The Huffington Post article describes how the opioid overdose death rate has been falling in Wilkes County, while the overdose death rate in other parts of the country has been steadily rising. They credit Project Lazarus for this reduction in overdose deaths.

While I’m sure Project Lazarus has played a huge role in reducing overdose deaths not only in Wilkes County and the state of North Carolina, other factors have helped. Being an opioid addiction treatment provider, of course I believe availability of addiction treatment reduced deaths too.

Project Lazarus also supported the opening of an opioid treatment program in 2011, Mountain Health Solutions. Started by Dr. Elizabeth Stanton, this program initially offered only buprenorphine. As it grew, it became obvious some patients needed methadone treatment, so option became available by late 2011. Mountain Health Solutions was eventually purchased by CRC Health in 2012, and has continued to grow. Located in a small town, we have nearly four hundred patients.

I am honored to be the medical director at this program. It’s one on the best programs I’ve seen, and we work hard to keep improving our quality of care. Our program has done outreach -particularly in the medical community- to try to reduce the stigma of medication-assisted treatment. If you read my blog, you know this can be both a joy and a challenge.

Initially, Project Lazarus paid for an intranasal naloxone kit for every patient entering our opioid treatment program. Now since our patient census has risen, Project Lazarus still pays half of the $50 cost of the kits. The opioid treatment program pays the other half, out of a $33 admission charge for new patients. I feel lucky to be able to partner with Project Lazarus, as I’ve seen these kits save lives.

I know of four occasions when a naloxone kit saved a person’s life. Three of these four times, that person saved wasn’t even in treatment for opioid addiction.

Most recently, a parent used a kit to reverse an opioid overdose in a child who accidently ingested the parent’s medication. The parent called 911 and while waiting for EMS to arrive, used one of the two vials in the kit. The child partially woke, and started breathing better. Then EMS arrived and took the child to the hospital. This child survived a potentially fatal overdose and is back to normal with no lasting damage, thanks in part to that naloxone kit and a parent who knew how to use it.

Naloxone kits can be obtained much more cheaply, but contain Narcan vials, a more dilute form of naloxone that is meant to be injected. Those kits, which cost a few dollars, contain a syringe and needle instead of the Project Lazarus kit for nasal administration. Trying to inject naloxone into a vein is technically much more difficult than spraying the more concentrated form of naloxone up into the nose.

And unfortunately, a kit containing a needle and syringe would meet resistance from the public. I can imagine all sorts of angry phone calls to our opioid treatment program: “My son came to you people to get off the needle and you GAVE him a needle and syringe??” Politically, the public would more likely oppose distribution of a naloxone kit with a needle than a kit for intranasal use.

Fifty dollars for an intranasal naloxone kit to save a life is a pittance in the overall picture. Some insurance companies will cover these kits, as will Medicaid, but most of our patients have no insurance. They pay for their buprenorphine/methadone treatment out of their own pocket. Fifty dollars is a big sum for these patients.

I am blessed to work for an opioid treatment program that gets financial help from Project Lazarus for these kits. And I am very blessed to work for a for-profit company, CRC Health, which is willing to bear half the cost of the kits, since this comes out of their profits. Most opioid treatment programs do charge patients an admission fee, but unlike Mountain Health Solutions, don’t put that money towards buying a naloxone kits for their patients.

This is an example of the success that can happen when agencies work together toward a common goal.

Warning Warning Warning

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If you are still using heroin, or know someone using heroin, please heed this caution. SAMHSA (Substance Abuse and Mental Health Services Administration) sent out a notification last week, warning people that a deadly form of heroin is causing deaths in the Northeast.

Since the first of the year, thirty-none overdose deaths occurred in Pittsburgh and Rhode Island from heroin contaminate with fentanyl. Fentanyl is a powerful opioid, and kills opioid addicts accustomed to using heroin alone. Trends like these can spread rapidly, so if you are reading this and know someone who uses IV heroin, warn them about this deadly heroin.

When I first read SAMHSA’s notification, I wondered if I should put the warning on my blog. Being realistic, I know some addicts will think, “How can I get some of that? It sounds like good stuff!” That’s the insanity of addiction…people are dying from a variety of heroin and other addicts want to try the deadly substance, believing they can use without harm.

In the interest of harm reduction, I’m going to describe precautions that addicts, still in active addiction, can take to reduce the risk of overdose death. This information can be accessed at: http://harmreduction.org/wp-content/uploads/2011/12/getting-off-right.pdf

