Archive for the ‘snorting drugs’ Category

Hepatitis C: What’s New?

A fair number of my patients screen positive for the Hepatitis C virus. Obviously, they want to know what a positive screening test means, and what they should do next. Since a positive screen doesn’t necessarily mean an infection with Hep C, I’d like to explain more about this test, about the virus, and what’s new in the treatment of Hep C.

Hepatitis C is a virus that mainly affects the liver, as its name implies. There are other viruses that affect the liver, creatively named Hepatitis A, Hepatitis B, and so on. But Hepatitis C is the biggie, with an estimated 3.4 million people in the U.S. with the infection. In fact, it’s the most common chronic blood-borne viral infection in the U.S.  Around the world, 180 million people are estimated to be infected with Hep C.

Anyone with a history of intravenous drug use should be screened for hepatitis C. In the U.S., this is the most common way of contracting the virus. Even if you didn’t share needles, if you shared cookers, water, spoons or other material, you may have contracted the virus. Even people who shared straws to snort drugs appear to be at risk, and should be tested.

It’s a blood-borne illness, so it can also be transmitted through tattoos with unclean needles, re-used medical supplies, and blood transfusion with tainted blood. However, risks of infection through transfusion in the U.S. are very low since testing for the virus became available in 1992.

Most people who have hepatitis C got it from another person’s blood, but it can be transmitted through sex. In monogamous couples with one infected partner, the virus is transmitted to the uninfected partner in only about 1 – 5% of cases. However, multiple sexual partners and high risk sexual activities result in higher transmission rates. You can’t transmit Hep C by hugging, kissing, sharing eating utensils or ordinary household contact, though a person with Hep C shouldn’t share razors or toothbrushes.

In May of this year, the Centers for Disease Control and Prevention recommended one-time testing for Hepatitis C in all baby boomers, meaning people born between 1945 and 1965. About one in thirty baby boomers have hepatitis C, according to the CDC. Because newer treatments can cure chronic Hep C infection, the CDC hopes to save an estimated 120,000 lives by uncovering infections in people who don’t know they’re infected.

The screening test for Hep C is relatively inexpensive, and screens only for antibodies to the Hepatitis C virus. If you screen positive with this test, it means you have been exposed to the Hep C virus. It does not tell us if you have chronic Hepatitis C infection. Up to 20% of people who contract Hepatitis C infections are able to clear the virus on their own, and will not have chronic infection. However, they will remain positive on this screening test, because they will carry antibodies against the virus for the rest of their lives. Patients diagnosed, treated, and cured of Hep C infection will also remain positive for Hep C on this antibody screening test, so it’s not helpful to screen these patients again. In fact, it may be confusing if the provider doesn’t understand what this antibody test means, and explain it adequately to patients.

There are six specific types, called genotypes, of Hepatitis C. Even if you clear the infection to one genotype, you can be re-infected with another genotype of hepatitis C. If you have active Hep C and continue to share needles, it’s possible to become infected with more than one subtype.

There’s no vaccine available for Hep C like there is for Hep A and B. Much like HIV, the Hep C virus undergoes frequent changes, so it’s like making a vaccine against a moving target.

If you test positive on screening for Hep C, you need to have further testing to see if you have Hepatitis C infection. The next step is a qualitative test for hepatitis C. At around $100 at the cheapest, it’s difficult for patients without insurance to afford the proper testing.  If this qualitative test is positive, you should then see a specialist to see if you need a liver biopsy. Most specialists base the decision to treat on a liver biopsy. There are other tests, but biopsy is still the gold standard.

If treatment is contemplated, it will be necessary to have genotype testing, to find out what specific type of Hep C you have. Treatments are different for different subtypes. Two new medications are used in the treatment of type 1, the most frequent type in the U.S., and give cure rates up to 75%. On the other hand, genotypes 2 and 3 are more easily treated and don’t require treatment to be as long as type 1. Quantitative Hep C testing, called viral counts, isn’t needed unless treatment is going to be done, when it is used to follow the response to treatment. Outside of that, the viral count provides little information.

