Opioid Settlement Money Part 2

This blog entry is a continuation on some of the ideas presented in my last blog, mainly that the opioid settlement money being granted to each North Carolina county’s commissioners needs to be spent wisely.

The guidelines that our state government has put forth can be found in this pdf: https://www.ncacc.org/wp-content/uploads/2021/04/Opioid-Litigation-Settlement-Overview-202109.pdf

These plans include very reasonable ways to fight the opioid epidemic, embracing prevention, treatment, and plans for additional services. I have thoughts regarding a few specific topics.

Housing

Housing is a problem for many people with opioid use disorder in my area. There’s not enough low-income housing available in general, but people with substance use disorders have unique problems with housing. For example, if a person seeking recovery lives with other people who use drugs, as often happens, they encounter a constant trigger for relapse. They need to move, but where can they go?

We do have recovery houses in our area, but they don’t accept patients on methadone or buprenorphine. Last blog, I explained how some medical practices and facilities have been found in violation of the Americans with Disabilities Act (ADA) if they exclude people from services because they are on prescribed methadone or buprenorphine. I don’t know if this law applies to recovery houses, but the bottom line is that there are no recovery houses available in our area for people on medications for opioid use disorder. We need this is our area and around the state.

Over the past few years, our area’s homeless population has grown. I think there are several reasons for this, including a rise in methamphetamine use disorder, which often co-occurs with opioid use disorder. Methamphetamine use seems to lead to people getting kicked out of their housing. Also, our homeless shelter closed a few years ago, pressured by a community that didn’t want “those people” present in their community. Thankfully, a church opened a temporary homeless shelter, but people can only stay there for fourteen days per year.

Ironically, the closed shelter was located very near our OTP. Since that shelter closed, “those people” formed a tent city in the woods behind our OTP, at least during warm months. I’ve admitted some of them into treatment for their opioid use disorder, and at least they can get to our OTP daily since they live in our backyard. However, most also struggle with methamphetamine use and are triggered by others in this homeless camp. As most of my blog readers know, there’s no medication that has been proven to help patients with stimulant use disorder. We try our best to engage them in counseling, but they need safe housing.

At one point I estimate there were ten or fifteen people living there, though only a handful were our patients. Several churches in the area brought food to these patients regularly, and our OTP had clothing and blankets which we provided when we could.

In an ideal world, recovery homes for patients in treatment on medications for opioid use disorder would be wonderful.

Transportation

I’d like for our state to spend part of the opioid settlement money on the transportation of patients to treatment. The nature of our outpatient treatment program means patients must come for dosing and counseling daily, at least until they stabilize.

Transportation is a barrier to treatment for patients in our rural county. We have no public transportation for people without Medicaid. Thankfully patients with Medicaid can ride vans that bring them to and from our opioid treatment program to dose daily, but it’s not feasible for patients without Medicaid.

Since requirements were loosened for take home doses during COVID, patients can get take homes much earlier than in the past. But new patients starting methadone still need to come daily until they get to stable doses. Some patients take longer than other to get to a stable dose and stop using fentanyl and other opioids. If they miss days, it interferes with dose increases and they spend longer in induction, placing them at higher risk for a bad outcome.

I’d like for someone to invent dependable transportation for our patients.

Of course, a mobile unit would be ideal but so far there’s no talk of starting this at the OTP I work for. It could work well, particularly in rural areas.

Fund Treatment

Of course, the most obvious need in patients with opioid use disorder is funding to pay for treatment. As I talked about in my last blog, the opioid settlement money should pay for evidence-based treatment.

The state opioid response grant (SOR) has paid for treatment at opioid treatment programs for indigent patients. To qualify for the grant, patients need to have an income below a certain cut off and have no health insurance or Medicaid. This grant has been a lifesaver for many patients. We have around two hundred patients now getting their treatment paid for by this grant at the OTP where I work.

The Opioid settlement money could be administered in a similar way, except I wish even patients with health insurance could get grant money. Right now, having health insurance disqualifies patients from the grant, but many of those patients can’t get their health insurance to pay for treatment. It’s not quite as bad for office-based buprenorphine treatment, but similar.

As I wrote about last blog, county commissioners need to take care not to give money to unproven treatment providers.

Just last week, WRAL in Raleigh ran a piece about a ten-million-dollar grant to combat opioid use disorder to a pastor running a non-profit organization called Hope Alive. Critics say this agency has no experience treating opioid use disorder. To make matters worse, WRAL did some research and found that this pastor served time for seven counts of embezzlement 1992 through 2004. [1]

Defenders of the grant decision say there’s no other providers of treatment in rural Robeson County, and the pastor’s criminal record was a very long time ago.

The last part of that I’ll agree with completely. Perhaps the pastor had a substance use disorder himself, leading to the criminal charges. Perhaps his past has made him a more effective person to lead a recovery service. I believe people can grow and change, or else I wouldn’t be working in this field.

But the first part…just because there’s no other programs in Robeson County doesn’t mean spending money on ineffective or unproven treatment will help anyone. Shouldn’t the treatment facility be vetted, to make sure it adheres to evidence-based treatment, before the state awards ten million dollars?