1. Don’t use alone. Use a buddy system, to have someone who can call 911 in case you stop breathing. Do the same for another addict. Obviously you shouldn’t inject at the same time. Stagger your injection times.
Many states now have Good Samaritan laws that protect the overdose victim and the person calling 911 for help, so that police don’t give criminal charges to people who do the right thing by calling for help for an overdose.
Take a class on how to give CPR so that you can revive a friend or acquaintance with an overdose while you wait on EMS to arrive.
2. Get a naloxone kit. I’ve blogged about how one patient saved his sister with a naloxone kit. These are easy to use and very effective. You can read more about these kits at the Project Lazarus website: http://projectlazarus.org/
3. Use new equipment. Many pharmacies sell needles and syringes without asking questions. Your addict friends probably can tell you which pharmacies are the most understanding.
Don’t use a needle and syringe more than once. Repeated use dulls the needle’s point and causes more damage to the vein and surrounding tissue. Don’t try to re-sharpen on a matchbook – frequently this can cause burrs on the needle point which can cause even more tissue damage.
4. Don’t share any equipment. Many people who wouldn’t think of sharing a needle still share cottons, cookers, or spoons, but hepatitis C and HIV can be transmitted by sharing any of this other equipment. If you have to share or re-use equipment, wash needle and syringe with cold water several times, then do the same again with bleach. Finally, wash out the bleach with cold water. This reduces the risk of transmitting HIV and Hepatitis C, but isn’t foolproof.
5. Use a tester shot. Since heroin varies widely in its potency, use small amount of the drug to assess its potency. You can always use more, but once it’s been injected you can’t use less. The New England overdose deaths described by SAMHSA may have been avoided if the addicts had used smaller tester shots instead of shooting up the usual amount.
6. Use clean cotton to filter the drug. Use cotton from a Q-tip or cotton ball; cigarette filters are not as safe because they contain glass particles.
7. Wash your hands thoroughly before preparing your shot, and clean the injection site with an alcohol wipe if possible. Don’t use lemon juice to help dissolve heroin, as it carries a contaminant that can cause a serous fungal infection.
8. Opioid overdoses are much more likely to occur in an addict who hasn’t used or has used less than usual for a few days, weeks, or longer. Overdose risks are much higher in people just getting out of jail and just getting out of a detox. Patients who have recently stopped using Suboxone or Subutex may be more likely to overdose if they resume their usual amount of IV opioids.
9. Don’t mix drugs. Many opioid overdoses occur with combinations of opioids and alcohol or benzodiazepines, though overdose can certainly occur with opioids alone.
10. Don’t inject an overdosed person with salt water, ice water, or a stimulant such as cocaine or crystal methamphetamine – these don’t work and may cause harm. Don’t put the person in an ice bath and don’t leave them alone. Call for help, and give mouth-to-mouth resuscitation if you can.

To people who believe I’m giving addicts permission to use, I’d like to remind them that addicts don’t care if someone gives them permission or not. If an addict wants to use, what other people think matters little. But giving people information about how to inject more safely may help keep the addict alive until she wants to get help.

The Harm Reduction Coalition has excellent information on its website: http://harmreduction.org

More about IRETA’s Guidelines for Benzodiazepines in OTPs

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This is a continuation of my last blog post about the IRETA (Institute for Research, Education & Training in Addictions) guidelines for management of benzodiazepine use in medication-assisted treatment of opioid addiction. You can read all of the guidelines at: http://ireta.org/sites/ireta.org/files/Best%20Practice%20Guidelines%20for%20BZDs%20in%20MAT%202013_0.pdf

Under the section of recommendations regarding addressing benzodiazepine use is found the following statement:
“Many people presenting to services have an extensive history of multiple substance dependence and all substance abuse, including benzodiazepines, should be actively addressed in treatment. People who have a history of benzodiazepine abuse should not be disallowed from receiving previously prescribed benzodiazepines, provided they are monitored carefully and have stopped the earlier abuse.”

The experts, after reviewing the best data, are saying that if a patient has abused benzos in the past, but isn’t abusing prescribed benzos now, it may be OK to continue benzos, with careful monitoring.

I don’t like this statement. It doesn’t conform to my present thoughts on the topic. I fear that the majority of patients with a history of benzodiazepine abuse or addiction will, sooner or later, revert back to problem use of the medication. That’s my anecdotal experience. Anecdotal experience is worth something, but data from clinical trials trumps anecdotal experience, and IRETA’s guidelines are based on both clinical trials and expert opinion.

So now I need to challenge my previously held views about benzos in the OTP. It’s unpleasant and uncomfortable to change a long-held view. But isn’t that what I ask of my patients? In the interest of science, I will re-consider my present opinion, but I won’t ignore the last part of the statement, which says careful monitoring needs to be done.

Careful monitoring includes, at a minimum, coordination of care between the OTP physician and the provider prescribing benzodiazepines, frequent benzodiazepine pill counts, and consulting the state’s prescription monitoring program regularly.

The IRETA guidelines say coordination of care is essential. The guidelines say that a patient who refuses to allow coordination of care between OTP physician and the physician prescribing sedative drugs may not be appropriate for treatment at an OTP with methadone/buprenorphine. The guidelines recommend the OTP physician get information on the patient’s diagnosis being treated with benzodiazepines and any observed misuse of the medication. The OTP doctor should also ask about the patient’s experience with non-benzo medications for the treatment of the patient’s disorder.

These are great ideas in a perfect world, but problematic in the real world.

Coordination of care is a term that’s batted around by non-physicians like a helium balloon, while in reality it’s as difficult as playing catch with anvils. Doctors, especially primary care doctors, are more pushed for time than ever. Many are at risk of losing their jobs if they don’t see enough patients per hour. (I know this because I was a primary care doctor before I fled the field for the more enjoyable addiction medicine.) Primary care doctors don’t want to spend valuable time on the phone talking to other doctors, especially if the other doctor works at “that clinic.”

