The Blues

 

This letter was published in the Raleigh News & Observer last week, about insurance coverage for treatment of opioid use disorder. It was written by Alex Gertner, an MD/PhD student at University of Chapel Hill’s School of Medicine and the Gillings School of Global Public Health.

I know Alex from his participation in UNC’s Project Echo, a program designed to connect new providers of office-based buprenorphine treatment with more experienced providers, for assistance and support. The goal of UNC ECHO is to get more primary care physicians and physician extenders to prescribe buprenorphine, so that people wanting treatment can get it more easily.

 

The opioid overdose epidemic continues to devastate North Carolina communities, even though effective treatments for opioid addiction exist that allow individuals to lead healthy, fulfilling lives. During this crisis, you might think that North Carolina’s largest private insurer would be helping as many people into treatment as possible, but that is unfortunately not the case.

As a medical student researching the opioid epidemic, I spend time in addiction clinics and talk with addiction providers from across the state. A complaint I hear from these providers is that Blue Cross and Blue Shield is making it harder for their patients to access treatment.

Buprenorphine is the main drug used to treat opioid addiction in office-based settings, like primary care offices. BCBS requires providers to request prior authorization to start buprenorphine. These prior authorizations can require days of back-and-forth discussions until approval, during which time a person seeking treatment is at risk of overdose. Sometimes authorizations are denied even after appeals from providers.

Part of the reason for these denials are BCBS’s criteria for approval, which conflict with evidence and best practices. As the criteria state, BCBS may deny a person buprenorphine if that person is using illicit drugs. But illicit opioid use is a symptom of addiction. That is like denying someone insulin because they have high blood sugar. The American Society of Addiction Medicine says that the use of addictive drugs only should not be a reason to suspend opioid addiction treatment.

BCBS will also deny buprenorphine if its thinks someone isn’t following a “psychosocial treatment plan,” such as counseling. Unfortunately, many communities across the state don’t have addiction counselors who take insurance. What’s more, evidence shows that counseling helps some people who get buprenorphine, but not others. Even if someone would benefit from counseling but isn’t getting it, that doesn’t justify withholding a medication that could save their life.

Office-based buprenorphine treatment doesn’t work for everyone. Some people need more specialized clinics known as opioid treatment programs. I called several of these programs and was told that BCBS rarely pays for this type of treatment. One provider told me people with BCBS seeking care at opioid treatment programs are better off being uninsured, because then they could access public funds to pay for treatment. Imagine if, at the height of the AIDS epidemic, insurers didn’t cover treatment at specialty HIV clinics. Drug overdoses are now claiming more lives than HIV at the height of the AIDS epidemic.

There are other ways in which BCBS is making it harder to get treatment, such as denying certain dosage formulations or charging high cost-sharing. Such actions may appear minor, but every disruption in treatment can lead to a potentially deadly relapse.

In contrast to BCBS, North Carolina’s Medicaid program covers treatment at opioid treatment programs and stopped requiring prior authorizations for the most common formulations of buprenorphine.

I wrote to BCBS to share these concerns. It said it follows CDC and FDA criteria for approving treatment. In fact, no CDC or FDA criteria recommend withholding buprenorphine because of illicit drug use or lack of psychosocial support. Federal recommendations stress the importance of access to opioid treatment programs.

The reason why BCBS applies such strict criteria may lie in a different part of BCBS’s response: “The street value of these products are high and these medications are used by addicts to maintain functionality between abuse, thus perpetuating the epidemic. A similar rationale is used for why we place prior authorization on extended release opiates.” It is true that buprenorphine has a street value, but that’s largely because it’s so hard to find treatment. Research shows that illicit buprenorphine use is mainly driven by attempts to self-treat addiction.

The use of the term “addict” in BCBS’s response is also troubling. The Office of National Drug Policy has stated that terms like “addict” can negatively affect perceptions of people suffering from addiction.

BCBS should end prior authorizations for commonly prescribed formulations of buprenorphine, align its approval criteria with best practices, and start covering opioid treatment programs. The opioid overdose epidemic is the public health challenge of our generation. How and whether North Carolina will emerge from this epidemic will depend in large part on BCBS’s response.

Read more here: http://www.newsobserver.com/opinion/article212771774.html#storylink=cpy

When I compare Alex’s vision and concern for such important health issues, I can’t help but to think of my days as a medical student. My concerns were narrow; I only cared about getting through medical school and into a good residency. But Alex is already working on an issue that’s so important to this country.

As you can tell from Alex’s letter to the editor, he understands the issues and eloquently advocates for Blue Cross/Blue Shield to deliver better assistance for patients with opioid use disorder. After I read his letter, the only thing I can say is “Amen!” All of the issues he listed have happened to my patients.

I pray Alex decides to work in the field of Addiction Medicine. We need him.