In order for agencies and programs to receive settlement money, there should be some standard process to prove that they use evidence-based programs or medications.

Treatment for incarcerated people

Our state’s county jails and state prisons don’t often offer medication-assisted medications to treat opioid use disorder in incarcerated people. They usually won’t continue treatment that a patient has been getting. There’s a pressing need for this to change. I was happy to see this added as a priority for how NC planned to spend the opioid settlement money.

Litigation around the nation has been decided in favor of people who were denied their usually prescribed medications of buprenorphine or methadone while incarcerated. I’m happy about this because the threat of a lawsuit motivates organizations to change quickly.

I wish the public knew how much suffering our patients endure in these county jails when they are denied their treatment medication. A patient dosing for months on methadone at 120mg could be locked up for unpaid traffic tickets and spend five days in jail going through hellish withdrawal. If a nurse can be found, the patient might be given their “detox protocol:” a single bedtime dose of clonazepam .5mg. Healthy adults usually don’t die from opioid withdrawal if dehydration is treated in a timely fashion with intravenous fluids. However, medically fragile patients can die from sudden and severe opioid withdrawal.

I’ve blogged about this before. I tell all my patients who have been through such an awful experience that they can contact the NC chapter of the American Civil Liberty Union, to ask about filing a lawsuit for being denied appropriate medical care. Such lawsuits have been won in other states.

But North Carolina’s plan looks farther than continuing legitimate medical care for people already in treatment. It also envisions screening of newly incarcerated people to start appropriate medications. That’s a wonderful idea. After all, we know that studies show reduced criminal activity in patients who start in treatment with buprenorphine or methadone, so it makes financial sense as much as medical sense.

The logistics of providing this care will be difficult, but some prisons already have such protocols. We can learn from them how to set up good programs that benefits incarcerated people with opioid use disorder and our communities.

1. https://www.wral.com/church-nonprofit-with-zero-track-record-of-providing-drug-treatment-awarded-10-mil-from-state-to-combat-opioid-crisis/20072234/

Opioid Settlement Money: Who Gets It?

By the term “opioid settlement money,” I’m talking about the $26 billion agreement reached in mid-2021 with the opioid manufacturer Johnson & Johnson and the big three opioid distributors: McKesson, Cardinal Health, and Amerisource Bergen. The settlement was reached between these parties and the organizations and agencies that sued them, which were over three thousand opioid-related suits nationwide.

Some states opted out of this settlement, preferring to continue to pursue lawsuits.

The settlement does not include other opioid manufacturers such as Purdue Pharma, Indivior/Reckitt-Benckiser, Teva, Mallinckrodt, or any of the pharmacy chains such as Walgreen’s, CVS, Walmart and others.

The agreement is more complicated than I’m able to explain in a brief blog, so if you have specific questions, I’ve found this is a great website: https://www.opioidsettlementtracker.com/globalsettlementtracker

States participating in the settlement now must decide how best to spend their money. Will it be a free-for-all like the tobacco settlement of previous years, or will the money go towards helping people who were harmed by the opioid epidemic?

I was pleased to learn that my state of North Carolina has a plan in place to distribute the money. According to an overview document, [1] North Carolina plans for 15% of the money to go to the General Assembly, to be spent on “…a wide range of strategies to address the epidemic.” The largest chunk, 80%, will go to local governments to spend. The last 5% will be used as incentive money to urge counties and municipalities to sign on to the agreement.

The state has set up oversight to make sure the money gets spent on these things: evidence-based addiction treatment, recovery support services, recovery housing, employment-related services, early intervention programs, naloxone distribution, post-overdose response teams, syringe exchange programs, criminal justice diversion programs, addiction treatment for incarcerated persons, and re-entry programs.

It’s a little more complicated than this, since counties have other options too, but all the options look like legitimate uses of this money, with potential to help the people who have suffered the most: people with opioid use disorder.

North Carolina’s plan is to allow county commissioners of each county decide how to spend their money, which could lead to some difficulties.

For example, what if one county’s commissioners want to spend it all on detoxification? They might not know that detoxification alone, when not paired with FDA-approved medications to treat opioid use disorder, has dismal fail rates. Detoxification provided to patients with opioid use disorder show relapse rates of more than 90%, with an increased risk for overdose death shortly after leaving detox.

I’ve said on other blogs that if treatment with this fail rate and increased risk of death were provided to people with any other chronic illness, malpractice lawyers would leap into action to sue the providers. They might even drop from helicopters like malignant spiders. But when detox treatment fails – as one would predict from fifty years of data – to benefit people with opioid use disorder, the patients are blamed for not wanting recovery badly enough.

However, detoxification results may improve if patients are started on long-acting naltrexone before they leave the detox facility. Its brand name is Vivitrol, and it is given as a monthly injection.

Of course, relapse rates would drop if detox facilities used methadone or buprenorphine, but we don’t often need inpatient facilities to accomplish this. It can be done safely as outpatient treatment, and more cheaply too.