I have found a few doctors in my area with whom I work well. I may not always agree with them, but I sense they are trying to do what’s best for their patients, and we can generally come to an agreement about the best plan of care.

And other doctors…not so much.

It’s not rare for my phone calls to prescribers of benzodiazepines to go unanswered. I’ve left up to four messages for one benzo-prescribing doctor at our local mental health clinic and have never received a return call. If we share a patient, I can’t coordinate care.

Even when I do get a call back, the conversation with the other provider is sometimes less than productive. The prescriber often says the patient is on Xanax because she has always been on Xanax, and there’s no clear diagnosis or plan of treatment for the underlying disorder. Prescriptions may be written twice a year with little discussion, with five refills. If non-benzo medications were prescribed in the past, the patient didn’t take them for very long before deciding that benzos were the only thing that worked for them. The doctor took this at face value and enthusiastically prescribed benzos ever since.

Sometimes I’ve suggested the doctor start a slow taper of the patient off benzos, if it’s clear the patient is misusing them. The doctor readily agrees with my suggestion, but month after month, on the prescription monitoring program website, I see the same amount of benzodiazepine being prescribed.

I’m not saying these are necessarily bad prescribers. I won’t call them doctors, because sometimes they’re also nurse practitioners or physician assistants. I do think many of them are pushovers, afraid of making patients angry by saying no. And some aren’t aware of best practice guidelines for prescribing benzodiazepines in general, even if the patient doesn’t have addiction.

Because I’ve worked in primary care, I know what happens. Benzo-seeking patients know which prescribers to go to, and they pester these providers incessantly until they are given the prescription they want. The providers, already pushed for time, give in to patient demands in order to get these patients the hell out of their office.

In my area, two or three prescribers are responsible for the majority of long-term benzodiazepine prescriptions. If I see a patient is on benzodiazepines, particularly alprazolam (Xanax) clonazepam (Klonopin) or diazepam (Valium), I can predict the prescriber. Addicts know who to go to; word gets around on the addict grapevine, an efficient mode for spreading news. I don’t feel I can coordinate care with these providers, even if I can talk to them about my concerns for a specific patient.

I agree with IRETA guidelines, but coordinating care with other prescribers isn’t always workable.

Getting back to the guidelines, later in the document is this important statement:

“Depending on capacity, it may be more appropriate for clinical settings to choose not to induct a person in MAT until benzodiazepine use has ceased and not manage a patient’s taper from benzodiazepines during MAT induction. This person may be more appropriate for inpatient detoxification.”

I heartily agree with this, and that’s what I’m doing at present. It’s much easier to get the taper from benzodiazepines done before MAT is started. Once the patient is on MAT, it’s nearly impossible – in my area – to find an affordable inpatient program that will accept patients on MAT, continue to dose them, and also treat the benzodiazepine or alcohol addiction. I hear from doctors in other states that they have inpatient programs willing to admit MAT patients with co-occurring benzo/alcohol addiction, and buprenorphine or methadone maintenance is continued during the admission. If I had that option available, I would use it.

IRETA guidelines say that patients with significant medical or psychiatric problems should be admitted to a hospital (or, I assume, medical detoxification units) for a benzodiazepines taper. Patients who have had benzodiazepine withdrawal seizures in the past also need to be hospitalized for a benzodiazepine taper, as should pregnant patients.

IRETA guidelines address induction of the dose of maintenance medication for patients taking benzodiazepines. Induction, usually considered to be the first several weeks of treatment, is the most dangerous time of treatment. Most overdose deaths happen during that time. As expected, the guidelines suggest using a lower starting dose of the methadone or buprenorphine in a patient with active benzodiazepine use, and daily observed dosing. The guidelines also say patients taking benzodiazepines who are starting MAT should not drive themselves to the facility each day until they have stabilized, and that they need to give permission for the program to call a relative if they come to the facility impaired. Impaired patients are not to be dosed, of course.

This section also recommends repeated attempts to talk with the patient about dose reduction of benzodiazepines and complete withdrawal from benzodiazepines at some point.

Under the section of IRETA guidelines addressing patient non-compliance with a taper agreement, they recommend trying to retain the patient in treatment if possible, but also say to eliminate take home doses so that the patient doses at the OTP facility each day. If the patient is misusing benzos to the degree that their safety is at risk, despite intensified psychosocial treatments, the patient may need to be referred to a non-MAT treatment for their opioid addiction.

I found interesting statements near the end of the IRETA guidelines, such as:
“Individuals who claim that “nothing else helps” should have a careful evaluation for addiction. Physicians should be aware that the subjective nature of anxiety allows for dishonest presentations of symptoms. The claim that “nothing else helps” is often a direct demand for benzodiazepines from the physician. A reasonable response is a trial of psychotherapy and medications without addictive potential.”

“Benzodiazepines should not be the first-line drug for any disorder.” And “Clinicians are advised not to use benzodiazepines to treat co-occurring psychiatric disorders.”

These statements illustrate the essence of the issue. Benzodiazepines have limited clinical indications. Use for more than three months has little benefit because of the quick development of tolerance to the anti-anxiety effect of the benzodiazepine. For that reason, they aren’t first-line drugs for anxiety disorders. And yet many prescribers take the “nothing else helps” statements at face value and prescribe benzodiazepines for years.