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When the DEA Raids Buprenorphine Doctors

 

 

I had another blog post ready to go this week, but I’m postponing it to blog about another situation.

So far this year, two well-known and respected Addiction Medicine physicians have had their offices raided by the DEA.

The first one occurred in March of this year. Dr. Stuart Gitlow, the past president of ASAM (American Society of Addiction Medicine), who has a small buprenorphine (Suboxone and other name brands) practice in Woonsocket, Massachusetts, was raided by the DEA.

According to news reports, [1] the DEA raided his home and office, looking at patient records for evidence of wrongdoing. They wouldn’t tell him what they were looking for, and wouldn’t comment to reporters later because, they say, the raid was part of an ongoing investigation.

I searched the internet for some sort of follow up story, but found none.

Dr. Gitlow is an unlikely target for a DEA raid. He is so famous for his work in the field of Addiction Medicine that he has a Wikipedia page. According to that page, he is a psychiatrist specializing in the treatment of addiction. He earned an MBA from University of Rhode Island, and went to Mt. Sinai School of Medicine where he earned his M.D. degree. He did a psychiatry residency at University of Pittsburgh, along with a Master’s degree in Public Health. Then he went to Harvard University for a forensic fellowship.

I’ve heard him give lectures at ASAM meetings and he’s as good as lecturers get. He teaches at the University of Florida, and he’s on the editorial board of the Journal of Addictive Diseases.

Dr. Gitlow confirmed in an interview that the DEA looked at patient records, but he had no idea what they were looking for.

Then in early May of this year, the offices of Dr. Tom Reach were raided by the DEA. Dr. Reach, like Dr. Gitlow, is an outspoken advocate of medication-assisted treatment.

A news article [2] described how Dr. Reach’s nine treatment centers were closed for the DEA inspection, disrupting patient care. Dr. Reach’s home was also raided. In the interview, he said he heard the DEA thought he was doing something wrong, but he had no idea what it could be.

They also looked for controlled substances, but Dr. Reach, like most buprenorphine physicians, has never stored these drugs on-site. The record keeping that is necessary for storing controlled substances is considerable. He doesn’t contract with public insurance, so it couldn’t be problem with that.

Dr. Reach said the DEA took hard drives and cell phones, making it harder to continue with patient care.

Dr. Reach was the past president of the Tennessee chapter of ASAM. Dr. Reach was one of several physicians who were on the expert panel convened last year to draft Tennessee’s new guidelines around physician prescribing of buprenorphine. He’s spent his own time at the Tennessee statehouse, advocating for patients with opioid use disorder and their physicians.

Thus far, no charges have been filed against either physician.

Both physicians are politically active. Dr. Gitlow ran unsuccessfully, twice, for state representative in Massachusetts, as a Democrat. Dr. Reach contributes money – some would say a large amount of money – to political candidates he supports. [3]

These two leaders in addiction medicine are far from the only doctors being raided. Dr. Larry Ley, who had several treatment programs in Carmel, a suburb of Indianapolis, was ultimately acquitted of felony drug charges that he faced. Law enforcement personnel, posing as patients, lied about their need for opioid use disorder treatment. Dr. Ley was then charged when he issued prescriptions for Suboxone. [4]

I thought it was a felony to obtain a prescription for a controlled substance under false pretenses. How can a DEA agent pose as a patient and lie about their substance use history to obtain a prescription? Wouldn’t that be an illegal act? Maybe that’s why Dr. Ley was acquitted.

In this case, it seems the county’s head of drug task force didn’t agree with the idea of medication-assisted treatment, saying, ““This type of ruse of a clinic perpetuates the problem because people are still addicted to the drug, and this is what is happening,” said the head of the drug task force, in a press conference held after Ley’s arrest. “This is not fixing the problem.” [4]

Dr. Ley had to close his treatment centers, was left penniless due to legal fees, and is now suing both the city of Carmel and the DEA for conspiring to force him out of business.

Meanwhile, the opioid overdose death rate in Indiana has risen by double digits.

The DEA is authorized to inspect buprenorphine practices at any time. If you are a long-time reader of my blog, you’ll recall my office was inspected in late 2012. I wrote about the experience in a blog post on 12/16/12. The agents were pleasant and cordial. They were willing to meet with me when patients were not scheduled, so it didn’t interrupt my practice at all. They asked about how many patients I had, asked to see copies of patient prescriptions, and asked if I stored any controlled substances on site (of course not). The two agents were polite and cordial.

What happened to Drs. Reach and Gitlow was very different. They were both raided by the DEA, with a warrant that says material can be seized. In a raid, the DEA is so convinced that there’s criminal activity that they take computers, cell phone, and records. Inevitably this disrupts the medical treatment of patients. For both Dr. Reach and Dr. Gitlow, patients had to be turned away from scheduled appointments because of the raids. As Dr. Reach pointed out in a newspaper interview, this can have very real and possibly fatal outcomes for patients depending on buprenorphine to provide stability and keep them from using illicit opioids like heroin.