What about the traditional abstinence-only based facilities who provide detox, then 28 to 42 days of inpatient rehabilitation? Should they get any share of the opioid settlement?

One of my colleagues got into some hot water lately when he voiced his opinion at his county’s Drug Overdose Prevention Coalition. He told the audience that in his opinion, several local abstinence-based residential programs, both of which bar patients on methadone or buprenorphine, shouldn’t be allocated any of the opioid settlement money. They both discriminate against patients on medications (buprenorphine and methadone) which are heavily evidence-based for the treatment of opioid use disorder.

 I admire his bravery, and everything he said was science-based…but not well-received.

He got angry letters from these two facilities, who wrote long letters about the benefits of their programs. Interestingly, the letters did not directly address the most pressing issue: is it fair or even legal to deny treatment services to people who are prescribed methadone or buprenorphine?

In fact, at one point in their letter, one facility says, “…at multiple points prior to admission, we are clear that we do not utilize addictive substances as part of our treatment milieu.”

They doubled down on their position that they not only can deny treatment to patients on buprenorphine or methadone, but that they consider them addictive substances. This may be why only 18% of their patients have a diagnosis of opioid use disorder (their data). I suspect most patients were discouraged during the admission process and abandoned their efforts to get help.

Courts across the country are deciding that patients denied medical services because they are prescribed either methadone or buprenorphine are being denied their rights under the Americans with Disabilities Act (ADA).

For example, in 2018, the Department of Justice found a medical practice violated the ADA when they refused to provide primary care and specialty services to patients who were legitimately prescribed MOUD (this abbreviation stands for medications for opioid use disorder, meaning methadone or buprenorphine). The medical practice agreed to a settlement where they paid a hefty fine and agreed to educate their staff and change their policy of discrimination against these patients. [2]

At least five nursing homes have been cited by the Department of Justice for violating the ADA when they refused to accept patients on MOUD. All the facilities agreed to change their policies, train their personnel, and some paid substantial fines as penalties for their behavior.[2]

The DOJ also investigated an orthopedic surgery practice in New England because they were turning away patients for orthopedic care who were prescribed buprenorphine. The practice made a settlement agreement with the DOJ to pay $15,000 to each person reporting discrimination, and the practice agreed to implement a non-discriminatory practice. [2]

Even Massachusetts General Hospital was found to have violated the ADA after investigation by the DOJ. They denied a patient a lung transplant because he had opioid use disorder treatment with MOUD, a decision which ended in an agreement for MGM to pay the patient and his family $250,000 for emotional distress and out of pocket expenses. [2]

With these legal precedents, is it legal to bar admission of patients on buprenorphine or methadone to residential treatment facilities, if these patients wish to remain on their MOUD? Is refusal to admit these patients a violation of the ADA?

Let’s assume for the sake of our discussion that these facilities don’t violate the ADA or any other law when they deny admission of patients with opioid use disorder who are on MOUD. Let’s say these facilities have the right to provide only the treatments they think are effective. Does that mean they should get money from the opioid settlement? What if the treatment they provide has poor rates of success, just like the detox-only providers? Is that the way we want to spend money meant to benefit people damaged by the opioid epidemic?

In other words, should there be a measure of effectiveness of treatment before money is granted by each county? Should treatment providers need to show how their program benefits people with opioid use disorder before the county grants money to them? Or can any charlatan with a good patter get dollars from the opioid settlement, if they talk a good game to county commissioners?

MOUD has the most evidence to show it reduces the risk of dying, improves physical and mental health, and other positive measures for patients. Yet I fear agencies and facilities that do not use MOUD will try to claim the opioid settlement money. How do we negotiate this?

I was forwarded a great commentary published in the Raleigh News and Observer recently, and here’s a link: https://edition.pagesuite.com/popovers/dynamic_article_popover.aspx?artguid=f0ca7281-4cf1-4369-b352-fc781dc82465

The authors raise good points. As a society, we need to decide how to move forward to spend this settlement money wisely, and the commentary provides food for thought.

I plan another blog post looking at other aspects of this issue, soon.

1. https://www.ncacc.org/wp-content/uploads/2021/04/Opioid-Litigation-Settlement-Overview-202109.pdf
2. https://www.lac.org/assets/files/Cases-involving-denial-of-access-to-MOUD.pdf

A New Drug on the Scene: Isotonitazene

As if fentanyl and its derivatives weren’t killing enough people, we another opioid to worry about. It’s isotonitazene, sometimes called “Iso” or “Nitazene” for short. it’s related to etonitazene and has similar drug effect profile.

This drug, which is not approved for medical use anywhere in the world, is a synthetic opioid with high potency. It has been identified in drug seizure analyses by the DEA on a regular basis since 2019. In 2020, the DEA issued a temporary order to schedule isotonitazene and its isomers as Schedule I controlled substances, with all the civil and criminal sanctions carried by this designation.

This drug has a high potential for addiction and causes respiratory depression in a dose-related fashion. Some reports suggest this drug may be worse at causing respiratory depression than other opioids, making it more dangerous. Its effects can be reversed by naloxone, though some sources say it might take a higher dose.