More statements about how to prescribe benzodiazepines from the IRETA guidelines:
“For people receiving methadone, physicians are advised to prescribe a benzodiazepine with a slow onset and long duration of action, at the lowest dose, and for the shortest duration possible.
Document education and treatment decisions during the initiation of benzodiazepines.
Avoid prescribing alprazolam to individuals receiving methadone.
Benzodiazepines with substantially lower abuse potential (e.g. oxazepam, clorazepate) are strongly preferred over benzodiazepines with a rapid onset, such as diazepam and alprazolam, which should be avoided because of their abuse potential.
Initiate short-term benzodiazepines with a prescription for no longer than one week.
For a short-course of treatment, the benzodiazepine prescription should be for less than one month.”
“Long-term maintenance of benzodiazepines is rarely indicated and should be avoided.
Providing a maintenance benzodiazepine dose in the context of MAT is to be considered a last-resort option after other alternatives have been exhausted.
One of the few who may benefit from a maintenance dose of benzodiazepine is a person who has long-term opioid and benzodiazepine abuse and is not able to stabilize on opioid substitution medication alone.”

These statements assure me that long-term benzodiazepine prescriptions are a bad idea for the majority of patients on medication-assisted treatment, but there may be some rare patients for whom it may be of benefit, though close monitoring is essential.

This is a controversial area. I appreciate IRETA’s time and effort in formulating these guidelines. I think they will be helpful as OTP doctors struggle to define a standard of treatment that is safe, yet not unduly restrictive for patients with serious mental health issues.

The Benzodiazepine Dilemma: New Guidelines for Opioid Treatment Programs from IRETA

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I’ve written about benzodiazepines before in this blog (See my post of November 3, 2012). I worry about overdose deaths and other complications in patients for whom I prescribe methadone who are also taking benzodiazepines, prescribed or illicit.

Now doctors at OTPs have help from the Institute for Research, Education and Training in Addiction (IRETA). This well-respected organization located in Pittsburgh, Pennsylvania just issued an evidence-based document titled, “Management of Benzodiazepines in Medication-Assisted Treatment.” You can access this document at IRETA’s website: http://ireta.org/

I love IRETA for tackling this subject. There’s much misinformation about the use of benzodiazepines, even for patients without addiction. But for patients with addiction, benzodiazepines can be deadly when combined with opioids including methadone and buprenorphine.

IRETA’s document first describes how and why these guidelines were created. Opioid treatment programs often have patients who also use benzodiazepines, both by prescription and illicitly. Physicians at OTPs have widely varying responses to these patients. Some programs have zero tolerance, meaning they won’t allow anyone on benzodiazepines to be in their opioid treatment program. Other physicians at OTPs actually prescribe benzodiazepines for their patients when they feel it’s clinically indicated. IRETA wanted to delve into actual scientific literature and consult a panel of experts for interpretation of that data. This IRETA document describes in detail how the literature search was done. It also goes into exhaustive detail about how each statement in the set of guidelines was vetted by experts.

This paper’s guidelines fall into seven categories:

General guidelines
Assessment for MAT
Addressing benzodiazepine use
MAT for patients with concurrent benzodiazepine use
Noncompliance with treatment agreement
Risk management/Impairment assessment
Special circumstances

Here are the general guidelines, taken directly from the document:

CNS depressant use is not an absolute contraindication for either methadone or buprenorphine, but is a reason for caution because of potential respiratory depression. Serious overdose and death may occur if MAT is administered in conjunction with benzodiazepines, sedatives, tranquilizers, anti-depressants, or alcohol.
People who use benzodiazepines, even if used as a part of long-term therapy, should be considered at risk for adverse drug reactions including overdose and death.
Many people presenting to services have an extensive history of multiple substance dependence and all substance abuse, including benzodiazepines, should be actively addressed in treatment. MAT should not generally be discontinued for persistent benzodiazepine abuse, but requires the implementation of risk management strategies.
Clinicians should ensure that every step of decision-making is clearly documented.
Clinicians would benefit from the development of a toolkit about the management of benzodiazepines in methadone treatment that includes videos and written materials for individuals in MAT.

Please note that under the third point of the general guidelines, it says patients shouldn’t be taken off MAT because of repeated benzo use, but need “risk management strategies.” That’s a little vague, but IRETA guidelines go into more detail later in the document.

IRETA’s second section of guidelines is about assessment for MAT. The guidelines say all of the usual things; for example, they say a doctor should do a complete evaluation of a patient presenting for treatment, as described in SAMHSA’s TIP (Treatment Improvement Protocol) 40 and 43. The evaluation should include the patient’s history of medical problems and history of all drug use, even over the counter medication. A mental status assessment and a drug screen should also be included.

Also under the assessment section, IRETA suggests adding patient education about the dangers of mixing benzos with methadone or buprenorphine. I like this idea, and I do something similar. When I ask about past drug use, I always warn patients about the potential bad outcome of mixing benzos and alcohol with the medication I’m going to prescribe, and I repeat the warning at the end of our interaction.

IRETA suggest doctors go farther, and give patients information not only about overdose risk, but also about the other problems benzodiazepines can cause. Benzodiazepines are associated with a greater risk of depression and suicide. Having a prescription for benzodiazepines doubles a patient’s risk for an auto accident, and increases the risk for other accidents, like falls. Taking a benzodiazepine prescription is associated with an increased risk for hip fracture.