For a DEA raid to take place, investigators have expectations of finding criminal activities. They would not raid for issues like overprescribing, substandard care and the like. These types of problems would be handled by the state’s medical board.

Of course, I don’t know the circumstances that lead to these DEA raids. It’s remotely possible that a Harvard-educated physician leader of ASAM is slinging dope on some corner of Woonsocket, Massachusetts, in his free time…but I doubt it.

The trouble with these DEA raids is that while they make the papers when they happen, no news releases state what was found. If no wrongdoing was discovered in the masses of material seized by the DEA, the public won’t hear about this. All that remains is the taint of criminal investigation.

I’ve been working with some organizations to try to get more office-based physicians interested in treating patients with opioid use disorder with buprenorphine, a potentially life-saving medication. I’ve reassured worried doctors that they won’t become DEA targets just because they prescribe buprenorphine. I told them that unless they store medication on premises, the chances of getting raided are very small.

I hope I haven’t erred in telling new doctors this. I legitimately thought the nation’s leading health experts are pushing treatment for opioid use disorders, to stem the tide of opioid overdose deaths we’ve been having oer the past twenty years.

Now, with raids on well-respected practitioners, I don’t know what to think.

1. http://www.woonsocketcall.com/news/city-doctor-s-home-office-raided-by-fbi/article_1e4270a0-2bb5-11e8-be84-b7f0c2501d63.html
2. http://www.wjhl.com/local/dea-agents-raid-watauga-recovery-centers-in-tn-va-and-nc/1156361147
3. http://doctorsofcourage.org/ralph-thomas-reach-md/
4. https://www.thedailybeast.com/addiction-doctor-dea-shut-me-down-so-mayor-could-clean-up-town?ref=scroll

The Recovering: Intoxication and Its Aftermath, by Leslie Jamison

This book will stay on my bookshelf to read again; that’s the highest praise I can give any book. Any person interested in substance use disorders and recovery from substance use disorders will find the book interesting and informative.

This is a memoir of the author’s drinking days and her forays into recovery, but it’s more than that too. Intertwined with her story, she divagates down some interesting roads.

She talks about artists, and the relationship between intoxication and the artistic temperament. Since she is an author, most of the examples she gives are of other authors, like David Foster Wallace, who wrote Infinite Jest, or Charles Jackson, who wrote The Lost Weekend. She does talk about the singer Billie Holiday, and about the misery her heroin use brought into her life, and about many other artists.

By page 352 (out of a hefty 448 total pages), the author reveals that her PhD dissertation was about authors who got sober, and how their sobriety affected subsequent work. No wonder she had interesting details about these writers and their struggles. In some cases, she could point out their best works were in sobriety.

I appreciate this idea. I’m bored to death of the cliché of intoxication as artistic muse. Sure, some works of art, be they literature, paintings, music, or other forms, were inspired by intoxicants. Yet how many renowned artists’ lives have been cut short by substance use disorders? The main examples that spring to my mind are musicians, like Janis Joplin, Kurt Cobain, Michael Jackson, Prince…how much enjoyment has the world be cheated out of from the early demise of these artists?

Dead artists don’t create. I hate to hear people imply that great talents must have substance use problems, as proof of how much they suffer for their art. That’s a tired, inaccurate lie.

In her narrative segments, she gives a window into the mind of an alcoholic, or anyone with an obsession that causes harm. She describes the usual justifications and rationalizations she used while drinking, and the same thoughts that came to her while sober.

In other segments, she talks about how race, class, and sex impact how society regards people afflicted with substance use disorders. She points out the inequities of the legal system, and how the percentages of blacks in prison is higher than of whites. She uses the cocaine laws of the 1980’s to make her point. Then, crack cocaine, which was more often used by blacks, carried the same penalty as ten times that amount of powder cocaine, more often used by whites. This meant blacks received much stiffer sentences of incarceration than whites for the same amount of drug. That’s one example of many of how minorities face more consequences for drug and alcohol use disorders.

She gives some history of the Lexington, Kentucky, Narcotic Farm, where people with opioid use disorders went voluntarily or were sentenced for recovery.

She gives a little history of how Alcoholics Anonymous was formed, and how the 12 steps and recovery community work together. She describes what scientists found years later – that peer support and contingency management treatments work, and AA has offered a version of them since the 1930s.

She also writes about the negative aspects of AA. She writes about how simplistic it is, how it’s too reductionist for complex people, and how some people may feel too smart for AA. It’s obvious that she is highly intelligent, and she admits, throughout the book, to her struggles with AA’s basic concepts.