Since this drug is sold illicitly, buyers get it through unregulated sources, so the purity varies widely and inconsistently, adding to the danger of this drug.

A recent article by the Washington Post goes into more detail about how the drug and its analogues have been found in the District of Columbia’s drug supply: https://www.washingtonpost.com/local/dc-politics/new-opioids-more-powerful-than-fentanyl-are-discovered-in-dc-amid-deadly-wave-of-overdoses/2021/11/29/680afb2c-4d43-11ec-94ad-bd85017d58dc_story.html

This article says that according to experts, isotonitazene analogues are more potent than fentanyl. Deaths from analogues, mostly protonitazene, have occurred in Tennessee, Texas, New Jersey, and Iowa, among other states. Overdose deaths have also been seen in Europe and British Columbia, Canada.

There have been some reports of overdosed patients presenting to the Emergency Department with respiratory arrest, which is a common mechanism of death with opioids, but also with no heartbeat. With other opioids, respiratory depression or arrest is often accompanied by slow heart rhythm (https://www.forensicmag.com/581896-NPS-Alerts-New-Synthetic-Opioid-and-Unusual-Overdose-Symptoms/ )

This all sounds pretty bad. Several doctors in my state have seen patients who mentioned this drug among the types of opioids they are using, so I plan to start asking patients about it.  I don’t know of any drug test available commercially to detect this drug, further complicating treatment.

Out of curiosity, I Googled the drug and how to buy it, leading to a depressing array of purchase options. One website based in China offers this drug for $450 for 10 grams, or $9000 for a kilogram. Of course, they offer a selection of other controlled substances to consumers. Who knows what would be shipped if anyone bought off this website – if anything at all. And it would be illegal, and subject to schedule 1 drug penalties if discovered, lest any of my readers feel tempted to purchase off the internet.

Some news articles say the drug dealers buy isotonitazene in bulk to add to whatever illicit opioid they are selling, to make it go farther. This practice led to series of deaths in some states.

In the Sept-Oct 2021 issue of the Journal of Addiction Medicine, Shover et al published an article titled, “Emerging Characteristics of Isotonitazene-involved Overdose Deaths: A Case Control Study,” in which they compared characteristics of 40 isotonitazene deaths with overdose deaths from other opioids. They found deaths from isotonitazene more often involved other drugs and were also more often found in combination with a designer benzodiazepine called flualprazolam.

 I suspect some dealer somewhere added this second drug to a bulk supply of isotonitazene, which was then sold on the street. This emphasizes the problem of knowing what a drug bought illicitly actually contains. Potent opioids, when taken with sedatives like benzos, are known to cause overdose deaths in the unsuspecting buyer.

So what do we do about Iso? I plan to ask new patients about their use of it, or if they’ve even heard of it. We need a cheap commercially available test for the drug to get better information about the extent of the problem. And we need to educate and warn patients and providers about the drug’s presence.

And keep giving out lots of naloxone kits.

Merry Christmas and Happy Holidays!

I hope all my readers have great holidays.

Here are some upcoming topics to be covered on my blog:

*The Opioid Settlement: Who Gets the Money?

*A New Opioid on Our Streets: Isotonitazene

“We will not regret, nor wish to shut the door on it…”

I know 12-step recovery isn’t for everyone. Some people tell of bad experiences with 12-step groups. And I know millions of people have been helped by these groups, too. So take what you like from this blog entry, leave the rest, and if you read something helpful, I’ll be happy.

I talk to many people recovering from opioid use disorder who voice regrets about their past. The stories vary; the patients’ main theme is regret for behavior during active addiction. I understand those feelings, and feel tempted to tell patients how to deal with these feelings… but I don’t say anything, for fear that I’ll sound too “preachy.” Who am I to tell someone that they can examine past regrets, learn from previous mistakes, make amends when needed, and face the future with a clean slate? Isn’t that a conversation for a priest, imam, rabbi, or pastor?

Yes, it is. And yet, this person is in my office. Many times my patients tell me they feel unworthy to join or rejoin a religious community, and feel judged by such groups. Some of my patients’ perceptions could be colored by their own shame, but I fear many of them are accurate in their perceptions. Addiction, the old word for opioid use disorder, is still regarded as a sin by some religious groups. Other groups know it isn’t a sin but a disease, which can cause us to do and say things we regret, which are contrary to our values

Twelve step groups like Alcoholics Anonymous and Narcotics Anonymous have mechanisms for dealing with past regrets and ruptured relationships. These groups didn’t invent anything new. They use the same approach as other spiritual and religious groups. This sound psychological advice can be found through other sources, but today I’m writing about how the 12-step programs offer a handy framework for handling regrets.

First, in Step 4, the recovering person assesses past behavior, called a “moral inventory” in recovery parlance.  That inventory is shared with themselves (ending denial), another trusted person, and the god of their understanding. Patterns of behavior emerge, giving information to be used in steps 6 and 7, where the person becomes willing to give up old behavior and ask the god of their understanding for help with this.