The IRETA guidelines remind us that there is “Substantial and growing literature that suggests long term use of benzodiazepines (especially in large doses) leads to cognitive decline.” (page 16 of the report) the guidelines also say that benzodiazepines are associated with emotional blunting, and long-term sleep and mood disturbances. Even more relevant, studies show that patients on benzodiazepines have worse outcomes in medication-assisted treatment.

The third section of IRETA’s guidelines is about addressing benzodiazepine use. They say that a patient should be willing to address their benzo addiction. IRETA says that uncontrolled use of benzodiazepines is a contraindication to treatment with methadone or buprenorphine because of the “extremely high risk for adverse drug reaction involving overdose and/or death during the induction process.”

I’m in the “amen” corner for that one! But it’s hard for me to know which patients use benzos occasionally to help opioid withdrawal, and which patients use benzos heavily in an uncontrolled manner. Most patients, seeing me for admission to MAT, minimize their use of benzodiazepines, knowing it’s a big issue. If they’re getting benzodiazepine prescriptions in large amount from multiple doctors, I can see that on our state’s prescription monitoring program. If the patient is taking benzos illicitly, I may not have a way to know this. Information from family members and friends can sometimes help, if the patient will allow. Or family members and friends may be as heavily involved in addiction as the patient presenting for treatment.

The IRETA guidelines remind us that patients on long-term benzodiazepine therapy are at risk for adverse drug reactions which can include overdose and death. The guidelines say that central nervous system depressants are not absolutely contraindicated with methadone, but also put patients at risk for overdose and death. I assume at this point in the document, its authors are referring to other non-benzo central nervous system depressants like carisopradol (Soma), zolpidem (Ambien), and the other “z” sleep medications, and perhaps pregabalin (Lyrica).

IRETA’s benzodiazepine guidelines for OTPs are extensive, so I’m going to split my review of the contents over two blog entries. Stay tuned…or even better, go read them for yourself:

http://ireta.org/sites/ireta.org/files/Best%20Practice%20Guidelines%20for%20BZDs%20in%20MAT%202013_0.pdf

1. Thomas et al, “Benzodiazepine use and motor vehicle accidents. Systematic review of reported association.” Canadian Family Physician, 1998 April;44:799-808.
2. Smink et al, “The relationship between benzodiazepine use and traffic accidents: A systematic literature review.” CNS Drugs, 2010 Aug.24(8)6390653.

Really Scary: How to Die from Methadone

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Here’s something really scary for Halloween.

Though methadone is a life-saving medication when used in the right way in the right patient at the right time, it can also be deadly. When methadone is used to treat opioid addiction, the first few weeks are the most dangerous. More than half of methadone drug overdose deaths occur during the first two weeks of treatment. The opioid treatment program physician is responsible for starting the methadone at the proper dose and increasing it in a proper way, but there are things the patient can do that increase the risk of overdose deaths. Here are a few of them:

1. Exaggerate your use of opioids to the doctor. Tell her you are accustomed to taking twice the amount that you actually use. You do this out of fear that you won’t get enough medication on the first day to keep you out of withdrawal, but the result may be that you get so much methadone that you don’t wake up.
2. Don’t tell your doctor about your benzodiazepine use. Even though you’ve been using two or three “ladder bars” per day, tell her you only used once last week, just to stave off opioid withdrawal. Assure her all of you drug screens will be negative for benzos, though you’re inwardly worried you won’t be able to stop taking Xanax. You tell this lie because you’re worried she would send you to a medical detox facility for benzos before accepting you into methadone treatment, and you don’t want to do that. Sadly, if you overdose and die from mixing methadone and benzo, you won’t have a chance to go to detox – or to see your children grow up.
3. Because the stupid doctor only started you on 20mg of methadone the first day, talk to drug buddies to see where you can buy extra methadone to supplement that dose. You are sure you’ll be in withdrawal, and can’t stand the thought of any discomfort. You don’t believe the doctor, who said your methadone blood level will increase each day even if you don’t go up on your dose, due to the very long action of methadone.
4. Since you know more than the doctor, drink alcohol with your methadone. You don’t believe that alcohol can kill you while you are on methadone, since alcohol is legal. After all, you don’t drink beer at the same time as your methadone dose, so you think it’s safe. Again, you don’t believe your doctor when she said alcohol later in the day is also dangerous, due to the very long action of methadone. What does she know? You are the expert on drugs.
5. You read on the internet that other people mix benzodiazepines and alcohol with methadone, and have not died. It must be true. Besides, you know your limits.

When I talk to patients about the dangers of overdose while on methadone, I hate to hear them say something like, “Don’t worry. I know my limits.” It gives me a shudder, because I remember the names of three patients who have said this to me…now all dead from drug overdoses.

Thanks to Dr. Payte for the inspiration.

