Happy Anniversary to Me

 

 

 

 

 

 

This blog entry is about random thoughts careening through my brain today.

Last week marked the eight-year anniversary of this blog. I started it in 2010, to promote a book I had written. The book did OK, but it’s out of date now. Things happen rapidly in the field of opioid use disorder treatment.

My blog has turned into a bigger thing than I ever planned. I enjoyed writing it more than I thought I would, and people were more receptive to the type of information I presented than I imagined they would be. People tell me my blog filled a void by providing information about medication-assisted treatment of opioid use disorder.

I’m glad. This makes me happy.

While there are other blogs about Suboxone, most are oriented towards patient problems and questions. I hope my blog entries help patients and their families gather more information, but I also want to edify treatment professionals, including other physicians, nurses, therapists, and counselors. To be able to do this, I must keep reading the latest information and going to conferences in the field of Addiction Medicine. Since this field is my passion, that’s been no sacrifice to make; plus, it keeps me up to date for my own patients.

But the writing can be vexing. Sometimes writing flows like lava down the side of a volcano, but sometimes I write a sentence three times before I’m happy with it. This has improved with more consistent writing, but there are days that I still sumo-wrestle with sentences.

Terms we use in this field have changed over eight years. If I want to re-blog something from more than six years ago, I need to read it carefully before posting again. I’ve missed a few “opioid addiction” phrases and readers have pointed out my error with some enthusiasm. Fair enough. Language is important. The proper term now is “opioid use disorder,” and patients are not “addicts.” They are people with opioid use disorder.

Some blog entries are informational and don’t change, so I recycle them: how to treat insomnia without medications, how clonidine works, and the like. Other blog entries are out of date within in year, like statistics on opioid use disorders and overdose deaths, and state laws around opioid and buprenorphine prescribing.

Buprenorphine’s reputation has changed. In 2010, many fewer people knew what this drug was. Now we have internet memes about Suboxone, and plenty of websites with data and opinion. We’ve had some excellent news pieces about the medication buprenorphine, and some websites set up only to tell the world how awful buprenorphine is. Everyone has an opinion, it seems.

Diversion of buprenorphine products has become a frequent topic, fueled by the perception that much of this medication is making its way to the black market.

My own opinion about medications for opioid use disorder and how treatment should be organized have changed. I’ve become more avid about harm reduction, but more conservative about where patients start treatment. I’ve also come to believe most new patients with opioid use disorders should be started on medication at opioid treatment programs, then referred to office-based programs once they stabilize, like the Vermont hub-and-spoke model. I realize those two views aren’t consistent.

We have too many lawmakers trying to legislate the care provided at treatment programs, but I understand why they feel it’s necessary. Some treatment programs cry “harm reduction” as an excuse for sloppy patient care while making large profits. Medicine in the U.S. is a for-profit enterprise, and no doctor should be blamed for making a profit; however, there’s profit and then there’s obscene profit.

I’ve met some of the best, brightest, and most dedicated people in the world in this field of medicine. I’ve also met some real con artists and shady characters in this field, working only for personal prestige and money. It seems to draw people from both extremes, and I try to maximize my contact with the former and minimize my contact with the latter.

I’ve developed a thicker skin writing the blog. I don’t post the worst of the comments, like the woman who commented that I would burn in hell for prescribing medication for opioid use disorder. She’s entitled to her opinion, but it’s my blog and I don’t have to air her view, particularly since it seemed spew-y and irrational.

I don’t post comments insulting to people with opioid use disorder, unless it’s to educate readers about how much misinformation still exists in the world.

Patients sometimes write negative comments about their care providers, and I usually encourage them to talk to their physician. If they don’t get satisfaction with that, I tell them to vote with their feet and go elsewhere. The trouble is, there may be only one provider in their area. What does the patient do then?

We do need more primary care physicians prescribing buprenorphine, but they must be respectful of the patients they treat. If as a physician you can’t understand that some behavioral issues are associated with opioid use disorders, you shouldn’t be working in the field.

The nation must educate physicians in all fields about medication-assisted treatment for opioid use disorder. Treatment for opioid use disorder has for too long been in its own silo, far away from mainstream medicine. Most physicians don’t know anything about MAT, except that they are opposed to it. These physicians MUST be educated. Our patients must be able to get good medical care without judgment.

Negative comments from other physicians about MAT undermine our patient’s progress and their self-esteem. It also prevents my patients from getting good medical care from primary care providers, surgeons, and especially emergency department physicians.

Physicians must start referring people with the illness of substance use disorder for treatment, rather than telling these patients they are bad people because they haven’t stopped yet. They must be taught to give my patients the same understanding and forbearance as patients with other chronic medical illnesses with behavioral components.

I’m happy with all the attention that new outlets have been paying to opioid use disorder and its treatment over the past several years. I also wish this attention could have been started around fifteen years ago, before thousands died from this problem.

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Opioids and Gabapentin: A Potentially Dangerous Mixture

 

A Canadian study, published late last year, showed co-prescribing of gabapentin and opioids was associated with significantly increased risk of opioid-related death.

I’ve had a few of my patients on methadone or buprenorphine misuse gabapentin, and even had one patient end up in the emergency room with an overdose from a mixture of buprenorphine and gabapentin, but I thought it was because the patient took way too many of the gabapentin. In the past I’ve thought of gabapentin as a “junior” substance of abuse. I thought most people with opioid use disorder wouldn’t deign to be interested in such a low-powered drug. I thought it might fall in the category with trazadone, Seroquel, or Benadryl…something young people might experiment with, but not what people with established opioid use would want to mess with.

After reading this study, I’ve changed my mind. Gabapentin with opioids is associated with increased risk of death. This is serious.

