Those of Us Who Lie


 

 

 

I’ve written this blog article several times. I deleted one version because it sounded too mean, and another version because it was too shallow and unrealistic. It’s a difficult subject. Talking about people with substance use disorder who lie has potential to feel accusatory and judgmental, but lying is part of the behavior of people in active addiction.

Some medical professionals see lying as a character flaw and prefer not to treat patients with addiction because of this trait. They feel patients with substance use disorders lie more than patients with other disorders. I’m not sure that’s necessarily true, since I remember lies of patients I treated when I worked in Internal Medicine: “Yes, I always take my blood pressure medication,” stated by a patient whose pharmacist called me to say she hadn’t picked up her refills for several months. Then there’s me: “Oh yes, I floss every day,” said to my dentist, who can clearly see I don’t floss daily.

We all lie. If we say we don’t, then we are…lying, at least to ourselves. Most lies are based in fear. We’re afraid we’ll appear to be irresponsible, or careless. We don’t want others to think we are bad people. We lie because we’re afraid we won’t get what we want. We’re afraid of the consequences that may occur if we tell the truth. We lie because we don’t want to disappoint other people, or because we feel shame.

With addiction, fear is amplified. Patients with addiction are afraid of so many things: running out of drugs, running out of money to buy drugs, physical consequences of using drugs, what friends and family will think if their drug use becomes known. Many addicts fear they are becoming bad people because they act in ways that violate their own values. They find themselves doing things like neglecting family or stealing in order to satisfy the addiction. So they lie.

Addiction needs lies to survive. A person with an addiction can’t get money for pills from a loved one if he says it’s going to purchase drugs, but he may be successful if he says it’s for food. If he tells family and friends how many drugs he is using, it’s likely he will encounter some opposition, making it harder for him to keep using drugs.

Lies are part of substance use disorders.

Sometimes what appears to be a lie is really denial. Denial occurs when a person has convinced himself something is true when it isn’t. In addiction treatment, denial is common. Here’s one example:

I was seeing a patient in one of the opioid treatment centers about her urine drug screens. Six out of the seven since admission to the methadone program were positive for cocaine.

“I’d like to talk about your cocaine use. Can you tell me a bit about why you use, what triggers cravings to use?”

“I don’t use cocaine. I hate it. I hate the way it makes me feel, all tired and depressed when I wake up the next day. It’s awful stuff. It’s from the devil.”

“OK, you’re saying you don’t use cocaine?”

“I don’t. I don’t use it at all. I stopped using it.”

“Um…, but how long has it been since you stopped?”

“I quit years ago, but I did slip up and use just a little bit the other day.”

“I’m getting confused. You’re saying you quit years ago, but used cocaine the other day. Let’s look at your drug screens. Almost all of them have been positive over the last six months, and I see where you have talked to your counselor about it four or five times. In her notes it says you denied any use. We sent off one of the urine samples for a second, more exact test, and it still showed cocaine. How can you explain this? Is it possible you’re really using more than you think you do?”

“That one time I was helping my boyfriend package it. He’s a coke dealer. I don’t agree with all that. I’m going to break up with him.”

I don’t think this patient was lying. I think she was in denial, and a part of her couldn’t accept the extent of her cocaine use. Denial needs to be treated as part of substance use disorders.

Addiction isn’t the only disease with denial. When I worked in primary care, I’ve seen advanced cancers in patients who were in denial about the severity of their symptoms. Patients with serious chest pain ignored their symptoms until having a massive heart attack. With any problem, one of our defenses against facing a difficult situation may be to deny it exists.

A few decades ago, harsh confrontation was felt to be necessary when dealing with denial in drug addicts. Now we know we get better results with gentler, more positive counseling approaches. For example, I’ve read Motivational Interviewing: Helping People Change, by Miller and Rollnick, third edition. I loved the second edition, which gave me ideas about how to change my goal from confronting to collaborating. This edition is even better. It’s giving me tools to help move patients from denial at their own pace. This feels more humane than old methods of yelling at patients, who already are turning away from unpleasant truths.

This method can also be used with patients who are intentionally lying.

Just because a person with addiction enters treatment, lying doesn’t automatically stop. Habits are hard to break, and people in treatment may lie when it’s just as easy to tell the truth, merely out of habit. Then there are incentives to lie in treatment settings. For example, if treatment is court-ordered, a patient in treatment may face jail time if she admits to a relapse. If a patient’s children have been taken by social services, admitting to continued drug use or even to a relapse may delay getting his children back.