She didn’t have an easy recovery. During her first try at sobriety, she tells how her primary relationship suffered, how depressed she felt much of the time, and how she didn’t feel as creative. She planned her relapse ahead of time at her seventh month of sobriety, with predictable results. She initially enjoyed her return to drinking but it didn’t take long to become more miserable than ever.

Her second try at sobriety went better. She was more enthusiastic about AA, and she eventually sponsored other people. She stopped focusing on herself and saw the importance of being part of a bigger community. She saw the value of people’s stories, even when they were so similar. Indeed, she saw value in the similarity of the stories, because people in AA could relate to one another even though their life experiences were different.

The emotions behind the events of drug and alcohol use connected people seeking recovery. People from different lives and lifestyles bond over shared emotional experiences common to during substance use disorder and their recovery. That’s why it’s not unusual to see a tattooed biker dude hugging a nun at a 12-step meeting

Though much of the book is about her struggles with alcohol, she describes traveling to and working in some exotic places, all of which became dreary under the influence of alcohol. She describes similar drabness in her relationships while drinking, coloring her world gray.

I have few criticisms about the book. I got bored with her constant relationship problems before, during, and after sobriety, but then I tend to have little patience with that sort of thing. If the relationship isn’t working, then end the relationship instead of bemoaning the dysfunction. I understand that sometimes relationships, even the best ones, need work. But she described mostly the work and rarely the rewards of these relationships.

I thought she should have ended her relationship with her long-term boyfriend Dave when she suspected he was cheating on her. While I read about her painful moments when she was at home and he was out doing who knows what, I kept muttering, “Dump him! Dump him!” But who among us hasn’t held on to a relationship longer than we should? So, I do understand. I won’t spoil the book by telling you whether they stay together or not.

Best of all, I like how the author ultimately embraced Alcoholics Anonymous in all its imperfections, while acknowledging other recovery paths are valid. At the end of her book in the section “Author’s Note,” I was happy to read her clear statements that one treatment doesn’t work for everyone, and that medications should be made available to help people. She specifically mentions buprenorphine, which of course warmed my heart.

She also talks about the War on Drugs, and about countries who have found a better way to deal with substance use disorders, without the moral disapproval that is so common in the U.S.

In short, it’s an interesting book with information tucked into an entertaining narrative about one woman’s alcohol use disorder and recovery. It’s the best book I’ve read on this subject since Caroline Knapp’s “Drinking: A Love Story.”

I highly recommend this book.

 

New Drug for Opioid Withdrawal

 

 

 

Last week the Food and Drug Administration (FDA) approved lofexidine for the treatment of opioid withdrawal symptoms, under the brand name Lucemyra.

This medication is an alpha 2a adrenergic receptor agonist, which means it acts on the same receptors as epinephrine and norepinephrine. However, when the specific alpha 2a receptors are activated, less norepinephrine is released, and so the actions of epinephrine and norepinephrine are reduced.

Lofexidine is not an opioid, and has no effect on the opioid receptors. It doesn’t cause euphoria or intoxication and thus is not a controlled substance.

So, you may be wondering, how does this medication help with opioid withdrawal?

Among many other places in the central nervous system, opioids act on a part of the brain called the locus ceruleus. The locus ceruleus, which in Latin means the “blue place,” is part of the system that controls the autonomic nervous system. When locus ceruleus neurons are stimulated, norepinephrine is released into the brain, and this causes overall stimulation of the brain.

Opioids slow the firing of these neurons in the locus ceruleus, reducing the release of norepinephrine. When the body gets opioids regularly from an outside source, the locus ceruleus gradually adjusts, to make up for the extra opioids. Then if the supply of opioids is suddenly stopped, the locus ceruleus becomes unbalanced, and releases an overabundance of norepinephrine. The heart rate and blood pressure increase, along with other symptoms: runny nose, yawning, tearing of the eyes, diarrhea, and nausea.

Alpha a2 agonists reduce this storm of norepinephrine, thus reducing the autonomic nervous system effects of too much norepinephrine, which cause many of the extremely distressing signs and symptoms of opioid withdrawal.

Lofexidine is in the same family of medications as clonidine, a blood pressure medication used for many years, which is also an apha 2a adrenergic agonist. Lofexidine also can cause low blood pressure, and physicians must monitor patients for this side effect.

Lofexidine has been sold in Great Britain since 1992 for management of opioid withdrawal symptoms. There’s some data to suggest it may work a bit better than clonidine and have fewer side effects, but it’s significantly more expensive than clonidine.

In the UK, lofexidine has been used to get patients through opioid withdrawal in preparation to administer naltrexone, an opioid antagonist that blocks opioids. Before initiating naltrexone, the patient must be through the withdrawal phase. Though naltrexone in tablet form hasn’t been too successful, due to problems getting patients to take this medication daily, the monthly depot injection has better compliance, for obvious reasons. The depot formulation works much better than the tablet form for this reason.