In step 8, the recovering person lists the people he has harmed while in active addiction. With the aid of a sponsor or trusted spiritual advisor, in Step 9 the recovering person makes plans for how best to make up for past behavior.

Amends can be as simple as saying, “I’m sorry,” to someone for past bad behavior, or amends can be more extended, like resolving to be fully emotionally present for loved ones. Some amends can be made in a moment and others take a lifetime of changed behavior.

Sometimes direct amends aren’t possible, if the person has moved away, died, or unable to be located. A more general amends can be made instead. For example, if a person shoplifted to support their addiction, it may be impossible to remember where and what was stolen. Part of the amends process is not to repeat the old behavior, but a more general amends may involve volunteering in the same community to help society in some way, like donating to a food bank or giving time to help a child in need.   

If the recovering person feels guilty about stealing money, amends may include apologizing for the past behavior, and making a plan of re-payment. For example, I know a person in recovery for over twenty two years who sends a check for $25 each month to a governmental agency to whom he owned money after a criminal conviction. He may never get the full amount paid off, but he’s taking action to fix what he broke.

Substance use disorders taught harsh lessons that came at exorbitant prices, so we should try to learn from past mistakes. Recovering people can move forward by planning amends for past actions, but also should consult a sponsor or spiritual guide for help. For example, if a person in recovery from opioid use disorder stole money from a drug dealer, it should not be paid back, especially if it puts the recovering person at risk. In some situations, the best amends may mean having no contact with the other person.

Some recovering people have long lists of bad behavior to make amends for, and other recovering peoples’ lists may contain only a few family members. Many people harmed only their immediate family, by not being completely emotionally available to their spouses or children during their addiction. Some recovering people feel just as bad about that as others feel about committing armed robbery for drug money.

The point of amends isn’t how bad the behavior was, but how the recovering person feels, and how he can leave behind guilt and shame and move forward.

Substance use disorders, like some other diseases, affects behavior. Rather than living with regrets, recovery means facing regrets, learning from them, fixing what we can, and then moving on. It doesn’t matter what you call it: making amends, cleaning your side of the street, getting right with the god of your understanding, or some other term.

Hot News

On November 18, 2021, SAMHSA (Substance Abuse and Mental Health Services Administration) posted an announcement (https://www.samhsa.gov/medication-assisted-treatment/statutes-regulations-guidelines/methadone-guidance )  regarding methadone take home doses. In brief, they said that SAMHSA is granting exceptions to opioid treatment programs (OTPs) for more extended take home dosing for up to a year after the COVID 19 Public Health Emergency is lifted.

Some restrictions do apply, but “stable” patients will be able to get up to 28 days of take home medication even after the COVID exceptions end, and “less stable” patients can get up to 14 days of take homes.

There are some limits, though. It’s up to each state opioid treatment authority (SOTA) to send a written concurrence to SAMHSA’s Division of Pharmacological Therapies. That is to say, if the state SOTA wants to be able to participate with this offer of extended methadone take homes, they must contact SAMHSA’s Department of Pharmacologic Therapies in writing to let them know.

So why would a SOTA want these advanced take homes? During COVID when take home restrictions were relaxed, fears of widespread deaths from methadone take homes and diversion of methadone didn’t occur. For the most part, extended take home doses appear to have improved patient satisfaction with treatment and increased treatment engagement. Overall, SAMHSA says there’s sufficient evidence to show the COVID exceptions have enhanced services and encouraged people to get and remain in treatment.  SAMHSA wants to allow patients this same freedom after COVID emergency exceptions end.

SAMHSA has identified certain conditions that must be met to identify a patient as “stable” or “less stable.”

Stable patients, who can receive up to 28 days of take-home medications, must have “total adherence” with their treatment plan for at lease 60 days, and have negative toxicology tests for at least 60 days. Their medical record must reflect the opinion of medical staff that the benefits of extra take homes outweigh the risks. There must be no serious behavioral problems and no recent diversion activity. Patients must be able to store medication safely. If patients don’t meet all these criteria, they cannot be deemed as stable.

Less stable patients, who can receive up to two weeks of take- home medications, are defined by SAMHSA as patients with partial adherence to their treatment plans for at least 30 days, and at least 30 days of negative toxicology tests. They must have no recent diversion activity and must be able to store their medication safely. Their medical record must reflect the opinion that the benefits of take-home doses outweighs the risks.

Patients who don’t meet either of these sets of criteria are not eligible for these relaxed take home exceptions.

This proposed exception will be in effect for a year after the COVID exceptions end.

SAMHSA’s announcement takes pains to explain that the decision to give extra take homes under this exception is subject to the clinical judgment of the provider, meaning the physician or physician extenders. SAMHSA expects providers to document their decision-making process and clinical discussions about extra take homes. The provider needs to balance the best interest of the patient with public safety when making decisions and do what will best support the individual patient in his recovery.

What do I think of this new extension of take-home doses? I’m all for it. It will allow us to continue to customize care to the needs of the patient. In the past, regulations dictating when patients could get advanced take homes felt rigid, and this was frustrating to very stable patients and their treatment staff.