Particularly in opioid addiction treatment, patients have incentives to lie in part due to the extensive regulations put in place by the state and federal governments. Some of those regulations are in place to keep the patient safe, and some are to protect against diversion of methadone onto the local black market. Patients in treatment may lose take home doses if they are truthful about drug use.

Even if take homes aren’t at stake, many patients don’t like to talk about relapses, and lie about their drug use. Patients may fear their counselor will belittle or shame them for using drugs. Again, methods like Motivation Interviewing can help the counselor be more collaborative than confrontational. The counselor can have the approach of let’s look at this relapse and learn from it what we can, in order to help you in the future. When a patient admits to drug use, that’s a good thing. Now we’ve got something to work on. That means the patient is facing their disease, and we can now work on relapse triggers. We can track the events leading up to drug use, and the patient can decide if they would do anything differently the next time, if in the same circumstances.

Some patients cleverly say that if they always tell the truth about drug use, they should be rewarded for their honesty by not having any consequences for drug use. For example, a patient who had been in methadone treatment for about three weeks told me he was drinking his Sunday take home bottle on Saturday. I was alarmed, because I feared he could have an overdose death. I told him I was glad he told me, but that I couldn’t give him a take home dose for Sundays in view of that. He was angry and felt he was being punished for being truthful, while my main concern was a possible overdose death if he continued to get take homes.

I use a phrase from Ronald Reagan in my work with people in treatment for addiction: Trust, but verify. I can’t take everything that is told to me at face value. I’d prefer to believe all my patient all of the time, but they have this disease which leads them to lie. When patient safety is at issue, I have to confirm what the patient tells me with other facts, like clinical observation, patient history, and drug screens.

I’ve learned I can’t reliably tell when someone is lying. Years ago I foolishly thought I was really good at detecting lies, but I’ve been wrong so many times that I no longer make that assumption. Even lie detector machines are often wrong, which is why they aren’t admissible in court.

I’m learning not to take lies personally. Lying is part of addiction, and old habits don’t stop right away. How I react to a patient’s lie is more about me than about the patient. Lies sometimes still make me angry, and this happens more often when I’m not in a good place myself. I try to pay attention to my own physical, mental, and spiritual health. When I’m healthy I’m more likely to view people who lie (not only my patients) with more calm and acceptance.

I understand lies because I understand fear. If I come from a self-righteous place in my own heart where I believe I never lie, I am likely to judge another person who lies. So I’m no paragon of truthfulness myself, but I am a work in progress, as we all are.

 

 

Mandated Training?


 

 

 

 

It looks like 2017 is going to be the year of governmental solutions to the opioid use disorder problem.

I blogged last week about the regulation passed by the Virginia Board of Medicine. Now there’s a proposed bill making its way through the NC legislature, advocating new laws to help solve the addiction problem. Legislators certainly have their hearts in the right place. I agree with many parts of the proposed bill.

But now, I’d like to suggest a new regulation: ask all doctors to take an eight-hour course on opioid use disorder and its treatment with medication-assisted treatments, as a prerequisite to renewing their licenses.

I can hear my colleagues already howling with indignation. I’d feel the same way if I were them. It’s hard to admit you don’t have the education you need in an area of medicine. But this specialized area of medicine powerfully influences nearly all other subspecialties of medicine, so the consequences of neglecting the disease of addiction can be enormous.

Before I listen to my fellow physicians’ protests, I’d like to give examples, from my own community, of some things medical providers have done with patients prescribed opioids, and with patients who have opioid use disorder. I believe they all could have been handled better. Patient details have been changed to protect identities.

Example number one:

One of my patients needed to have surgery on his lumbar spine. He went to see the orthopedic specialist and was told he had to taper off methadone before the procedure could be done. I asked my patient why the doctor told him this, and the patient said he didn’t know. The patient said he was also told he couldn’t be “allowed” to have any pain medicine after he left the hospital after this surgery.

I’ve had other doctors in my area tell patients the same thing. One local weight loss surgeon tells patients they have to come off their evidence-based treatments (methadone or buprenorphine) for their potentially fatal medical illness (opioid use disorder) before he will agree to do any sort of gastric bypass weight loss surgery.