Liver function tests, called LFT’s, are relatively cheap, and are often done at the same time as the first Hep C screening test. If they are elevated, it usually means there’s inflammation in the liver. Many things can cause an increase in LFTs. Alcohol is the most common cause, but all viral hepatitis infections can cause elevations too. However, it’s possible to have normal LFT’s and still have active Hepatitis C. We can’t assume you don’t have Hep C infection even if your LFT’s are normal.

If you have Hepatitis C, you should NEVER drink alcohol. Even patients infected with Hep C but with no problems on liver biopsy will go downhill fast if they drink alcohol. The dangers of alcohol in patients with Hep C cannot be overstated. Don’t. Drink. Ever. Not even a cold beer after mowing the lawn.

In my next blog post, I’ll talk about the exciting new treatment developments.

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.

Am I Addicted to Prescription Pain Pills?

I am a guest blogger on addictionblog.org, and recently had a well-received article published on that site about how to know if you are addicted. I thought I’d repeat a version of that column here.

 There’s so much confusion about the differences between the disease of addiction to opioid pain pills and mere physical dependency on pain pills. Even some doctors don’t understand the differences, regretfully. Any person who regularly takes opioid pain pills for a period of weeks to months, for whatever reason, will develop a physical dependency to these drugs. That’s a biologic event. But addiction is much more than just the physical process. With addiction, there’s also a psychological component. People with addiction think about the drug often, spend time using and recovering from the drug, and continue to use the drug even though bad things happen. In physical dependency alone, this doesn’t happen.

 Here are a few specific questions that I ask patients, that help me decide if they have the disease of addiction:

  • Do I take more medication than prescribed? Do I take early doses, or extra doses?
  • Do I take medication in ways it’s not intended? For example, do I snort it, or chew it for faster onset? Do I inject it?
  • Do I get medication from friends, family, or acquaintances because I run out of my prescription pills early?
  • Do I become intoxicated, or high, from my medication? Without telling my doctor?
  • Do I drink alcohol with medication, even though the pharmacist advised against this?
  • Do I look forward to my next dose of medication?
  • Do I get impaired from my medication, to the point I’m unable to function normally?
  • Do I take pain medication to treat bad moods, anxiety, or to get to sleep?
  • Do I use street drugs like cocaine, marijuana, or others?
  • Have I driven when under the influence of pills, when I know I shouldn’t be driving?
  • Do I get prescriptions from more than one doctor, without telling them about each other?
  • Do I spend a great deal of time worrying about running out of medication?
  • Do I spend a great deal of time thinking about my medication, and how it makes me feel? 

One “yes” answer to any of these questions is worrisome, though not necessarily diagnostic of addiction. I think of addiction as a continuum, and it’s easier to diagnose with multiple “yes” answers. For example, people taking prescriptions may have a few worrisome symptoms, like taking an extra pill occasionally. Perhaps they did this because of a temporary increase in pain. Without any other symptoms, I probably wouldn’t diagnose addiction. At the other end of the spectrum, if a patient is crushing pills to inject or snort, I feel confident making the diagnosis of addiction.

 Sometimes addiction only becomes apparent over time. This is why doctors need to see patients frequently who are prescribed potentially addicting medication, like pain pill, stimulant, and benzodiazepines.

 If you had one or more “yes” answers to the above questions, please see a doctor who knows something about addiction, because untreated addiction usually gets worse. In fact, it can even be fatal.

Misuse of Suboxone

After I made some posts on this relatively new blog about Suboxone film, including pictures of the film, the number of hits to my blog increased dramatically. But I saw a pattern. I was getting hits from search engines, after people entered phrases that indicated they were looking to either snort or inject Suboxone.

 Over the past thirty days, the number of hits to my website from people entering phrases related to injecting Suboxone is: 138

 Phrases about snorting Suboxone: 114

 Phrases indicating attempt to get high from Suboxone tablets or film: 26

 Maybe not everyone who entered such phrases actually was looking to learn how to misuse the drug. Maybe some of the entries were people merely gathering information. But I suspect most people were addicts trying to get information about the misuse of Suboxone.