The Canadian study by Gomes et al., says gabapentin is often prescribed for pain, and obviously opioids are as well, resulting in many patients who are prescribed both. The purpose of the study was to discover if co-prescribing gabapentin and opioids resulted in higher risk of death from accidental opioid-related reasons.

Before describing the study, let’s talk more about this medication, gabapentin, sometimes marketed and sold under the brand name Neurontin.

Gabapentin is a medication that is structurally similar to the neurotransmitter GABA, but gabapentin has no activity at the GABA receptor. Gabapentin appears to attach to calcium channels, but we don’t know the exact mechanism of action of its anti-seizure and anti-analgesic effects.

This medication isn’t changed into other compounds, meaning gabapentin is the active drug. It’s metabolized by the kidneys, and so the dose must be adjusted in patients with kidney failure.

This drug is odd because its bioavailability goes down as the dose goes up, which means that as the dose goes up, the amount available in the blood stream goes up too, but not by as much as one would expect, due to the decrease in bioavailability.

Its half-life is around 6 hours, and so it is dosed three times per day. It can be removed by hemodialysis.

Gabapentin can cause sedation and suppression of respiratory rate, both by itself and when combined with prescription opioids. In fact, the product’s monograph was changed in 2014 to emphasize the risk of suppression of respiratory rate when combined with opioids. This may be more important in patients with COPD, renal insufficiency, and older age.

Gabapentin can also cause dizziness, fatigue, and swelling of the lower legs. It is not categorized as a controlled substance because studies didn’t show it to be prone to misuse or addiction. In fact, it has been studied for use in alcohol and marijuana use disorders, with some evidence of benefit.

Gabapentin is prescribed for an assortment of reasons, and not all are FDA approved. Gabapentin is approved for the adjuvant treatment of partial seizures in kids and adults, which means it can be used as an add-on to main seizure treatment medications. It is also indicated for the treatment of pain after a bout of shingles, called post-herpetic neuralgia.

That’s it. There’s no FDA approval for the many other conditions for which it’s commonly prescribed, like fibromyalgia, anxiety, hot flashes of menopause, pain of diabetic neuropathy, or alcohol withdrawal symptoms, though there are studies that support its use for some of these conditions. There’s evidence gabapentin may help with restless legs syndrome and itching from kidney failure.

Use of gabapentin for other than FDA approved uses isn’t unusual and it isn’t necessarily bad medical practice. Many medications are used “off-label” which means they are used for purposes for which they don’t have FDA approval.

A newer version of gabapentin, called pregabalin, is marketed under the brand name Lyrica, and it is classified as a controlled substance because of its potential for addiction and misuse. It has FDA indication for treatment of neuropathic pain, post-herpetic neuralgia (pain from previous shingles outbreak), epilepsy, fibromyalgia, and diabetic peripheral neuropathy pain.

The article I’m describing today did not look at any data relating to pregabalin.

The study was a nested case-control study, which means each opioid user who died of opioid-related causes was matched with four control subjects, with age, sex, start date of opioids, and presence or absence of chronic kidney disease being similar for each index case and the controls.

This was a big study, with 1256 index cases and 4619 controls.

An analysis was conducted to see how many of the index cases, patients who died of opioid-related reasons, were also prescribed gabapentin within 120 days of the index date. The dose of gabapentin was further categorized as high, medium, or low dose.

The results showed that 12.3% of the people who died of opioid-related causes were prescribed gabapentin within 120days preceding death. Of the age and sex matched control patients who did not die, only 6.8% were prescribed gabapentin within 120 days.

This means that patients on opioids who were co-prescribed gabapentin had odds of an opioid-related death 49% higher than patients on opioids who were not prescribed gabapentin.

The authors also found a significantly increased risk with higher dose gabapentin than low or moderate dose.

The authors of the study used the same method looking at anti-inflammatory medication prescriptions, to see if those medications increased risk of opioid-related death, and found no difference in use of anti-inflammatories in patients who died compared to controls who did not die.

It’s important to note that patients with opioid use disorder who were being prescribed methadone were not included in this study. Patients with cancer diagnoses and who were in palliative care were also not included. The authors didn’t explicitly say why these patients were excluded, but patients in these groups may not represent general patient populations. Patients with cancer, getting end-of-life care, are likely to be prescribed much higher doses of opioids, due to a shifting of the focus of their care. At the end of life, comfort is of more importance that functioning.

As for patients on methadone, perhaps the authors thought patients with substance use disorders would be more likely to misuse their prescribed gabapentin. Maybe the authors thought including such patients would skew the data, and gabapentin would appear to be more dangerous than it is. This study was not done on people with substance use disorders; it was done on the general population.

This is a powerful study because it was so large, and it spanned sixteen years. Canada has a population similar to that of the U.S., so I think it’s safe to assume their data should be valid for patients in the U.S.

What does this mean for me and my patients? I don’t treat pain, I only treat opioid use disorders. But are my patients, for whom I prescribe buprenorphine and methadone, at increased danger if they are co-prescribed gabapentin by another doctor? Yes, by my interpretation of this data, they are at increased risk. For sure, if they take more gabapentin than prescribed, they are increased risk for death, but this study shows that even when taken as prescribed, this medication is associated with increased risk of death.

Association doesn’t always mean causation, but given what we know about how these medications who, a causal relationship is strongly suggested.

In the past, I had more of a “pick your battles” attitude. I was happy if my patients stopped drinking alcohol or using benzodiazepines. For the latter, we have good studies (for example, Park et al., 2015, BMJ, “Benzodiazepine prescribing patterns and deaths from drug overdose among US veterans receiving opioid analgesics”) that have shown a four-fold increase in the risk of overdose death when benzodiazepines are co-prescribed with opioids. Now I will add gabapentin and pregabalin to my list of medications that can harm my patients.