I was eager to have a discussion with my patient’s orthopedic surgeon, but my patient told me not to bother. He said he wasn’t going back to that surgeon anyway, and planned to get a second opinion at a nearby teaching hospital. I told him I thought this was a very good idea, though I was disappointed I couldn’t talk to the orthopedic surgeon. I was actually looking forward to that conversation. Probably the maniacal gleam in my eye made my patient tell me not to call.

Example number two:

Several weeks ago, I saw a new patient who was seeking admission to our opioid treatment program after being kicked out of a pain clinic. “Tim” (not his real name) had been going to several different pain clinics for years, and had been misusing his medication for at least two years. He was snorting oxycodone, around 150mg per day, and failed a pill count done by his pain medicine physician. His pain management doctor dismissed him from the practice, citing a “zero tolerance,” with no referral or further help. His friends told him about our treatment program, so he came for admission.

Tim was offered a choice between methadone and buprenorphine as treatment medications. He was so vehemently opposed to buprenorphine that it made me curious. He said that buprenorphine made him so sick, he nearly died.

I had already looked at his information on the prescription monitoring program, and saw that a few months ago, the physician assistant at his pain clinic prescribed Belbuca, along with relatively high doses of the usual immediate and extended release hydromorphone. This had piqued my interest.

Belbuca is a form of buprenorphine that’s approved for the treatment of pain. We don’t use it to treat addiction because it doesn’t have FDA approval for that purpose, and therefore isn’t covered by the DATA 2000 law.

Obviously this physician’s assistant who prescribed Belbucca failed to realize it would precipitate withdrawal in this patient who had been on full opioids for months.

I asked him to describe what happened after he took the first Belbucca. He said he felt like he had immediate onset of intense nausea and repeated vomiting so bad that he called EMS to take him to the hospital. He said he thought he was dying.

It doesn’t sound like anyone who saw the patient at the hospital told my patient his reaction was completely predictable.

I tried to explain to my patient that he may not get sick with buprenorphine if it were prescribed properly, but he was having none of it. That was OK, because methadone is still a great treatment for his opioid use disorder.

Example number three:

Some patients at our opioid treatment program stabilize on buprenorphine and then transfer to an office-based setting for care in a less restrictive setting. These patients have done well for months, so we wish them well, send their requested records, and encourage them to continue getting counseling in some form.

However, for some reason, some pain clinics take these patients off buprenorphine and start short-acting opioids. I’ve blogged about this problem before, dismayed at the predictable return of their opioid use disorder. They fail pill counts, and then get kicked out of treatment, having been set up to fail by their provider.

Now, things are getting weirder.

One patient, who did well for seven months at our opioid treatment program, transferred to a local office-based buprenorphine program. She did well for a few months, until she was switched to immediate and extended-release hydromorphone, which had been her drug of choice when she was in active addiction.

This patient predictably lost control of how she was taking this hydromorphone, started injecting it, and failed a pill count. Her doctor then told her she must go for an assessment at a substance abuse treatment facility in order to continue being prescribed hydromorphone.

Ummm…here’s the thing…she was started on buprenorphine in the first place because she had an opioid use disorder.

I’m not saying every patient with opioid use disorder immediately loses control of their medication if they’re prescribed opioids. But after less than a year of recovery from severe, intravenous opioid use disorder, you don’t have to be psychic to predict this would happen. Handing this patient a bottle of her drug of choice with a thirty-day supply triggered a relapse back to intravenous drug use.

Example number four:

I’ve saved the craziest for last. This example is tragic, both because of the bad patient outcome, and because so many doctors dropped the ball on this patient.

The patient, who developed opioid use disorder during treatment of chronic pain syndrome, developed severe mid-back pain. He told the emergency room doctor that he had been injecting the pain pills prescribed to him by a local pain medicine practice, and the emergency department physician noted track marks on his arms.

The patient had a limited work up and was sent home with a diagnosis of non-specific back pain and referred back to his pain clinic. The patient, miserable with intense and severe pain very unlike his chronic pain, returned to that hospital’s emergency department three more times. On the next to the last time, he says he was told that the doctor would not see him because he was a pain medication seeker.

Several days later, on his last visit to the emergency department, the patient was nearly comatose, with a high fever and labs indicating sepsis, and overwhelming blood infection. The patient was immediately admitted to the hospital and started on a range on antibiotics, but failed to improve. His relative demanded transfer to the local teaching hospital, an hour away.