There’s nothing in this document that prevents providers from limiting take homes if a patient isn’t doing well, or if a patient on advanced take homes hits a rough spot on the road to recovery, so providers can still adjust take home schedules if things don’t go as well as hoped.

However, I’m concerned about programs with providers who may not know their patients very well. Some OTPs hire providers who appear once per week, mostly to do new intakes. That’s not enough to get to know patients well, especially at larger program. Provider decisions may be shaky.

But overall I’m happy federal authorities are re-imagining how treatment at opioid treatment programs should be delivered.

Recovery Means…

It’s nearly Thanksgiving, so of course I’ve been thinking about gratitude. Recovery is one of the biggest things I feel grateful for, so I thought I’d share again some of the specific features of recovery that I’m most grateful for.

Recovery means…

….taking the worst and most embarrassing thing in my life and turning it into my greatest asset.

….becoming less judgmental of other people.

….remaining teachable.

….having more free time, after the burden of looking for the “next one” has been lifted.

…looking in the mirror, and feeling content at what I see.

….being satisfied with the small pleasures in life.

….developing a thicker skin for judgmental or chronically angry people. They aren’t going to ruin my day.

….re-connecting with the human race.

….re-connecting with the God of my understanding.

…reconnecting with myself.

….doing what I need to do for my well-being, even if other people don’t approve.

….being happy when I make progress, no longer expecting perfection.

….understanding it’s more important what I think of me than what other people think of me.

….talking frequently with other people who share my passion for recovery.

Recovery goes beyond 12-step programs or medication-assisted treatment. Recovery can apply to issues other than drug addiction. It can apply to eating disorders, co-dependency, gambling problems, sex addiction, or any other compulsive activity that is bad for our health. We can be in good recovery in one area of our life and be in active addiction in other areas. We have good and bad days. We relapse, and we try again, and we stop listening to the voice of addiction that tells us we should give up because we will always fail. We learn from our failures and come to look at them as opportunities for growth. We turn stumbling blocks into stepping stones. We lift up our fellow travelers when they weaken and they do the same for us.

We do recover. And for that, I am grateful.

Something Old: Tianeptine

I first blogged about this drug in 2016, when I first heard about it. Recently some addiction medicine physicians were talking about it again. These physicians, who treat opioid use disorder, occasionally encounter patients who buy tianeptine at gas stations, head shops, and online. These patients are seeking an alternative to traditional opioids, and the tianeptine is advertised as being useful for a variety of effects.

Internet ads say it treats anxiety and depression, ADHD, and seizures, among other things. The ads boast that this drug can “reduce stress-induced atrophy of neuronal dendrites.” Other ads offer to sell it but say it is “not for human consumption,” with a wink and a nod, to protect sellers.

It’s an interesting medication, but not available in the U.S., Canada, or the United Kingdom. It is sold in Europe under the brand names Coaxil and Stablon. It’s used to treat depression, though some sources say it is more toxic to the liver than other antidepressants. Though structurally similar to tricyclic antidepressants, it exerts its action in a different way, via glutamate receptors. Other antidepressants are thought to work because they increase serotonin and norepinephrine levels, so tianeptine is novel in this sense.

Scientists know depression causes structural and functional changes in the brain, and some articles about tianeptine say this medication can reverse some of the stress-induced changes seen in depressed brains. We don’t fully understand all aspects of neurotransmitters and mood, and this medication shows us that serotonin and norepinephrine are not the only determiners of mood. [1, 2]

But what about this medication’s addictive potential? Why would people take it compulsively?

According to internet forums, people described a euphoria similar to opioids, though the described dose was usually far in excess of the recommended 12.5mg three times daily. One person took 500mg and described euphoria. Other people mixed it with other drugs, so it’s hard to know what effect the tianeptine had. Other people described a difficult withdrawal from tianeptine.

Kesa et. al., 2007, says tianeptine has some stimulating activity at the mu opioid receptors, thought it has a low affinity for those receptors. Apparently it takes high doses to produce euphoria, moderated through those opioid receptors.

In the Annals of Internal Medicine, 2003, Leterme et al describe five cases of tianeptine abuse. Withdrawal was said to be difficult, due mostly to anxiety.

From the collective experiences I read, it seems tianeptine is a weak opioid agonist, but at high doses gives an opioid effect. It sounds like people describe a typical opioid addiction after using these high doses daily for more than a few weeks. They described classic signs and symptoms of opioid withdrawal. At least one case report described neonatal abstinence syndrome in a baby born to a woman who regularly used tianeptine.

Most people taking tianeptine use other drugs, including opioids. It’s rare that people use only tianeptine.

Tianeptine is being sold as a dietary supplement in places like gas stations, so it’s easily available. is sometimes called, “Za-Za” or “Tianna Red,” and packaging says it promotes attention and energy.  These dietary supplements don’t require any FDA approval or any inspections by state or federal agencies, so there’s no quality control. Potency and purity could vary considerably between lots from the same manufacturer. Or the product may not contain any tianeptine.

Earlier this year, Alabama was the second state to make the substance illegal to sell at convenience stores, by making it a Schedule II controlled substance.