Please note that lofexidine isn’t a treatment for opioid use disorder, but only for opioid withdrawal symptoms. Many times, people assume that once the withdrawal is treated, to the problem goes away. We’ve seen since the 1950’s that keeping people with opioid use disorder away from opioids doesn’t treat the opioid use disorder, but it can be a prelude to treatment.

According to GoodRx.com, lofexidine will be available in pharmacies by August of this year, but the manufacturer hasn’t released pricing information yet.

So how big a deal is this medication? Not so big, in my opinion. I’ve never prescribed it, obviously, but from what I read, it works perhaps minimally better than the far cheaper clonidine which we’ve used for decades.

I suspect with the big price attached to this medication, we can expect to see brand name Lucemyra promoted heavily in the next year.

Tiny Candle of Hope

 

 

Every Friday at 6 pm at the Crossfire Biker’s church in North Wilkesboro, NC, people gather to attend a tiny meeting of Narcotics Anonymous, called the Brushy Mountain Group.

It’s not a large meeting; only six to eight people are there on any given Friday. It’s not an old and established meeting; it only started three months ago. But this meeting’s impact could be massive because it has the potential to change the lives of the participants.

This meeting was started with the intention of giving all people seeking recovery a place to get well. Applying the spiritual principles of acceptance and unconditional love, this NA meeting welcomes every person who wishes to recover from the disease of addiction.

This meeting makes no distinction between members who are prescribed methadone, buprenorphine, anti-depressants, stimulants, or other medications. Everyone is welcome to attend and everyone is welcome to share their experience, strength and hope. The recovering people who happen to be prescribed methadone and buprenorphine are treated as full members.

For critics who say Narcotics Anonymous is meant to be a program of complete abstinence from all drugs, people at this meeting have no issue with this statement. They know there is a difference between using drugs and taking medication. Surely the founders of NA never meant for members to be completely abstinent from all medications!

These members know the Third Tradition of Narcotics Anonymous says, “The only requirement for membership is the desire to stop using.” The assumption is that this means using drugs, not medications. At this meeting, members make their own decisions about their “clean date.” For most, the clean date is the day after their last illicit drug use.

At this meeting, the Fifth Tradition of Narcotics Anonymous is felt to be of the upmost importance, and should be a main guiding principle of every meeting: “Each group has but one primary purpose: to carry the message to the addict who still suffers.” No clean time distinctions are made. This still-suffering addict may be a newcomer, or it may be a member with twenty years of recovery. Suffering is suffering, and the group is there to support suffering members.

If a participant shares about taking medication, no one clutches at their pearls and gasps. No one  tut-tuts and asks them to shut up and talk to someone after the meeting. These people are given the same esteem as all other members. The others listen in respectful silence, and sharing continues after that person is finished.

Participants don’t often share about medication, except in passing. Most share about how they are feeling and how their emotions affect their recovery. They talk about situations that could cause a relapse, and they share gratitude for achievements big and small. They talk about how to handle the guilt from their actions in active addiction, or about how they want to do a better job raising the children.

In other words, an observer couldn’t tell this meeting was any different from any other NA meeting where recovery is underway.

This meeting is a tiny candle, spreading just a flicker of light into a small corner of one community darkened by the opioid use disorder epidemic.

But what if this light spread…what if more 12-step meetings welcomed people on methadone or buprenorphine with open arms, with hugs and unconditional love instead of judgment and put-downs?

Then 12-step recovery could be ablaze with the light of changing lives.

That’s my prayer.

 

Older Patients at Opioid Treatment Programs, Part 2

 

 

Co-occurring medical issues complicate treatment of our patients at any age, but are more common in older (over fifty) patients.

Any of our older patients who report chest pain need an immediate workup for coronary artery disease (CAD). Since almost all our patients smoke or have smoked, CAD occurs frequently. Few of them know if they have high cholesterol or not, though most know if CAD has occurred in close family members, or if they have a personal history of diabetes or high blood pressure, which are other risk factors for CAD.

Some of our patients have used stimulants, which can cause certain types of heart disease including palpitations from cardiac arrhythmias. Long-term stimulant use can also cause cardiomyopathy, a disease that permanently weakens the heart muscle.

Methadone, but not buprenorphine, can cause a certain type of heart problem known as prolongation of the QT interval. To simplify, prolongation of the QT interval involves the electrical system of the heart. An extreme prolongation can put patients at risk for a potentially fatal heart rhythm problem. Patients with heart disease may need an EKG before and during methadone treatment to look for this specific problem. Minor heart ailments like mitral valve prolapse, or a murmur with no underlying structural problems may not be influenced by methadone at all. When in doubt, it’s easy to get an EKG.