Upon arrival at the teaching hospital, this 44 year -old man was diagnosed with a spinal abscess that extended from the neck all the way to the end of the spinal cord. This infection had obviously started at the area of his intense back pain. His spinal cord was being bathed in pus rather than spinal fluid.

He was not expected to live.

He was taken to the operating room, where the infection was drained and washed away, and dead tissue removed. Against all odds, the patient survived, though he was a quadriplegic when he woke up after surgery.

After being treated with antibiotics for many weeks, he was sent to a physical rehabilitation hospital for months. Eventually, he regained some strength in his arms and legs, and against all odds, improved to the point he could feed himself, and could walk with great difficulty, with two canes. He was eventually released from the physical rehabilitation hospital.

Eight months since his last appointment, he went back to his pain clinic. The doctor resumed prescribing the same medications that the patient had been misusing.

Wait a minute, you will say. Surely that doctor wasn’t told about the whole IV use, spinal abscess, quadriplegia thing, right? Wrong. Records show he did know.

The patient, after trying very hard not to inject these medications, finally came to our opioid treatment program, and asked for help. He was referred to us not by our local hospital’s physicians, not by anyone at the teaching hospital, not by social workers at that hospital, not by the physical rehabilitation hospital, and not by his pain management doctor.

His friends, in treatment at our OTP for their opioid use disorder, and told him to come to us for help.

He was started on sublingual buprenorphine and has done beautifully.

One day, after he’d been on a stable dose of buprenorphine for a few weeks, I asked him what he thought when his pain management doctor offered to put her back on hydromorphone. He said, “I was surprised. I didn’t think it was a good idea, but I was in pain and in withdrawal, so I just took the prescription.”

I understood. After all his time in the hospital, this patient hadn’t had any treatment for the disease of opioid use disorder. He’d only had treatment of the sequellae of opioid use disorder.

At that time, saving his life was the most important thing. But later, why not address the original disease that caused this million-dollar hospital treatment admission? Why not direct the patient to treatment of his opioid use disorder when released from the hospital and/or physical rehab facility? Why not pause for more than a moment before writing a prescription for the same drug that caused the whole mess?

 

All physicians make mistakes, usually out of ignorance, and I’m no different. But now, the opioid addiction problem is so bad that each state is passing laws to fix the problem. Isn’t it worth passing a law that makes sure all physicians are part of the solution?

At a minimum, let’s teach all doctors that substance use disorders are diseases, and that we do have treatments available. Some treatments work better than others, and medication-assisted treatment of opioid use disorder works very well. In fact, there’s more evidence to support MAT than anything they are doing in their practices. Why not refer patients with problems rather than shaming and ignoring them?

Let’s teach physicians that failure to diagnose and refer patients with substance use disorder for appropriate treatment is malpractice, just as it is for all other medical problems.

 

 

Virginia Board of Medicine Changes Opioid Treatment Program Regulations

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In a surprising turn of events, last week the Virginia Board of Medicine passed regulations applying to the prescribing of buprenorphine not only in office-based settings, but also in opioid treatment programs.

At a time when many governmental agencies are trying to figure out ways to keep people from dying from opioid overdoses, the Virginia medical board is more concerned with diversion and misuse of the life-saving medicine, buprenorphine.

Last Thursday, the Virginia Board of Medicine outlawed opioid treatment programs from giving buprenorphine monoproduct take home doses. All patients on the buprenorphine monoproduct have to be dosed on- site at the opioid treatment program, with directly observed dosing. If patients are willing to switch to the combination product, buprenorphine/naloxone, they will be allowed to continue their earned take homes.

I know why the Virginia Board of Medicine restricted the monoproduct; they are convinced people are misusing this medication, injecting it and selling it on the black market. To be sure, this does happen, and I agree that we must do what we can – within reason – to prevent medication misuse and diversion. But I doubt the members of the Virginia Board of Medicine know that opioid treatment programs already have diversion control programs in place, both for buprenorphine and for methadone, a more powerful opioid.

It appears that rather than open a dialogue with opioid treatment programs and their physicians, to get a better idea of how to help patients, the Virginia Board of Medicine unilaterally issued an edit that will adversely affect these patients.

People on the front lines, working at opioid treatment programs in rural areas, know that the medical board ruing will cause considerable hardship for patients who are in good recovery.

Patients have several options, and all of them present some complications that will have to be overcome. Patients can either chose to stay on the monoproduct and dose daily at their opioid treatment program, switch to the combination product and continue to get take home doses, switch to methadone and get take home doses, or drop out of treatment altogether.