 Then I also receive a few posts that I don’t approve for this blog site. Recently I got an interesting post from an IV addict who describes how he separates the buprenorphine from the naloxone before injecting the tablets, but I’m certainly not going to publish that information. True, you may be able to find this information elsewhere on the internet, but not here.

 All of  this is challenging me to re-consider what I believe about Suboxone.

 I prescribe it from my private office, and I’m having misgivings about this. Are my patients injecting or snorting? I don’t think so, but now I wonder if I’m fooling myself.

 Maybe the only safe way to use Suboxone is through opioid treatment programs, where patients have to come each day to get their dose and take it in front of a nurse,  just like we do with methadone. 

Comments?

Who is Snorting Suboxone Tablets or Film?

Lately I’ve been amazed at the traffic my blog site has been getting. Then I look at the statistics, and the increase is from people who put phrases like “inject Suboxone film” and “snort Suboxone film” into search engines. From this information, I’m starting to have the unpleasant suspicion that there are more than just a few people who snort the tablets, and are worried they won’t be able to snort the film.

After examining the film myself, I don’t think it’s “snortable.”

At the risk of sounding like a shill for the drug company (I don’t take or receive money from any drug company in any form or fashion), this film is better than the tablets. I have quite a few patients reporting to me after using the film for the first time, and nearly all prefer the film to the tablets. They say it dissolves quickly, and while it doesn’t necessarily taste any better, it’s gone more quickly so that the unpleasant taste doesn’t linger.

 Patients describe the difference between sitting for fifteen minutes with a mouthful of saliva, trying not to swallow, versus five minutes or less of letting the film dissolve, with minimal saliva formation. Many patients believe they are absorbing more medication. I don’t know if that’s true, but it makes sense. If the tablet causes a large volume of saliva to accumulate, it seems logical that due to the dilution, less medication would be available for absorption.

 However, if the price of the film increases after March, 2011, I don’t know if patients without insurance will stay on it. Many of my patients can barely afford the medication, along with the cost of my office visit and of drug screening. That $75 coupon provided by the drug manufacturer each month has been a big help, but I don’t know what will happen with the price next year. If there’s a generic buprenorphine/naloxone tablet that works well and is cheaper, many of my patients would probably switch again from the film back to a tablet. 

Which brings me again to my concern about snorting (and even injecting) Suboxone tablets. Lately I’ve trolled the various websites and I see references to snorting, even though pharmacologically that makes little sense. I still suspect it’s due to addiction to the act of snorting, which has become such an ingrained habit in some addicts that they feel a compulsion to use all medications in this way. 

Comments from any Suboxone-snorting addicts out there?

The New OxyContin Formulation

Over the last three weeks, at least five of the opioid addicts I’ve admitted to treatment said they wanted help because they couldn’t abuse the new form of OxyContin.

 And I say: Hallelujah! It’s about time!!

 This new tablet, approved by the FDA in April of this year, appeared recently on the black markets of this area, replacing the older, more easily abused OxyContin. The new tablet is bioequivalent to the older tablet, meaning the same amount of oxycodone, the active ingredient, is available to the body when swallowed whole, as it’s meant to be. In other words, the same amount of pain reliever is given to the body. However, it’s more difficult to crush for the purpose of snorting or injecting, because it turns into a gummy ball.

Purdue Pharma, the drug company that makes OxyContin, admits this new formulation isn’t abuse-proof, but hopes it will be more resistant to abuse.

The patients I’ve talked to say the new tablet is a big disappointment. One patient, who usually chews her pill to get a faster high, said it was like trying to chew a jelly bean. Other patients said they could crush the tablet, but got a kind of gelatinous mess that was impossible to snort or inject.

 For pain relief, the opioid in OxyContin lasts much longer when it’s taken as directed and swallowed whole. Addicts prefer to crush and snort or inject because of the quick high they feel with this route of administration. But when used in this way, it leaves the body faster, and the addict usually needs to find more opioid within six to eight hours to avoid withdrawal.

Before I applaud Purdue Pharma for this change, my cynical mind asks a few questions: Why didn’t the company make this change earlier?