It’s tempting to issue a blanket policy against gabapentin. Blanket policies make life easier for the opioid treatment program, but such policies treat every patient the same.

For this issue, I think the best course is to talk to each patient, evaluate each patient, and ask them how much benefit they receive from gabapentin. I will advise them of the increased risks of this medication, and we will decide whether it’s best to stop or continue the gabapentin. Some patients may decide the benefit it worth the risk. Other patients may decide it’s better to stop taking gabapentin. Either way, I’ll document this in their charts, and re-visit the issue regularly.

I am grateful, as always, to the website sponsored by the North Carolina Governor’s Institute: http://addictionmedicineupdates.org/ for bringing this article to my attention. The tireless people at the GI support excellence in substance use treatment around the state.

1. https://doi.org/10.1371.journal.pmed.1002396

 

Driving on Methadone

 

 

 

 

“How can you let those people get behind the wheel and drive after you shoot ‘em up with methadone?”

This question, frequently asked by law enforcement and other people, reveals key misunderstandings about the pharmacology of methadone. That’s OK; I don’t expect laypeople to know methadone pharmacologic principles. Oh, and we don’t “shoot them up.” We give them controlled oral doses of methadone measured to the nearest milligram of liquid, and observe our patients consume this medication on site.

While laypeople may not have a reason to understand medication-assisted treatment, I think it’s essential for law enforcement officers to understand. They need to know why our patients are not impaired when they leave our parking lots after dosing.

When patients on methadone (or buprenorphine) are dosing every day, they have a tolerance to the drowsiness that opioids cause opioid-naïve people. Our patients, assuming they have reached a stable dose and aren’t using any other drugs, have blood levels of medication that don’t fluctuate much through the day. Because methadone is such a long-acting medication, the blood level doesn’t even reach its peak until around three hours after dosing.

Because of the frequent misunderstandings and assumptions of law enforcement personnel, I’ve composed a sample letter that opioid treatment programs may forward to the law enforcement officer of their choice.

Dear Officer Zealous:

First of all, thank you for patrolling our streets and highways and for your efforts to keep them safe. I know you have a difficult job and I deeply appreciate your willingness to take on this responsibility.

However, please stop arresting my patients for whom I’ve prescribed methadone and buprenorphine (better known under the brand names Suboxone, Subutex, or Zubsolv). You mistakenly think all people taking these medications have no right to be driving, and you are wrong. I’m writing this letter to give you better information, so you can do your job more efficiently.

Our nation is in the middle of a crisis. Opioid use disorder is an epidemic, and too often its sufferers die of overdoses. Medication-assisted treatment with methadone and buprenorphine works very well to prevent overdose deaths, and it’s been proven to help patients have a betterquality of life in recovery.

I doubt you’ve been provided any information about medication-assisted treatment, so I want to offer data to you.

Methadone has been around for fifty years and has a proven track record. It’s been studied more than perhaps any other medication, and we know it does a great job of treating opioid use disorder. Buprenorphine has only been available in the U.S. for about 17 years, but has been used in Europe for decades with success.

With both methadone and buprenorphine, the proper dose of medication should make the patients feel normal. Patients should not feel intoxicated or high, and should not feel withdrawal symptoms as the day wears on. Methadone and buprenorphine are both very long-acting opioids, and can be dosed once per day. They both can provide our patients with a relatively steady level of medication, compared to short-acting opioids usually used for intoxication. Therefore, using methadone to treat opioid addiction is not “like giving whiskey to an alcoholic,” as has incorrectly been asserted. The valid difference lies in the unique pharmacology of methadone. Opioid addicts can lead normal lives on this medication, when it is properly dosed.

In addition, both of these medications block other opioids at the opioid receptor. When a patient is on an adequate dose of methadone or buprenorphine, if she relapses and uses an illicit opioid, the medication blocks the effects of the illicit opioid. The patient feels no euphoria, which reduces the urge to use illicit opioids in the future. Both methadone and buprenorphine work in this way to deter use of other opioids for the purpose of getting high.

Treatment of opioid addiction with methadone and buprenorphine is endorsed by the CSAT (Center for Substance Abuse Treatment) branch of SAMHSA, by the U.S.’s Institute of Medicine, by ASAM (American Society of Addiction Medicine), by AAAP (American Association of Addiction Psychiatry), and by NIDA (National Institute of Drug Addiction. In study after study, methadone has been shown to reduce the risk of overdose death, reduce days spent in criminal activities, reduce transmission rates of HIV, reduce the use of illicit opioids, reduce the use of other illicit drugs, produce higher rates of employment, reduce commercial sex work, and reduce needle sharing. Medication-assisted therapy is also high cost effective.

Indeed, the current debate of government officials at the highest levels has been how best to expand medication-assisted treatment with methadone and buprenorphine, not to make it less available. So please don’t do anything which may discourage opioid addicts from receiving life-saving treatment.

Over the years, many studies have been done on methadone and buprenorphine to see if patients are able to drive safely on either of them. In study after study, data show patients on stable doses of both medications can safely drive cars, operate heavy equipment, and perform complex tasks. Please see the list of references at the bottom of this letter if you wish to investigate for yourself.

I’m not saying, however, that patients on methadone or buprenorphine can’t become impaired. Impairment can occur if patients are given too high a dose of methadone or buprenorphine, which most often occurs during the first two weeks of treatment. For that reason, patients are warned not to drive if they ever feel sedated or drowsy.