Should this drug be illegal in all states?

I think so, given the potential for physical dependency, which has been described in case reports. There have also been reports of tianeptine overdoses, though it’s often mixed with other drugs, making it hard to tell how much tianeptine contributed to the overdose. Tianeptine can be reversed with naloxone,

1. Kasper et. al., “Neurobiological and clinical effects of the antidepressant tianeptine,” CNS Drugs, 2008;22(1);15-26.
2. McEwen et. al., “The neurobiological properties of Tianeptine (Stablon): From hypothesis to glutamatergic modulation,” Molecular Psychiatry 2010 March;15(3): 237-249.

Advocating for Patient Care with Opioid Treatment Program Administrators

The Addiction Medicine Conference was excellent. I stayed glued to my computer screen for all of Friday and Saturday, and it was worth it. There wasn’t one weak presentation; all were great. The national speakers were as good as expected, but our statewide speakers were excellent as well. We are fortunate to have talented Addiction Medicine providers in our state.

One of my little parts of the conference was on the topic of how to advocate for patient safety with OTP administrators. I thought it went OK, but it was a little depressing. I’m not the only provider who struggles with advocating for change without getting fired.

One doctor described how administrators, upset with a judgment call he had made on a patient, confronted him about his decision. This never feels good, and naturally produces feelings of anger in the physician. We are very likely to think, “Who are you to question my medical decisions? Have you gone to medical school? To residency? To repeated trainings? Have you passed a board exam in Addiction Medicine?” And yet, medical providers are often questioned by administrators, who in some cases may have only a high school education.

I do much better in my relationships with corporate personnel when I remember their job is not my job. We share some common goals, and don’t share others. It does no good to vilify them as bean counters or money crunchers because those counters and crunchers keep the business afloat and sign my paychecks. They make it possible for a facility to be open to serve our patients. Even so, healthcare providers must be able to provide quality medical care.

I wrote down some of my thoughts before the session and worked most of them into the conversation.

Here are a few of my points, in expanded forms:

Don’t take conflict personally.

OPTs are in the business of making money. Some are owned by venture capitalists, so their focus will be on profit. If the physician is perceived as impeding this goal, conflict will naturally occur. We can argue about whether this is right or wrong, but in the U.S., healthcare is a business.  Healthcare is not considered to be a right, but a privilege. If you don’t like it…vote.

It’s not only OTPs who are profit -focused. Hospitals, for-profit and non-profit alike, want to make money. The physician practices they own are scrutinized by administrators. My point is that these days, few medical practices are owned only by doctors or other medical providers, so the push-and-pull between administrators and care providers happens in all types of settings, not only OTPs.

When advocating for change, back it up with data. We have many published guidelines and best practice documents. We have SAMHSA’s TIP 63, and the ASAM practice guidelines. When administrators are shown how practices at their particular OTP are outside accepted standards, it should sway the decisions of these professionals. If an aspect of treatment is addressed in written guidelines, it’s harder to dismiss than one doctor’s opinion.

Also, since OTP administrator often aren’t science people, follow up your discussion of standards with real-life narratives. Give an example of a patient who had difficulties because of present policies, and how that could be improved. Some administrators respond much more to concrete examples that have real consequences.

Be cheerful and friendly with OTP administrators. It costs nothing and can smooth a lot of friction. It’s a bonus when you really like the administrator, but even if you don’t, keep it to yourself. You catch more flies with honey…and other things.

Do not use sarcasm, no matter how loudly a situation screams for it. Your humor will not be appreciated, and you will make people angry.

I’ll give you a real-life example that I regret:

At one of the first opioid treatment programs I worked for, the president of the company wanted doctors to order liquid valium to be added to methadone in patients who struggled with co-occurring benzodiazepine use disorder. He thought we could gradually lower the Valium dose and achieve benzo taper, allowing patients to remain at their usual dose of methadone.

What I should have said was: “There are no studies to show safety or efficacy of this idea, and dosing both at the same time might increase the risk of overdose death, since blood levels of both would be peaking at the same time. Plus there’s no assurance these patients wouldn’t continue to use the same illicit benzodiazepines that they’re already taking. Also, we couldn’t let those patients drive themselves home, as their driving would be impaired from Valium.”

What I actually said was: “Sure, boss. And let’s mix that in some Jack Daniels and give them a fat one to burn on the way home.”

My humor was not appreciated.

Be cheerful and friendly with patients and other staff, too. If you don’t feel that way – fake it. Our patients have enough to deal with and don’t need to contend with a provider in a foul mood. If you need help with a personal problem, get it. Don’t bring it to work with you.

This should go without saying, but because I’m guilty of it, I’m mentioning it: don’t grumble.

Don’t talk about administrators disparagingly. They may be terrible people, focused only on how large their bonus will be this quarter, giving little thought to the welfare of patients or staff. Even so, don’t grumble about it, because this is how workplaces get poisoned. Grumbling contributes to a general milieu of discontent and that doesn’t help anyone. Don’t be part of it. If you get so miserable that you can’t bear it, dust off your curriculum vitae and go somewhere else.