Since my background is Internal Medicine, I feel comfortable reading and interpreting EKGs, as I did in primary care. I refer to cardiologists when there’s a problem. Most often, the cardiologists say that the benefit of methadone outweighs the risks of QT prolongation. That’s helpful, because my patients and I need information about the risk versus benefits of medication, to decide how to best move forward. Each patient is different, the patient must be part of the discussion of risk. Some patients don’t mind the extra risk, while others can be very bothered by it.

Respiratory problems can be made worse by methadone. Buprenorphine can also affect breathing, but to a lesser effect. However, almost always, these two medications reduce the overall risk of death when compared with uncontrolled use of illicit opioids in patients with respiratory problems.

The more severe the respiratory problem, the trickier methadone administration can be. Since opioids, including methadone and buprenorphine, can reduce respiratory drive, COPD with retention of carbon dioxide is one of the most worrisome conditions.

Patients who retain carbon dioxide have such severe obstructive lung disease, most often caused by cigarette smoking, that the patients have problems expelling carbon dioxide, a waste product of respiration. The CO2 accumulates, giving a chronically elevated level. This happens slowly, so that patients’ bodies make accommodations to keep the blood pH normal. Normal patients breathe faster when the body accumulates carbon dioxide, but patients with severe COPD can no longer do this. When respiratory depressants like opioids are used by these patients, there’s a danger that breathing will slow more, causing a potentially fatal build-up of carbon dioxide. In these fragile patients, it is best to use a much lower starting dose of methadone than usual, and to increase more slowly than usual. It’s also much more important to limit other sedative medications (like benzodiazepines, pregabalin, and others) that could further slow breathing.

Patients with kidney failure generally don’t need to have their dose adjusted. Methadone has no active metabolites, and is mostly metabolized by the liver. Less than one percent of the blood concentration of methadone is removed by dialysis, so the patient can dose daily as usual, with no adjustments needed after dialysis. However, the patient with end-stage kidney disease may be debilitated in general by their illness, so physicians need to be cautious when starting methadone, and follow the adage “start low, go slow” with dosing.

Methadone is stored in the liver and metabolized there, but it doesn’t harm the liver. However, if liver function is impaired, the metabolism of methadone may be slowed. This can cause a potentially fatal accumulation of this medication, so any patient with new-onset acute liver failure needs to be monitored more closely. In these patients, we may want to ask them to return to our OTP three hours after dosing, when the methadone level will be at its peak, to assess for sedation. Trough blood levels can be helpful in these patients too.

We used to worry that buprenorphine damaged the liver, and recommended patients with liver disease avoid buprenorphine. However, some big studies didn’t show any worsening of liver function in patients on buprenorphine, so again, the benefits outweigh the risks in most cases.

Two specific types of co-occurring medical problems challenge opioid treatment program staff regarding patient take home status: changes in mental status and mobility issues.

Let’s take mental status issues first.

Cognitive decline is always problematic with aging patients, and perhaps doubly so in patients with substance use disorders. Watching a patient who has done well on methadone for years become more forgetful and scattered in their thinking is so sad. Underlying causes vary. The decline could be due to a reversible cause, from onset of Alzheimer’s disease or other dementia, or other medical problems.

Because we see our patients so often, opioid treatment program staff – nurses, counselors, physicians, and physician extenders – may notice slight changes in cognitive function before their other medical care providers. It’s then up to us to convince patients to go to their primary care provider for a medical workup. We always hope a reversible cause will be found.

Medications can cause changes of mental status in our patients. The classic drugs of misuse have typical signs and symptoms, but sometimes mental impairment can be caused by other medications: toxic levels of anti-convulsants, bingeing on drugs like gabapentin, pregabalin or muscle relaxants, or interactions between medications. Benzodiazepines are infamous for causing mental slowness and even associated with increased risk of dementia.

Patients diagnosed with chronic mental decline, like that seen with dementia, are most difficult to manage. With these patients, take home doses are a quandary.

A patient with dementia may gradually lose the ability to manage take home doses appropriately. Sometimes our first clue that something’s wrong with a patient can be when they come to dose days earlier than they are supposed to. They are confused about what happened to their take home doses, or why they came back to the facility early.

This is such a dilemma. We don’t want the patient to feel as if we are punishing them by revoking take homes, but we can’t in good conscience allow them to walk out of our OTP with take homes if they can’t remember if they’ve dosed today. It’s a safety issue.

Patients with significant memory problems must come to the facility to dose every day, which can be a hardship. If their mental decline has been accompanied by physical decline, problems are compounded. Sometimes patients have dependable relatives living with them who can help them take their medications at the appropriate times, but that’s not always possible.