Patients on medication-assisted treatment can also become impaired if they mix other drugs or medications with their methadone or buprenorphine. In fact, benzodiazepines (like Xanax, Valium, Klonopin) and alcohol act synergistically with maintenance opioids. They can cause impairment with smaller amounts of alcohol or benzos than expected. And of course, patients can still become impaired with other drugs, such as marijuana.

As you probably know, a urine drug screen won’t detect impairment. The urine screen only tells you if a person has taken a given drug or medication over the last few days to weeks. Drugs are detectable in the urine long after the impairing effect wears off.

You can do blood tests, but these aren’t useful for patients on methadone. The dose required to stabilize one of my patients would impair or even kill a person who’s never taken opioids, so the meaning of the blood level depends on the patient’s experience and history.

My family and I drive these roads too, and I don’t want impaired drivers on our highways any more than anyone else. However, due to your desire to do a good job, you have mistakenly targeted patients on medication-assisted treatment for the disease of opioid addiction.

I know you have formed bad opinions about methadone and buprenorphine patients from seeing both drugs misused on the street. I hate that, because you probably rarely get to see our more typical patients on medication-assisted treatments.

The vast majority of my patients have jobs, families, and responsibilities that they meet, despite having this potentially fatal illness of opioid addiction. If you are fortunate enough to encounter one of my patients on a random traffic stop, please don’t give them a hard time. Please congratulate them on having the courage to find recovery from addiction, and tell them to do what works for them. In some patients, that means medication-assisted treatment.

Thanks for reading this long letter and thanks for all you do in the name of keeping our roads safe. If you want to know more about how we treat opioid use disorder at our facility, please call our program manager at xxx-xxx-xxxx and we would be happy to provide you with an after- hours tour and lots of information.

Sincerely,

Dr. XYZ

Medical Director, OTP

 

P.S. And please don’t attempt to intimidate patients from coming to get help for this fatal illness of opioid use disorder by parking your squad car just outside our facility’s entrance. Some of these patients may have old warrants, but by stalking them where they come for help, you discourage people who want to escape addiction and want to better their lives. If you do park near us, you should expect a staff member to approach you with a smile, a cup of coffee, and a pile of information about opioid addiction and its treatment.

ATTACHMENT:

Methadone and Driving Article Abstracts

Brief Literature Review

Institute for Metropolitan Affairs

Roosevelt University 2/14/08

1. DRIVING RECORD OF METHADONE MAINTENANCE PATIENTS IN NEW YORK STATE

BABST, D., NEWMAN, S., & State, N. (1973). DRIVING RECORD OF METHADONE MAINTENANCE PATIENTS IN NEW YORK STATE. DRIVING RECORD OF METHADONE MAINTENANCE PATIENTS IN NEW YORK STATE,

When a comparison was made within specific age groups, it was learned that the accident and conviction rates were about the same for methadone maintenance clients as for a sample of New York City male drivers within the same period. The findings from other related studies discussed in this booklet are consistent with the results in this study.

2. The effects of the opioid pharmacotherapies methadone, LAAM and buprenorphine, alone and in combination with alcohol, on simulated driving.

Lenné, M., Dietze, P., Rumbold, G., Redman, J., & Triggs, T. (2003, December). Drug & Alcohol Dependence, 72(3), 271.

These findings suggest that typical community standards around driving safety should be applied to clients stabilized in methadone, LAAM and buprenorphine treatment.

3. Maintenance Therapy with Synthetic Opioids and Driving Aptitude.

Schindler, S., Ortner, R., Peternell, A., Eder, H., Opgenoorth, E., & Fischer, G. (2004). Maintenance Therapy with Synthetic Opioids and Driving Aptitude. European Addiction Research, 10(2), 80-87

Conclusion: The synthetic opioid-maintained subjects investigated in the current study did not differ significantly in comparison to healthy controls in the majority.

4. Methadone-substitution and driving ability
Forensic Science International, Volume 62, Issues 1-2, November 1993, Pages 63-66
H. Rössler, H. J. Battista, F. Deisenhammer, V. Günther, P. Pohl, L. Prokop and Y. Riemer

The formal assertion that addiction equals driving-inability, which is largely practiced at present, is inadmissible and therefore harmful to the therapeutic efforts for rehabilitation.

5. Methadone substitution and ability to drive. Results of an experimental study.

Dittert, S., Naber, D., & Soyka, M. (1999, May).

It is concluded that methadone substitution did not implicate driving inability.

6. Functional potential of the methadone-maintenance person.

Gordon, N., & Appel, P. (1995, January). Functional potential of the methadone-maintenance person. Alcohol, Drugs & Driving, 11(1), 31-37.

Surveys on employability and driving behavior of MTSs revealed no significant differences when compared to normal population. It is concluded that MM at appropriate dosage levels, as part of treatment for heroin addiction, has no adverse effects on an individual’s ability to function.

8. Influence of Peak and Trough Levels of Opioid Maintenance Therapy on Driving Aptitude. Baewert, A., Gombas, W., Schindler, S., Peternell-Moelzer, A., Eder, H., Jagsch, R., et al. (2007). European Addiction Research, 13(3), 127-135.

This investigation indicates that opioid-maintained patients did not differ significantly at peak vs. trough level in the majority of the investigated items and that both substances do not appear to affect traffic-relevant performance dimensions when given as a maintenance therapy in a population where concomitant consumption would be excluded.

9. The influence of analgesic drugs in road crashes.

Chesher, G. (1985, August). The influence of analgesic drugs in road crashes. Accident Analysis & Prevention, 17(4), 303-309.

Methadone, as used in treatment schedules for narcotic dependence, produces no significant effect on measures of human-skills performance.

10. Influence of narcotic drugs on highway safety.

Gordon, N. (1976, February). Influence of narcotic drugs on highway safety. Accident Analysis & Prevention, 8(1), 3-7.