Opioid Use in the Veteran’s Administration System

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Recent news reports have denounced rates of opioid prescribing for war veterans. According to the Center for Investigative Reporting, rates of opioid prescribing by VA doctors have increased two hundred and seventy percent over the last twelve years. The VA is now prescribing more than one opioid prescription for each patient it treats. (1)

The dramatically different opioid prescribing rates between different VA systems are concerning. For example, doctors at a VA hospital in Oklahoma prescribed 160.7 opioid prescriptions for every one hundred patients, compared to doctors at a VA hospital in Manhattan, who prescribed 19.8 opioid prescriptions for every one hundred VA patients treated. That’s more than an eight-fold difference.

Of particular interest, out of the 130 VA systems evaluated, Mountain Home, Tennessee, ranked as the sixth most frequent prescriber of opioids. Located in Johnson City, TN, this VA system had a rate of 138.8 opioid prescriptions per 100 patients for 2012. The worst system was Muskogee, OK, with 160.7 per 100 patients, followed closely by Beckley WV, Lexington, KY, and Huntington, WV. (But remember, Tennessee’s Department of Mental Health said there was no need for an opioid treatment center to be located in Johnson City. Nope. No problem there.)

We already know that in some states, the numbers of U.S. citizens who die from drug overdoses outnumber deaths from motor vehicle accidents. But veterans treated by VA doctors die from prescription drug overdoses at almost twice the rate of civilians. (1)

To be fair, we need to consider the changing nature of war injuries. Soldiers are surviving catastrophic injuries which would have been fatal in the past. This is partly due to better body armor and partly because of better and quicker medical care at the time of the injury. Some experts say some Iraq and Afghanistan soldiers have survived severe burns and amputations that killed Vietnam-era soldiers.

These patients surely need heavy opioids, at least early in their treatment. No compassionate doctor would skimp on pain medication for an acutely injured person. But acute pain is different from chronic pain. As the patient recovers, it’s time to consider backing off on opioids, and consider trials of non-opioid means of pain control. Patients often need help getting off prescribed opioids, which may mean tapering them over weeks to months, in order to prevent opioid withdrawal. This often takes more time and patience than writing another opioid prescription.

Due to the nature of the Iraq and Afghanistan wars, thousands of veterans have been diagnosed with traumatic brain injury (TBI). We are only beginning to understand the relationship between TBI and the risk for developing addiction. Similarly, war veterans have higher rates of PTSD (post-traumatic stress disorder) and depression. These mental disorders increase the risk for developing addiction to drugs including alcohol in all people, including war veterans.

I’ve admitted a few war veterans to the opioid treatment programs where I work. I dread trying to coordinate care with their VA doctors. Many times, after getting a release from the patient, I’ve called the VA to talk with their doctor. I can’t think of one time when I’ve reached the doctor to whom I wanted to speak. Sometimes I got a nurse, and left a message for the doctor to call me back, knowing I’d never hear from them.

I don’t have any way to know what those VA doctors are prescribing for my patients. Often, at least in my area, it’s a heavy benzodiazepine or two, and one or more opioids. Because the VA doesn’t report medication to my state’s prescription monitoring program, I’m left in the dark. I hear that’s supposed to change, but not soon enough for me.

The VA can fix this problem of inappropriate prescribing. I’ve been at ASAM (American Society of Addiction Medicine) conferences, and have met knowledgeable VA physicians. I’ve heard them lecture at these meetings. The VA must allow these experts teach their colleagues who are dated or oblivious in their prescribing habits.

I hope to see the time come when it’s as easy for a war veteran to access treatment for addiction as it is to get opioid prescriptions. These treatments should, of course, include medication-assisted treatments with buprenorphine and methadone.

Our veterans deserve the best care possible.

1. http://cironline.org/node/5261

Another Life Saved by Project Lazarus Naloxone Kit

Back to Life

Last week I talked to a young person, a patient at an opioid treatment program, who saved someone with her Project Lazarus naloxone kit. As you know if you read this blog regularly, Project Lazarus is a non-profit organization that started in Wilkes County, North Carolina, dedicated to reducing drug overdose deaths. As part of the project, Project Lazarus pays for naloxone kits for patients entering medication-assisted opioid addiction treatment. The patients are given a prescription for a kit that will be filled for free at a local pharmacy.

These kits are ingenious, because the naloxone is already packaged in a syringe with a spray attachment. There’s no needle. The person administering the drug pushes the plunger of the syringe to spray the medication into a nostril. Naloxone is absorbed through the skin of the nostril and into the bloodstream, reversing the effect of all opioids. In this way, naloxone immediately brings the person out of opioid-induced sedation or coma.

I talked to this person who used her kit, to get the full description of events. I’ve changed some details to prevent anyone from recognizing her.

Cindy said she was driving across town when she had the sudden urge to visit a relative, whom we will call Bob. Bob was on parole, and Cindy wanted to stop by and say hello. Bob isn’t an addict, but has occasionally experimented with illicit drugs, including opioids. When Bob opened the door for Cindy, his first words were, “I think I’ve just taken an overdose.” An acquaintance sold Bob some prescription opioid pills, and moments before Cindy stopped by he took all of them. Right away, he began to fear he’d taken too much.

Cindy wanted to take Bob to the hospital but he refused, fearing his parole officer would find out he’d used illegal drugs. Cindy agreed to stay with Bob, and warned him that if he passed out, she would call EMS, but Bob begged her not to do this.