In 2002, a Purdue Pharma representative testified before congress, saying that the company was working on a re-formulation of OxyContin, to make it harder to use intravenously. This representative said they expected to have the re-formulated pill on the market within a few years. (1)  But it took eight more years.

Sterling, the drug company that makes Talwin, another opioid pain medication, was able to re-formulate their drug within a few years when they discovered it was being abused frequently. This was in the 1980s, when, presumably, medication technology wasn’t as advanced as today. Sterling added naloxone, an opioid blocker that’s inactive when taken by mouth, but puts an addict into withdrawal when it’s crushed and injected. It worked great. Talwin isn’t a commonly abused drug.

 I’m assuming that Purdue Pharma holds the patent for this new formulation that makes their tablet gummy when crushed. Purdue probably teaches its sales staff to market the new OxyContin as a safer option than older versions, perhaps available in cheaper generics. So did they wait to re-formulate until their patent was ready to expire? I don’t know, but time will tell.

At any rate, this drug is now just a little bit safer, for now. People with addictions are often clever and creative. I won’t be surprised if soon there’s a way to defeat this new technology.

Just think what addicted people could do, if they directed their talent and intelligence in ways that would help and not hurt them. There would be no stopping them.

1. United States Senate. Congressional hearing of the Committee on Health, Education, Labor, and Pensions, on Examining the Effects of the Painkiller OxyContin, 107th Congress, Second Session, February, 2002.

Snorting Suboxone

Why do people snort Suboxone? I know why people say they snort it: to get high.

 But buprenorphine is designed to be dissolved in the mouth, where it quickly diffuses across the thin mucosal surface, directly into the venous blood system. Go to the mirror, lift your tongue to the roof of your mouth, and look at the two large veins on the underneath surface of your tongue. These veins are covered by a very thin membrane.

Why would buprenorphine have a faster onset when snorted? It’s still diffusing across a mucosal surface. But the nasal mucosa isn’t as moist as oral mucosa, and the skin thicker, so I theorize snorted buprenorhpine should take longer to diffuse into the venous system. Yet many addicts are convinced they get high from snorting buprenorphine.

Some addicts think it makes them high because “It’s closer to the brain.” Well, yes, but that doesn’t matter. Snorted drugs diffuse across the nasal membranes and into the small veins of the nose, which return blood from the nose to the heart. Then after cycling through the lungs, the blood goes through arteries to the brain. Same with blood returning from the tongue. There’s no difference.

I suspect the addicts who snort buprenorphine are addicted to the act of snorting. This may be the same phenomena we see when intravenous drug users continue to inject saline or ice water, with no active ingredients, to feel the rush that comes with the ritual of injections.

Just as Pavlov’s dog began to salivate at the ringing of a bell, after the bell had become with associated with food, these addicts are conditioned. Their brains pair the ritual of the needle, or the ritual of snorting, with the euphoric high. Their brains may be releasing dopamine, the chemical transmitter of pleasure, during the ritual of injection or snorting.

Breaking such an association in recovery can be difficult. Recently I talked with patients who regularly injected ice water, to remind themselves of injecting heroin. I was appalled, because the tonicity, or concentration, of water is much lower than that of the blood stream. When water is injected into the blood system, it causes red cells to lyse, or break apart, releasing cell products into the blood stream. This probably isn’t too harmful unless it’s done frequently or in large amounts. When you are dehydrated and go to the hospital, that plastic bag of fluid they drip into your veins isn’t filled with water, but a solution of Ringer’s Lactate, normal saline, or half-normal saline. These solutions are balanced, to prevent lysis of red cells.

I’m not sure about my conclusions about snorting Suboxone. I’ve tried to find some studies on bioavailability to support my theories, but don’t find anything. This is probably because no one thought people would snort this medication.

And as bizarre as snorting pills may seem to some, I’ve had one patient who found the taste of Suboxone so bad, she started inserting it in her vagina. She said it took effect just like when she put it under her tongue to dissolve. Alarmed, I contacted the drug company and asked them what could happen, and would this harm the tissues of the vagina. They had no idea, as no studies or tests have been done with this route of administration.

 Just when I start thinking I’ve heard it all…

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