A review of the literature on narcotic drug use and driver safety indicates that narcotic users do not have driving safety records that differ from age-matched individuals in the general population. Maintenance on methadone also does not appear to increase driving risk.

Guest Dosing at Opioid Treatment Programs

 

 

 

 

“Guest dose unto others as you would have others guest dose unto you.”

I think all opioid treatment program physicians should follow this twist on the Golden Rule.

That is to say, when OTP physicians are contemplating the appropriateness of approving one of our patients to be guest dosed at another OTP, we need to consider whether we would want to be on the receiving end of a similar patient.

First, let me explain what guest dosing is for my readers who may be unfamiliar with it.

Patients of opioid treatment programs have to dose daily on their medication, unless they meet criteria for take home doses. For buprenorphine (formerly known as Suboxone or Subutex) regulations have loosened in many states, so that take home doses are granted much earlier. (The federal regulations have completely dropped the time in treatment requirement for take home doses of buprenorphine.)

But for methadone, patients have to dose at the facility each day for at least the first ninety days, and after that, if doing well, they can get up to three take homes per week for the next ninety days, then up to four per week after a half of a year, and so on.

What happens if the patient needs to go out of town before they are eligible for these take homes?

There are three options: leave treatment, the worst option, because of the increased risk of death for patients who leave treatment; special take home doses, often risky if the patient isn’t able to take them as prescribed; and guest dosing.

Guest dosing means a patient of one treatment program can be dosed at another program if that patient travels to another area. All opioid treatment programs send their patients for guest dosing and allow guest dosing for patients of other facilities. It should be a smooth and simple process, under ideal circumstances.

But sometimes circumstances get complicated.

Most difficult are the last-minute guest dosing requests. These tend to come at particularly stressful times for the patient, because often a patient’s family member is sick, or just passed away. The patient needs to be with his family.

Setting up guest dosing at the last minute is more difficult for the referring clinic, the accepting clinic, and the patient. Most clinics ask for 24-48 hours advance notice for guest dosing, but some situation don’t allow that much time. We do the best we can, try to explain circumstances to the receiving clinic, and usually are able to work out something.

Guest dosing requires good communication between clinics. Usually the home clinic needs to fax a form with the patient’s picture, their dose, and any take home doses to be dispensed. Most receiving clinics like to see at least the last three drug screen results. Some receiving clinics ask for a doctor’s signature to assure the physician is aware of the guest dosing request. Then when the guest dosing patient arrives at the receiving program, the nurse calls to verbally confirm all of the info on the guest dosing request.

Some opioid treatment programs charge steep guest dosing fees, affecting the patients’ ability to pay for guest dosing. Some clinics charge a one-time fee to set up guest dosing, and after that pays the same as any other patient dosing at that clinic. Some programs charge elevated fees every day the patient guest-doses.

As the medical director, I am consulted any time one of our patients wants to guest dose at another clinic, and any time a patient from another clinic wants to guest dose. We have general guidelines for guest dosing, but often have to consider other factors.

For example, at both of the treatment centers where I work, we prefer not to guest dose patients during induction. Induction is the riskiest time of treatment, and usually lasts at least thirty days. But each request must be considered and the risk/benefit analyzed. What about if a patient admitted three weeks ago finds out a close relative is dying, and wants to be with them? I might agree with guest dosing such a patient, if she is doing well, isn’t actively using benzodiazepines or alcohol, and won’t be gone for many days.

Some clinics won’t allow guest dosing for any patient with positive drug screens. Generally I would agree with that, but for me it depends on what the drug is, and why the patient needs to go out of town, and for how long. For example, if a patient is stable on his dose, but is still smoking marijuana with every drug screen positive for THC, I’d still support guest dosing if this patient needs to work out of town. I’m not OK with continued illicit marijuana use, but the problems caused by missing a work opportunity may be greater than problems caused by marijuana use. If that same patient were using benzodiazepines or alcohol, I probably wouldn’t agree with guest dosing, due to the much higher risk of methadone when combined with these drugs. If the marijuana-smoking patient wanted to guest dose out of town in order to attend a friend’s bachelor party…I’d be hesitant, as I’ve heard rumors that these events tend to involve heavy drinking of alcohol. I’d have to talk to the patient.

Guest dosing in patients on buprenorphine used to be difficult, since so many OTPs weren’t using buprenorphine. Now, most OTPs do offer both buprenorphine and methadone to their patients in treatment, so they can accept guest dosing for both.

But since buprenorphine is such a safer medication than methadone, usually we can get permission for take home doses, if the patient doesn’t already qualify for them. Even though federal regulations dropped the time-in-treatment requirements for take homes in buprenorphine patients, my state still requires time in treatment, unless we ask for an exception, which is usually granted.

So who should not be approved for guest dosing? As above, patient in induction shouldn’t be guest dosed unless there are extreme extenuating circumstances – death in the family, personal medical crisis, or other extraordinary circumstance.

Sometimes I get frustrated not with patient of other treatment programs, but with the people who work at other treatment programs.

For example, last weekend we had a patient show up on a Saturday for guest dosing with no advance notice. Ordinarily, we ask for 48 hours’ notice to make sure guest dosing goes smoothly. Since it was a Saturday, our nurse had to stop dosing our own patients, call me for permission to guest dose her, and then call her home clinic for needed information.

We had already guest dosed this patient a few times within the past few months, so we kind of knew her. Otherwise, I’d have been tempted to say no, because it’s an inconvenience to our waiting patients and a hassle for our nurse. But it seemed harsh to deny her due to her clinic’s ineptitude.

If we had sent a patient to another OTP with no advance notice, I can almost guarantee they would say no, too bad, your counselor should have set this up days ago.