At first they talked and watched TV, but within an hour Bob got sleepy and his head nodded. Initially Cindy could still wake him by shouting, but she was alarmed to see his breathing slow. She said his lips began to turn blue, and he was taking huge noisy breaths only a few times per minutes. She lived nearby, so she sent her boyfriend to get her naloxone kit. She pushed the plunger and sprayed the naloxone into Bob’s nostril. She said it took less than a minute for him to wake with a start. He even jumped out of his chair. He was standing up and breathing heavily. It was a few minutes before he felt like himself again. Cindy started to call 911 but Bob again pleaded with her not to do so because of his fears about what would happen with his parole situation.

Cindy was (correctly) worried the naloxone wasn’t going to last, so she sat with Bob through the whole night. Several hours after the first naloxone dose, she gave him a second dose, since he was again breathing slowly and heavily. It worked as well as the first. Thankfully, he was OK after that.

The next morning, Bob was grateful to Cindy for saving his life. He knew he had nearly died, and told Cindy he was never going to use drugs again. The event happened a week or so ago, and Cindy says as far as she know, Bob hasn’t used any drugs since.

Cindy saved Bob’s life because she had the Project Lazarus kit. I asked her what she would have done without it, and she said she would have called 911 even over Bob’s objections – she wasn’t going to watch him die.

This whole episode illustrates some of the problems that can contribute to overdoses. First, it isn’t only addicts who die from overdoses. Bob is a young adult who by Cindy’s report has only experimented with drugs. The trouble is that with opioids, your first experimentation can be the last thing you ever do. If Bob isn’t an addict, he may be able to stop using after this near disaster.

Second, it shows the new Good Samaritan law doesn’t go far enough. Bob was fearful about legal consequences of getting much-needed medical help. If Cindy hadn’t dropped by, this young man probably would have died. He had a brief period of time between realizing he may have taken an overdose and becoming so sedated he was unable to call for help, but he didn’t call, because he feared legal consequences. I think the Good Samaritan law should be broadened to include seeking help for oneself as well as for other people.

Third, would it have been better for Cindy to forget her kit and call the ambulance for Bob? Maybe, though not from Bob’s point of view. Stories like these travel fast along the drug addiction grapevine, so I’m hoping more people will get interested in having a kit that can reverse an overdose, if for no other reason than getting help without involving authorities.

I advocate making these kits available for anyone who wants one, if that’s financially possible. Over the period of a little more than a year, I’ve heard of two lives saved from opioid overdoses because other people used their naloxone kits. In both situations, the person saved was not the addict for whom the kit was prescribed, but a relative of that addict. This underlines the importance of getting these kits in the hands of friends and family members of all opioid users, even if the users are not addicts. Since the recent passage of the Good Samaritan law, it’s legal for physicians to prescribe naloxone for family member and friends of opioid addicts.

In the news last week we learned Project Lazarus of Wilkes County will get an infusion of $2.6 million over the next two years from both a private charity and government funds. The naloxone kits are only one part of the total program, and I hope to see funds for the kits expand so that any doctor can write a naloxone prescription for any opioid addict, friend or family of an addict that can be filled for free.

The New Good Samaritan Law: Go ahead…Call 911

New Good Samaritan Law for North Carolina

New Good Samaritan Law for North Carolina

In an effort to reduce drug overdose deaths, North Carolina governor Pat McCrory approved a law earlier this month that limits legal consequences for people who call 911 to summon help for a friend who has overdosed. In the past, drug users have been reluctant to summon medical assistance for an overdosed companion, fearing police may arrive, and charge them with possession of drugs and/or paraphernalia. As a result, people die from overdoses due to a lack of timely medical care. In its place, the overdosed person’s companions may try an ineffective home remedy for overdose.

The new law doesn’t give a pass for all drug possession. It says that a person acting in good faith to seek medical assistance for an individual suffering a drug overdose will not be prosecuted for possession of less than one gram of cocaine or one gram of heroin. I don’t know if that means possession of larger amounts may still be prosecuted, but I suspect so. There is no mention of prescription drug possession specifically in the law, but I hope prescription opioids would be treated the same as heroin.

This new bill, called the Good Samaritan Bill, also says that if an underage drinker summons medical help for another person, the underage drinker will not be prosecuted by law enforcement, including campus police. The law says the underage drinker must use his own name when contacting authorities, reasonably believe he was the first to call for help, and must remain with the person needing medical help until it arrives to be covered by this law.

The bill has provisions for doctors to be able to prescribe an opioid antagonist such as naloxone to any person at risk of having an opioid-related overdose. Doctors can also prescribe this medication to the friend or family member of a person at risk for an overdose, even if that person is not a patient of the doctor. Also, a private citizen who possesses an overdose kit can administer it to another person who has had an overdose, so long as they use reasonable care. This law says the private citizen is immune to civil or criminal liability.

This is a great new law, and hopefully it will reduce witnessed overdose deaths. But the law won’t help unless addicts and their companions are aware of this law. Spread the word!