Know where your work boundaries are. If your care of patients is impeded by the decisions of non-medical administrators, you may need to look for another job. Now, with so many new employment options for Addiction Medicine providers, this is much easier than it was twenty years ago.

I opened my first solo addiction medicine practice over eleven years ago, and I’m glad I did. It provided some financial security while I navigated the sometimes-choppy waters of OTP employment.

Right now, I work in my own office only one morning per week because I work at the OTP the other days. I sublet my office to help pay for rent, and that works well. I feel less financial insecurity because I know if I had more time (read if I get fired), I could easily ramp up my buprenorphine practice.

Ten years ago, when I interviewed for the job of medical director at the place I work now, I told the administrator doing the interview that I had just quit an OTP where my medical judgment was undercut. I told him, forcefully, that I had no desire to return to a similar predicament and if that was going to be an issue, let’s not go any further with the interview. He indicated that the program would not interfere in any way with my decisions, and he kept that promise.

That program has changed hands several times and he no longer works there, but so far, I still feel I can deliver quality care. It’s not perfect, but there haven’t been any deal-breakers in the past ten years. This is a record for me.

Part of the reason I’ve stayed employed at one facility is personal growth. Over the years, I’ve gotten better at asking myself, “How important is it?” If it won’t adversely affect patient care, I want to remain amiable to change, even if I perceive the change to be silly or ineffective.

In summary, I approach patient advocacy with program administrators with the spirit of the Serenity Prayer. I try to accept the things at the opioid treatment program that don’t matter in the long run, and try to change things that could adversely affect patients. And I constantly pray for the wisdom to know the difference.

Addiction Medicine Conference

I usually blog about our North Carolina Addiction Medicine conferences after they take place, but today I wanted to do a little advance advertising, in case any addiction medicine professionals haven’t heard about the conference.

Our fall conference is this week, October 22 and 23, 2021, and you can read more about it here: https://addiction-medicine.org/fall-conference/The conference has some great speakers line up. On the first day we’re scheduled to hear updates on COVID 19, on state overdose data, and on both state and federal policies. Then Dr. Keith Humphreys, renowned author, will speak about the implications of the changing cannabis policies in the U.S. I’m particularly looking forward to hearing him because I’ve read his chapters in the ASAM Textbook of Addiction Medicine, among other things. He is a prolific writer in the field, with thoughtful insights.

Later in the day we have an assortment of workshops to chose from with everything from Addiction Medicine 101, for the basics, to harm reduction strategies. Then later in the afternoon Dr. Ed Salsitz is scheduled to talk about the fentanyl crisis.

Dr. Salsitz is a big part of why I decided to work in the field of opioid use disorder treatment. I first heard him speak at an ASAM conference just after I started working at an opioid treatment program for the first time. I was deeply conflicted about my work, coming from an abstinence-only, 12-step based background. Several people in my recovery meetings strongly criticized me because of my work. When I listened to Dr. Salsitz describe the evidence supporting the use of medication to treat opioid use disorder, I saw reason to feel good about working in this field. I appreciated his lectures against the stigma attached to both the disease and the treatment of opioid use disorder. I eventually decided it mattered more to me what the science showed than what people, with no real medical information, thought about me and my work. Thank you, Dr. Salsitz.

Then the second day, we have plenaries from several outstanding physicians: Dr. Ashwin Patkar will speak about abstinence versus moderation, and Dr. Steven Prakken will talk about psychiatric comorbidity in substance use disorders. Later, we will hear about reasonable screening for co-occurring physical comorbidity from Dr. Shuchin Shukla.

Then we have more workshops to pick from. I’m always conflicted about which one to attend, but I’m hoping since this is a virtual event, the sessions will be recorded so that I can listen later to all of them.

After that, one of the afternoon plenary sessions is about contingency management in the treatment of stimulant use disorder, presented by Dr. Dominick DePhilippis. I’m eager to hear this talk, because as I indicated in a recent blog, we have had many patients in treatment for their opioid use disorder who also have stimulant use disorder. I need some ideas to implement for treatment, and I know contingency management is one of the most heavily evidence-based treatments for this.

Then at the end of the day is a crowd favorite: “What’s New and Trending,” presented by Dr. Thomas Penders. He will talk about kratom, CBD, delta 8 and other things.

At each conference, we have special closed sessions for North Carolina medical providers who work at opioid treatment programs. This year, I was excited to see one of our topics was, “Advocating for patient care within an OTP corporate structure.”

This is great, I thought. Finally, maybe someone can tell me how to do this. I’ve struggled with the problem the twenty years I’ve worked at opioid treatment programs.

Then I was asked to be on the speaking panel for this topic. I felt a little panicky because what do I know? But as I’ve been contemplating the topic, I do have some experience to share, though sometimes it is what not to do.

I’ll let you know how it goes.

It’s not too late to register for this virtual conference, and you can get credit hours too.

Here’s the link again if you are interested: https://addiction-medicine.org/fall-conference/ There’s a physician and a non-physician link at that site.