The whole goal of treatment is to help drug addicts regain their ability to live a normal life. Opioid treatment programs should make every effort to remove obstacles to travel during treatment, while still following state and federal regulations. And of course, the freedom to travel and guest dose must be balanced with patient safety. Ideally, the decisions regarding guest dosing should be made by the physician, who is informed by the input of the treatment team, so that the best possible decisions can be made.

Oh, and please, OTP counselors everywhere… it is “guest” dosing, not “guess dosing.” I cringe every time I see that written in any records from any program. We do not guess a dose. We do guest dose patients.

Diagnostic Overshadowing

Perspective

 

 

I was trying to get through a pile of non-Addiction Medicine journals when I came across an article titled “The Ethics of Behavioral Health Information Technology: Frequent Flyer Icons and Implicit Bias,” in the October 18^th, 2016, issue of the Journal of the American Medical Association.

According to the authors, Michelle Joy M.D. et al, at least one electronic medical record (EMR) system provides a way to display an icon shaped like an airplane, as a way to inform treating physicians that the patient is a “frequent flyer.” This term has long been used to describe patients who repeatedly come to emergency departments or other providers on a regular basis.

This term has been used for decades. I’ve used it myself in the past. It’s a short-hand phrase that usually means, “This patient is a pain in the ass because he/she keeps coming back for inappropriate reasons.” More elegantly and succinctly, the authors of this article say the term frequent flier is short-hand for “problem patient.”

This article points out the ethical harms of stigmatizing patients in this manner, and presents the term “diagnostic overshadowing.” This means a physician’s attitude towards a patient can be skewed by the idea that the patient is seeking care for inappropriate reasons. The article goes on to cite studies showing patients with mental health conditions are less likely to get appropriate medical care compared to patients without mental health issues, likely due to this diagnostic overshadowing.

I see this every week in my patients with opioid use disorder. Even my patients who are in recovery and doing well say they are treated differently when they go to our local hospital emergency departments, or even to their primary care doctors. After they reveal they’re on buprenorphine or methadone to treat opioid use disorder, they detect changes in the attitudes of their care providers.

Often, the patient will say, “I know I’ve tried to score drugs from him before, but this time I didn’t get a chance to say anything before the doctor accused me of being a drug seeker.” The doctor, reading the past records, jumped to the conclusions that this person is only in the emergency department to get pain pills. The doctor shuts down further communication because of his diagnostic overshadowing. The patient doesn’t get a chance to receive appropriate care. Maybe just as bad, that patient is given the message that they don’t deserve respect, due to their diagnosis of opioid use disorder.

If this happens to patients years after they’ve been in recovery, just think about what happens to people in active opioid use disorder. They are pre-judged as drug seekers, and the emergency department doctors sometimes decide, before gathering information, that the addicted person has no valid medical problems. The doctor starts with an assumption that the patient is a bad person, rather than a sick person.

This attitude leads to medical disasters. Patients with current intravenous drug use are more likely, not less likely, to have serious medical problems.

I’ve seen two patients who had serious infectious medical emergencies that were missed by local emergency room doctors. Both patients were seen multiple times at two local hospital emergency departments. Both said they were treated with distain by personnel. One was seen a total of four times before she went, on her own, to the emergency department of a nearby teaching hospital, where she was immediately diagnosed, and taken for emergency surgery.

I believe these two patients encountered doctors who experienced the diagnostic overshadowing described in the JAMA article, because they had opioid use disorders. Their doctors assumed they only wanted pain pill prescriptions and weren’t all that sick.

What do we do about diagnostic overshadowing?

We must educate physicians more completely about addiction and mental health disorders. I’ve written in previous blog posts about the lack of training, at least in the past, for physicians about substance use disorders. Specific training in medication-assisted treatment of opioid use disorders wasn’t taught at all. This is slowly changing, and medical schools now teach students about these vital medical problems. This will help younger physicians, who are getting their training now.

What about older doctors, already in practice? I think all of us working in substance use disorder and mental health disorder fields have an obligation to educate our peers. I know I held significant bias against methadone before I knew anything about it. One doctor friend encouraged me to read and learn. When I did, I found piles of information supporting this evidence-based treatment.

Now I try to pass along what I’ve learned. Sometimes I’m successful, sometimes not. I’ve talked to doctors in my community, with a wide range of results. Some physicians have become allies, supportive of the patients we share. Others have not been willing to listen or learn about MAT. One doctor told me if I prescribe MAT for one of his patients, he will dismiss that patient from their practice.

The only difference between this doctor and me was in our willingness to learn. Had I not agreed to read some of the tons of studies showing that methadone helps patients with opioid use disorder, I’d still be opposed to methadone, as he continues to be. It’s a reminder to remain teachable.

It’s easy to become frustrated with my colleagues. For example, I can’t remember even one patient being referred to our opioid treatment program by the local hospital’s emergency department physicians. I have not been successful at educating these doctors.

Up until last year, we didn’t get referrals from our local substance abuse and mental health treatment provider for the county. One patient specifically asked them to refer her to a methadone clinic, and was told, “We don’t do that.” Fortunately, she had friends who told her where to find our treatment center.

Our program manager, nurse manager, and I met with the treatment program’s supervisors, who said they had no idea their facility was trying to prevent patients from accessing opioid treatment programs. They promised to fix the situation, and we now get referrals from this program.

So things do change, but not quickly. All of us advocating for MAT need to be patient, yet persistent. Maybe then we can eliminate diagnostic overshadowing for our patient populations.

 

 

Physicians’ Decisions to Start Buprenorphine: The Key Factors

Just a little “If cats were doctors” humor.