Let’s look at each option.

This medical board appears to assume patients could just switch to the combination product, with no problem. But there is a problem – a big financial problem. I’ve looked carefully at the costs of the generic monoproduct compared to the generic combination product. In my area, there’s about a $120 per month difference between the two, at a dose of sixteen milligrams per day. That’s a best-case scenario.

Let’s assuming the opioid treatment programs were able to pass on only their direct increased cost of medication to the patients. An extra $120 per month to stay in treatment doesn’t sound like much to some people, but to uninsured blue-collar workers who make up the majority of opioid treatment program patients in rural areas, that extra cost is prohibitive. It’s enough to force patients out of treatment.

People fortunate enough to have money and insurance can pooh-pooh this all they want, but an extra $120 per month is unaffordable for many patients enrolled in opioid treatment programs.

What about the small but significant number of patients who say they don’t feel as well on the combination product as the monoproduct? The medical board members exhibit a stigmatizing and biased attitude when they assume all patients who request the buprenorphine monoproduct are intent on injecting and/or selling their medication.

I’m convinced some patients do absorb more of the naloxone in the combination buprenorphine/naloxone tablets than they are “supposed” to. People do respond differently to medications, with no bad intent. These patients can recover nicely on the monoproduct, with careful monitoring, and they don’t have the headache and vomiting sometimes seen with the combination product.

While I agree physicians need to take extra measures when prescribing medication which have value on the black market, we should already be doing this, both at opioid treatment programs and office-based buprenorphine offices.

At opioid treatment programs, we have diversion control plans, including frequent bottle recalls to assess for diversion in all patients, on buprenorphine or methadone. We sometimes check patients’ arms for track marks, particularly if they have a previous history of intravenous drug use.

According to the Virginia Board of Medicine, if patients can’t tolerate the combination product buprenorphine/naloxone, or if they can’t afford it, they can just dose each day at their opioid treatment program.

That position overlooks our patients’ realities too.  In rural areas, patients may drive an hour and a half one-way to get to their opioid treatment program. For a person who is doing well and who has earned a week of take homes, the sudden imposition of dosing daily means three hours out of their day, plus the extra expense of travel. That can be a deal-breaker for financially fragile patients, too.

Think how insulting it would feel for patients who have done well in medication-assisted recovery. Think of patients who have done well for many months, have passed drug screens, passed all bottle recalls, and who have become employed. They have recovered into responsible and productive members of society…only to have legislators decide they can’t be trusted to have take home medication.

What would your response be? I’m afraid I might react very badly.

Since dosing every day at the opioid treatment program isn’t an appealing option, and for patients who can’t afford the extra cost of the combination product, or who can’t tolerate the side effects, methadone is a viable option. It works well, and it’s been proven over the last sixty years to be an effective treatment.

It does have some disadvantages, though. There’s still quite a stigma against methadone, and it is harder to taper off of at some point in the future, if indicated. It has more medication interactions and is more dangerous during the induction phase. It’s possibly less forgiving when mixed with alcohol or benzos than buprenorphine.

It also has street value and can be diverted, which is why all OTPs have diversion control plans, which brings us back to the original reason why the medical board wants to outlaw buprenorphine take homes. If they want to outlaw buprenorphine take homes today – a drug much less likely to kill people than methadone – will they outlaw methadone take homes tomorrow? I think that’s highly likely.

Because buprenorphine is so much safer than methadone, SAMHSA dropped the time in treatment requirement for buprenorphine take homes. Their purpose in doing this was, I thought, to encourage more people with opioid use disorder to get into treatment, and consider using the safer drug, buprenorphine.

Virginia’s new requirement puts an end to any take home doses for the monoproduct while ironically continuing to allow take home doses for patients on methadone, a much heavier opioid more likely to cause overdose death when misused.

The last, and worst, option for patients who will be faced with the decision of what to do when their buprenorphine take home doses are revoked by the Virginia Board of Medicine is to leave treatment.

I really hope this doesn’t happen. One study (Zanis et al, 1997) showed an eight-fold increase in overdose death for patients who left treatment at opioid treatment programs.

At a time when the rest of the world is trying to engage people in medication-assisted treatment of opioid use disorder, and make it more attractive to patients at risk for dying, the Virginia Board of Medicine is throwing up barriers to treatment.