If patients’ illnesses worsen to the point they can no longer be taken care of at home, what do we do? How can we continue their care while in a nursing facility? That gets tricky. If the facility or a relative is willing to bring the patient each day, we can do that. If that’s not practical due to physical frailty, sometimes the nursing home is willing to dose our patients, but regulations say OTPs can only dispense medication to the patient for whom it is prescribed. That is, a relative or personnel from the nursing home can’t come to pick up the patient’s dose and take it to him, as can be done in a pharmacy.

Finding solutions which are practical and workable that don’t violate any OTP regulations can be problematic.

Even getting patients on methadone and buprenorphine into assisted living facilities can be complicated. Last month on the AT Forum website (http://atforum.com ), an article was referenced that recounted the difficulties of finding nursing facilities willing to accept patients on buprenorphine or methadone. [1]

This article said some facilities have policies against admitting patients being treated for opioid use disorder with buprenorphine or methadone. The article said this stance was probably based on a bias against MAT in favor of abstinence-based approaches to treating opioid use disorder. Some experts believe this is illegal, because it violates the Americans With Disabilities Act.

Mobility issues from falls, broken bones, orthopedic conditions, or recent surgeries sometimes collide with my assessment of the patient’s stability from opioid use disorder. What if a patient deemed too unstable (or too new to treatment) for anything other than one take home per week has a sudden medical issue that limits his mobility? This situation occurs more than you might imagine.

We used to be able to dose patients in their cars if it was difficult for them to walk into the facility. Now, the DEA opposes this, worrying a nurse carrying a dose of methadone to a car in our parking lot could be intercepted by someone with criminal intent. I agree this could happen, but the rare occasions when we’ve had to dose patients in their cars, we sent two staff: one nurse to carry and administer the medication, and a witness (usually the patient’s counselor) to witness it being given to our patient and no one else. This also protects our nurses against accusations they mishandled the dose in any way. But the DEA says we can no longer do this.

Some OTPs take a hard line and say if you can’t walk into the OTP, you are not appropriate for treatment. That seems unkind, particularly if a patient has done well with us in the past, and is now having a temporary medical issue limiting mobility.

I think the best approach is to get input from the patient’s physician and try to decide action that’s in the best interest of the patient.

First, I talk to the patient’s physician for specific recommendations of the patient’s mobility. Then I talk to the patient, usually with a counselor, and we ask about family members who could help the patient take extra take home doses as directed. We can ask for state and federal exceptions for extra take homes, so long as we do all we can to ensure patient safety, and describe the situation to officials, to give a better idea of our thought processes and safety concerns.

Sometimes I am surprised, and the other physician wants the patient to get up and walk around, particularly after surgery, for a better outcome. If that’s the case, no extra take homes need to be provided.

Some patients are so debilitated that being around other people presents a health hazard. We had a patient on heavy cancer chemotherapy. When her white blood cell count was extremely low, her doctor recommended she avoid crowds. This occurred during the height of cold and flu season last year, so we requested extra take homes for her, to keep her from having to come to our OTP and sit in a waiting room with other patients.

Her oncologist and I had to weigh the risk of extra take homes against the risk she could contract a simple viral illness that could kill her in her immune-suppressed state.

These types of situations will occur with frequently given the overall aging of the U.S. population, and the aging of patients on medication-assisted treatment. We need to remember this aging is a good thing – patients getting help with MAT are surviving, and living until old age

1. https://www.statnews.com/2018/04/17/nursing-homes-addiction-treatment/

 

Medication-assisted Treatment in An Aging Population

 

 

Patients prescribed medication-assisted treatments with buprenorphine, methadone, and naltrexone are getting older…as we all are. This is wonderful, because it means our patients are surviving, making it to old age. Methadone has been prescribed for the longest of the three, so we tend to see more older patients on it.

Aging in our patients can present specific challenges; research literature shows high rates of physical and psychological illness in opioid users in general, meaning as this population ages, we can expect to see even more co-occurring illnesses.

When looking for information about aging MAT patients, I was appalled to see a journal article define “older adult” as those fifty and above. I’ve always thought of “older” as being, well, older than me. I’m no longer pushing fifty – I’ve been pulling it behind me for nearly seven years, so I felt a little resentful on behalf of my patients.

Anyway, the article was titled “Older Adults Prescribed Methadone for Opiate Replacement Therapy: A Literature Review,” and the author said that the U.S. had 1.7 million people over age 50 in 2000 who needed substance abuse treatment. That number is expected to rise to 4.4 million by 2020. [1]

This article said the numbers of patients over 50 years old who are on MAT is expected to rise, and this group of patients has special needs. They say these patients tend to age more quickly (physiologically) due to past lifestyle.

I see that in my patients. Around 90% are smokers, and cigarettes cause a whole host of medical issues. Some patients have had poor dietary habits since childhood, from a combination of factors. Many patients haven’t had the time or energy for self-care, prior to entering recovery, and this takes a toll.