 

 

 

 

Physicians are less likely to prescribe buprenorphine for patients who use illicit benzodiazepines or drink excessive alcohol, who have a spouse with a drug use disorder, or who have Medicaid as their form of payment.

This information comes from an article in the most recent issue of the Journal of Addiction Medicine (Jan/Feb, 2018). Knudsen et al. describe the findings from their investigation about the decision-making process of buprenorphine prescribers.

The authors sent surveys to 3553 physicians, selected at random from all fifty states and the District of Columbia, who were eligible to prescribe buprenorphine and had at least one patient for whom they prescribed buprenorphine. Of this group, 1174 (about a third) of those physicians responded.

These surveys contained twenty patient vignettes describing the various attributes of a prospective patient, then asked about the physicians’ willingness to prescribe buprenorphine for the patient. This study is based on conjoint analysis, which is a way to quantify the contributions of several factors in a decision-making process.

I read all about this method, and following the statistical analysis process was challenging. I wish I could explain it to my readers, but I can’t.

Seven patient attributes were described in the case vignettes, and were the basis upon which the physicians answered whether they would or would not prescribe buprenorphine from their office. The seven attributes were: type of opioid and route of administration, treatment history, risky substance use (benzodiazepine or alcohol use), co-occurring infections (HIV and Hepatitis C), spousal involvement in treatment and whether the spouse was also a drug user, employment status, and method of payment for the office visits.

Of those seven factors, the use of benzodiazepines (or alcohol) had the largest relative importance for the physicians in deciding if they would prescribe buprenorphine or not. In other words, out of all those seven factors, doctors were more influenced not to prescribe buprenorphine if the patient is also using sedative-type drugs.

That makes sense, and I was relieved to see this sample of physicians recognized the risks of this population of patients with opioid use disorders. We know that alcohol and benzodiazepines do increase the risk of mortality and of relapse in patients on medication-assisted treatment with buprenorphine or methadone.

Maybe the physicians felt the risk of treating such patients with buprenorphine is still less than no treatment at all, but that opioid treatment programs are safer settings to start these patients than an office-based setting. At opioid treatment programs, patients can be dosed with buprenorphine, but watched more closely. They can be evaluated for impairment every day when they come to the facility to get that day’s dose. Office-based physicians should be able to refer to local opioid treatment programs easily, and form close working relationships with these facilities.

The next most important factor determining the physicians’ willingness to prescribe buprenorphine was method of payment. Patients with Medicaid were less likely to be started on buprenorphine in the setting of office-based practices.

This did not surprise me.

Medicaid doesn’t pay physicians well for office visits. Medicaid pays much better for surgeries or procedures…that is, “doing” something…. but not well for thinking and patient management in the office setting.

Recently I tried to see how much Medicaid pays for an office visit for a patient being monitored on buprenorphine. It varies by area, but the going rate seems to be $40 to $45. Considering the visit takes about 15-20 minutes, which doesn’t count time spent coordinating care or meeting Medicaid paperwork requirements, that’s not great reimbursement. I don’t know if a practice could break even if they saw only Medicaid patients, unless they saw a high volume, and that’s no fun for patient or doctor.

This study underlines the importance of raising payments to physicians for seeing Medicaid patients, if you want primary care physicians to prescribe buprenorphine from an office setting.

Also, something must be done about eliminating the byzantine Medicaid requirements. It’s altogether too hard to become certified to accept Medicaid, so some doctors don’t bother with it.

The third most important factor was whether a prospective patient’s spouse was going to be involved in the patient’s care, and whether that spouse had an addiction issue too.

I completely get that idea. When I’m admitting a patient and they tell me they live with a significant other who is still using illicit opioids, I worry. Not only could the S.O.’s use of drugs be a trigger for relapse for my new patient, but also that might be at temptation to give some of his dose to the S.O.

We know from research that social contacts influence whether people take drugs or not. Having a stable, non-drug using spouse is a good prognostic sign.

The four other factors didn’t seem to affect whether this group of buprenorphine physicians would start buprenorphine or not.

HIV or Hep C status didn’t matter, and that’s a good thing. Patients with these infections should be able to access treatment.

Surprisingly, the type of opioid used and the route of administration didn’t matter very much. I would have thought that physicians may have considered heroin users higher risk patients than prescription opioid users, but that wasn’t the case. I was surprised that a history of intravenous use didn’t make prescribers hesitate.

In an office-based setting, I think the physician (or physician extender) should ask specifically if the prospective patient has ever injected buprenorphine. If the answer is “yes,” an opioid treatment program, with observed daily dosing until stable, is probably a safer and better choice for these patients. I ask my new patients, and most people who use intravenously have also injected buprenorphine.

Previous treatment episodes didn’t influence physicians’ decisions to prescribe buprenorphine, and neither did employment status.

I would have though physicians would be a little less inclined to start prescribing for a patient who is unemployed, but that wasn’t the case in this study.

I thought this was an interesting article, and showed some insight into how physicians who prescribe buprenorphine decide for whom they will start treatment, and which factors are deterrents to starting a new patient in treatment.

 

Buprenorphine Regulations

Map is from vox.com

In response to the rise of opioid use disorders in this country, lawmakers in heavily affected states are passing laws they hope will help. But well-intentioned laws may have unintended consequences, requiring re-evaluation of those laws.

Nearly one year ago, The Virginia legislature asked the Virginia Board of Medicine to regulate prescribing of buprenorphine. Legislators were worried about the diversion of prescribed monoproduct buprenorphine to the streets. You can read about this in more detail in my blog entry dated February 24, 2017.

It’s been a year since that blog entry, and I have a little bit of data regarding some of the consequences of Virginia’s new rules.