Information from the ASAM Conference: the CDC

At the recent ASAM conference, Dr. Ileana Arias, Deputy Director for the Centers for Disease Control and Prevention, spoke at a plenary session, explaining the public health impact of our epidemic of prescription drug abuse and addiction. She did a great job explaining how bad the problem of opioid addiction has become in the U.S. She also had some great slides. The above slide shows how by 2008, poisonings overtook motor vehicle accidents as the number one cause of death in the U.S. Overwhelmingly, the poisonings were drugs, and the vast majority of these drug overdose deaths involved opioids. Dr. Arias explained the ice berg phenomenon, where for each person who dies from opioid overdose death, an estimated 118 are estimated to meet the diagnosis for opioid abuse and dependency. She presented information showing that the amount of prescription opioids sold quadrupled between 1999 and 2010.

Dr. Arias spoke at our conference to encourage us and to let us know the CDC was committed to help solve our nation’s prescription opioid addiction problem.

She outlined some of the measures the CDC is taking to help prevent opioid addiction and overdose deaths.  She explained the new lock-in programs now being used by some insurance companies, where the patient can have only one doctor and one pharmacy to prescribe and fill medications. The CDC is advocating for all states to have prescription monitoring programs, and for those state programs to be linked, so that a doctor can access medications filled in other states.

Dr. Arias mentioned the progress being made in Florida, where pill mills are being shut down. Unfortunately, some pill mills have moved to other states like Georgia, Texas, Louisiana, Ohio, and – my favorote state to criticize – Tennessee.

She also spoke of the success of medication take-back days, where people drop off old medication for appropriate disposal so that it doesn’t fall into the wrong hands, and she described many other actions the CDC has started.

This was all great information, familiar to those of us treating opioid addiction over the past five to ten years. I’m grateful the CDC has joined the effort to quelch this problem. Their resources and experience can help a great deal. I just wish all doctors in the country could hear her message.

The addiction medicine doctors had a chance to make comments and further suggestions to the CDC through Dr. Arias, and I was pleased to see how carefully she listened.

One of the suggestions I liked the best addressed the expense of maintaining state prescriptoin monitoring programs. Apparently these can cost around a million dollars a year to administer. One doctor said why not have the pharmaceutical companies that make and sell controlled substances pay or help pay for the monitoring programs? These companies are the main entities that have benefitted from the sales and diversion of their products; why not ask them to bear at least some of the cost for detecting the problems they cause? Genius, though it would be hard to mandate the pharmaceutical companies to do this.

One doctor suggested that law enforcement personnel be educated about the types of treatment available to opioid addicts, so they can stop being barriers toward effective treatments, namely medication-assisted treatments using buprenorphine and methadone.

Another doctor suggested the CDC promote the naloxone programs that provide kits to reverse fatal opioid overdoses. Why not help fund these projects and/or help create more? The Harm Reduction Coalition estimates there are around 155 naloxone programs in the U.S. Some are government-funded and some are privately funded, but around 10,000 fatal opioid overdoses have been reversed. Like Project Lazarus in North Carolina, many of these programs started at a grass roots level because citizens got involved.

Another doctor made the extremely common sense suggestion that the best way to allow more patients into suboxone treatment would be to allow doctors to treat more than one hundred patients at a time. At present, suboxone doctors are allowed to have no more than thirty patients on buprenorphine in their first year prescribing, and no more than one hundred after the first year. This would cost next to nothing for the government to implement, and expand treament dramatically.

One of our past ASAM presidents endorsed mandatory physician education as a requirement for maintaining medical license.

One person compared the prescription opioid addiction to HIV infection in past years, and commended the CDC on its past efforts to reduce the stigma associated with having HIV. This person asked the CDC to make public service announcements to help reduce the stigma of addiction, and encourge people to get treatment.

Another doctor asked the CDC to produce public service announcements telling people to lock up their medications, to prevent medication diversion to a teen or other person for whom it was not prescribed. This doctor also said that patients need to know that not all pain conditions require prescription opioids. He recommended telling the general public the true risks of opioid addiction, which have been downplayed. In the past, pain medicine experts underestimated the incidence of addiction in patients prescribe opioids for chronic pain for more than three months.

The CDC representative, Dr. Arias, confirmed that the CDC already has plans to make PSAs about pain pills and pain pill addiction, much like their present (and very successful) anti-smoking television PSAs.

All great information, and now let’s get the word out to all physicians, and the public too.

The Big Sleep: Do Sleeping Pills Cause Premature Death and Cancer?

Adults who use sleeping pills are more than three times more likely to die prematurely compared to matched controls who 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 (Klonipin). 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.

But 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.

This study really intrigued me. It’s the first I’ve read or heard about this association between sleeping pills and death, other than overdoses from mixing such drugs with opioids. After reading this article, my first thought was, “I wonder if more studies will show the same thing.” Then I started looking on the internet and found other studies that show an association between sleeping pills and increased risk of death. Many of these studies had flaws, but the overall impression is that this is a real correlation. The author of this current large study, Dr. Kripke, goes so far as to say the risks of hypnotic medications outweigh their benefits. He also admits his bias against hypnotics. (2)

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 sleeping pills and death. This current study is helpful because of its large size, and the author points out that 19 other studies have shown a relationship between hypnotics and increased risk for death.

Let’s also consider that sleeping medications bring in more than a billion dollars a year to the drug companies that sell them. I’ll be looking for more studies that are not funded by drug companies.

  1. BMJ Open2012;2:e000850 doi:10.1136/bmjopen-2012-000850
  2. http://www.medscape.com/viewarticle/759336

 

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