A New York study of older OTP patients on methadone [2] sampled 156 patients enrolled in OTPs. Twenty-nine percent were age 55 or older (45 patients) These patients, as compared with their younger counterparts, were significantly more likely to have been in treatment longer, less likely to be using heroin currently, but more likely to have an alcohol use disorder.

The older patients were less likely to be impulsive or hostile, but more likely to have chronic medical problems and more likely to be on medications for those problems. Older patients were more likely to be on more liberal take home schedules, due to less illicit drug use compared to younger patients. Despite having more chronic medical issues, older patients’ scores on life satisfaction scales weren’t different from younger patients.

Improving the health of our older OTP patients is a challenge, and I have a few suggestions to help.

Get them to a primary care provider. Some OTPs are fortunate enough to be able to offer primary care to their patients. That’s wonderful, but if, like me, you work at an OTP that can’t do that, patients will need to be referred. This should be easy, but it’s not, at least in some areas of this country My patients tell me when they call for an appointment as a new patient, they are told they can’t be accepted if they have a history of substance use disorder or treatment for chronic pain. They say they’ve called all the practices in the area and none will accept them.

Could this be exaggeration by patients? Maybe, but I’ve heard this over and over. Some patients say the receptionist who answers the phone takes their name and birthdate, then calls back to say they can’t be accepted. The patients think it’s because the prospective physician sees they have past histories of filling controlled substances on North Carolina’s prescription monitoring program. I hear the same things from patients with private insurance, Medicaid, and self-pay.

I’ve never heard any physician to admit to doing this, since it would unethical, and probably also a violation of the Americans With Disabilities Act.

Federally Qualified Health Centers (FQHCs) will take these patients. We have a center that does an excellent job with our patients; however, it’s an hour’s drive away. Some patients have difficulty getting transportation for that distance.

Medicaid patients should be assigned to a doctor or practice, and it’s printed on their Medicaid card.

Health maintenance can’t be neglected.  

Often a patient says something to the effect of, “I didn’t expect to live this long. I never thought of doing those things.” This is called a “sense of foreshortened future,” meaning the person senses he will not live to an old age and is destined to die young. It’s seen in people who have experienced trauma in their lives and can be a symptom of post-traumatic stress disorder (PTSD). But now here he is, over 50, and not accustomed to taking care of himself.

And yes, it also means that rite of passing age 50: the screening colonoscopy.

Our patients need routine PAP smears, mammograms, prostate exams, and vaccinations. They need their blood pressure and cholesterol profiles checked when appropriate. We need to encourage our patients to keep up with these simple measures.

After patients get into recovery, it takes time and effort to adjust thinking, and accept the idea that good self-care can extend the quality and length of life.

Opioid treatment programs, like all other medical practices, should keep an updated medication list and updated problem list.

That should be easy to accomplish, but at my OTP, our present software system has no provision to document this essential information. I’m left to figure it out with paper charts, which isn’t ideal, but workable. But I can only see that data if I’m in the office with the chart in front of me.

Methadone has interactions with many medications. The list is long, and difficult to remember, so I use a smart phone app that will tell me about drug interactions. There are many out there: Epocrates and Medscape are but a few. If you work in an OTP, get this phone app. It will save you time and effort.

See complicated patients more often.

This applies to older patients, but also to younger ones if they have a complicated medical history. Sometimes it’s hard to convince patients they need to see me if they are doing well. Particularly if they have their own doctor, and they are doing fine, why should they waste their time? Of course, I think it’s time well-spent, but I understand their thinking. I delay seeing my doctor too. Life is hectic and that’s never at the top of my list.

I’ve started “warning” new patients with more than a few medical issues that I will want them to see me every 3 months. We can flag this in our computer system, along with flagging when they will be due for a yearly physical.

I count diseases like heart disease, diabetes, COPD/emphysema/asthma, and other chronic conditions as complicating illnesses. There are dozens of others, and I also count chronic mental illnesses, even though they are treated by psychiatrists. Many of those medications can have interactions with methadone, making it prudent to see these patients more often.

More than anything else, keep talking to patients about quitting smoking. Smoking-related illness is the number one killer of people in recovery. It’s not easy, but keep encouraging and supporting them. My state has a quitline to help anyone wanting to quit at: https://www.quitnow.net/Program/This is sponsored by the American Cancer Society, for no cost to the patients.

In my next blog, I’ll talk about some of the most challenging co-occurring problems in my patients: deteriorating cognitive function and limited mobility.

1.  Doukas et al., and published in Addiction and Preventive Medicine, February 10, 2017.
2. Rajaratnam et al., Journal of Opioid Management, 2009 5(1), pp 27-37.