Initially, the new Virginia Board of Medicine (VBOM) regulations said the buprenorphine monoproduct could only be prescribed for pregnant ladies and nursing mothers. They did this because the monoproduct, containing only buprenorphine and no naloxone, has a higher street value and is more likely to be injected and misused than the combination product.

The VBOM received so many complaint letters that they finally changed the regulations to say that each buprenorphine physician could prescribe buprenorphine monoproduct to up to three percent of their patients. Each of these patients must have documentation of their intolerance in their chart.

It was hoped that this compromise would limit the amount of buprenorphine monoproduct being prescribed, while still making allowances for some patents with intolerance to naloxone in the combination product.

The VBOM didn’t stop there. They passed regulations about care at opioid treatment programs (OTPs), which are already the most heavily regulated medical providers in the nation. The VBOM said if buprenorphine monoproduct was used, the patient had to consume it on site, with observed dosing, and that no take home doses could be allowed for the monoproduct.

To clarify, this meant that OTP patients dosing with buprenorphine monoproduct had to either switch to the combination product, buprenorphine/naloxone, to get their usual take homes, or dose daily at the OTP on the monoproduct and forfeit all the take homes they had earned.

Or they could switch to methadone, where take homes are still allowed, following standard guidelines.

This is the irony – methadone is a heavier and stronger opioid than buprenorphine, and more likely to cause overdose death if taken illicitly or diverted. Virginia patients can get methadone take home doses, after they have a period of stability and meet the guidelines which have been in place for decades.

OTPs must follow both state and federal guidelines, and must obey the stricter of the two. The federal guidelines dropped the time in treatment requirement for buprenorphine, meaning the federal agency decided to allow the admitting physician to decide how many take home doses were appropriate, from day one, for a buprenorphine patient.

Essentially, Virginia went the opposite direction, and eliminated take homes, at least for the monoproduct.

At the time the new regulations were implemented, there were 600 Virginia patients on buprenorphine at OTPs. Monoproduct was used because was about half the price of the combination product, and kept treatment more affordable for patients. Also, because OTPs already followed stricter regulations than office-based programs, the risk of diversion was felt to be lower than at office-based programs.

Of those 600 patients, 384 patients attended one of the four OTPs owned by Acadia Healthcare in Virginia. They collected data on what happened to their Virginia patients after these new regulations were implemented. Since I work for Acadia, that data was released to me for an upcoming presentation, but I’ll give my readers an early view.

Of those 384 patients, 260 made the switch to the combination product so that they could continue to get take home doses. In other words, two-thirds of the patients switched, and one-third did not.

The cost of medication doubled, but rather than pass this on to the patients, Acadia Healthcare absorbed all the extra cost. The patients paid the same as if they were getting the cheaper monoproduct. This was fortunate, since an overnight doubling of costs could have caused hundreds of patients to leave treatment.

To some lawmakers, an extra couple of hundred dollars per month might not seem like much. But to many patients, it’s the difference between being able to stay in treatment or having to leave and go back to illicit drug use.

So, what happened to the patients who didn’t make the switch?

• 15 switched to methadone, and will be able to get take home doses once they meet criteria. It’s takes a while, but at least they can get take homes eventually.
• 21 transferred to out-of-state opioid treatment programs because they had an intolerance to the combination product.
• 24 (6%) patients dropped out of treatment.
• 58 remained on the monoproduct and accepted that they will have to dose every single day that they are in treatment. Since all these clinics are in rural areas of Southwestern Virginia, I suspect some of these people are driving long distances daily, and incurring extra expenses for that travel.
• 6 patients were lost to follow up, and couldn’t be contacted to see what happened.

Studies show the risk of death increases as much as eight-fold for patients who leave treatment, so those 24 people are at high risk. I suspect the 6 people who couldn’t be found are also in that risk group.

I have a little bit of data about what’s happened on the receiving end with patients on buprenorphine at Virginia OTPs. One OTP located in Boone, NC, received 12 patients in transfer from Virginia. Those patients could have been OTP patients or office-based patients; I don’t have that data.

I have my own office-based buprenorphine practice in the Lake Normal area of North Carolina, which is 73 miles from the North Carolina-Virginia border. My practice got around twenty phone calls last year, just after Virginia’s law changed. These patients were willing to drive from Virginia to my office if I would prescribe buprenorphine monoproduct. I declined to accept any of those patients, both because it is unworkable in the long run to come from such a distance, and because I was concerned about regulatory scrutiny in my own state.

You can draw your own conclusions based on this limited data. It appears that roughly two-thirds of patients, if forced to switch to the combination product, can do so and remain in treatment.

But remember, costs weren’t increased for those patients enrolled at Acadia OTPs.

That would not have been the case for office-based self-pay patients, who would have paid roughly double each month for their prescriptions for combo products at the pharmacy. Community pharmacies would not have absorbed the extra cost.

I combed the internet, trying to discover data on what happened to office-based patients in Virginia on the monoproduct. If data is out there, I haven’t found it. Or perhaps it’s still being collected and analyzed. I also looked to see if overdose death data changed much in 2017, but it’s likely too early for this.

The American Society of Addiction Medicine has written a public policy statement addressing regulations on office-based buprenorphine policy. This document outlines the most reasonable approach to assure appropriate care for patients while limiting onerous regulations for providers. State legislators would do well to read this policy and abide by its specific recommendations.

https://www.asam.org/docs/default-source/public-policy-statements/statement-on-regulation-of-obot.pdf?sfvrsn=df8540c2_2

I’m tempted to give a summary of ASAM’s statement, but ASAM warns against this, at least without their permission. They don’t want people to use just a section of their policy to justify a position; they want their statement to be read in full.

I think that’s smart of ASAM. I encourage interested readers to check it out.