I have a suggestion. Why not use some of those millions Virginia extracted from Purdue Pharma in their lawsuit settlement, and pay part of treatment costs for your Virginia citizens with no insurance?

If Virginia feels it’s imperative to offer the buprenorphine/naloxone tablets for patients with opioid use disorder who are able to tolerate that medication, help them pay for it.

For patients who don’t tolerate the combination tablet, let opioid treatment programs to continue to do what we do best…care for complicated patients with opioid use disorder.. Let us continue to do bottle recalls and arm checks to assess for continued IV drug use in patients who have that history.

I suspect, if diversion data could be examined, we will find what we found with methadone ten years ago. The diversion then was fueled by patients at pain clinics, who had little or no oversight, not the opioid treatment programs with active diversion control programs.

If we find some opioid treatment programs have lax diversion control, address that through the channels already in place, rather than trying to invent something new.

But please don’t erect new barriers for patients seeking to recover from opioid use disorder. It will – literally – kill people.

Happy, Joyous, and Free…

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Avid readers of my blog will recognize the following as a re-run, but I’m feeling under the weather this week, from a virus that’s been circulating in the community:

 

JB: Please tell me about your experience with pain pill addiction and your experiences with buprenorphine (Suboxone).

XYZ: For me, my opiate addiction got so bad, I was taking two hundred and forty to three hundred and twenty milligrams of OxyContin per day, just to stay normal. It had gotten really, really bad. And it started out with a reason. I had kidney stones, and I was in all this pain, but then it got to the point where it solved some other problems in my life and it got out of hand. I tried a lot of different things. I went to detox, and they helped me, but it was…it was almost like I never came out of withdrawal.

JB: How long were you off pain pills?

XYZ: Even after being clean for thirty or sixty days, I would still feel bad. Bowels, stomach…really all the time.

JB: Did it feel like acute withdrawal or just low grade withdrawal?

XYZ: No…I’d try to fix it myself, sometimes, and I would just put myself back where I was. It got to the point where I was making myself sicker and sicker and sicker. And then I got off of it, and stayed off of it for a hundred and twenty days, I guess…but still just sick. Just miserable, and not feeling right. I was miserable. I wouldn’t eat, I was losing weight…

It [buprenorphine] gave me something that replaced whatever was going on in my head physically, with the receptors. It took that [prolonged withdrawal] away, to the point that I felt well. All that energy I would spend getting pills…and I was going to the doctors almost daily. Because taking that much medicine, nobody would write me for that much, so I had to doctor shop.

My only life was going to the doctors, figuring out what pharmacy I could use. I had a whole system of how many days it could be between prescriptions, what pharmacy to go to. It was sick. I was just trying to not get sick.

JB: And you were working during that time?

XYZ: Yeah! I was working, if you want to call it that. I wasn’t a very good employee, but I held a job. I was a regional vice president for “X” company. I traveled a lot, so I had new states where I could see new doctors. That was bad. When I came off the road, I owed $50,000 in credit card bills.

JB: And your wife didn’t know about it?

XYZ: No. It all came tumbling down. And I had gotten into trouble, because they were company credit cards, and they wanted the money back! So, all of the sudden my wife found out that not only do I have a pain pill problem, but we’re $50,000 short, and I wasn’t very ethical in the way I got the money, because it really wasn’t my credit, it was my company’s credit card.

JB: So addiction made you do things you wouldn’t do otherwise?

XYZ: Absolutely. I lied to people, I took money from people, I ran up credit cards tens of thousands of dollars, and really put my family in serious jeopardy at that time. But buprenorphine took away that whole obsessive-compulsive need for pills, made me feel better, and took away all the withdrawal symptoms at the same time. I didn’t worry about it. To be honest, I was such a hypochondriac before. I haven’t been sick in years now. I haven’t had a backache or headache that ibuprofen didn’t cure [since starting recovery]. I was fortunate it was all in my head. I would milk any little thing. I had two knee operations that probably could have been healed through physical therapy, but I was all for surgery, because I knew I’d get pain pills.

JB: That’s the power of addiction!

XYZ:  Yes. Finally I did some research about buprenorphine, online. Actually, I had some good family members, who did some research and brought it to me, because they were concerned for me, and they brought it to me and said, “Hey, there’s a medicine that can help. Call this number,” and I found places out there that would do it [meaning Suboxone], but my concern was the speed that a lot of them were doing it. A lot of them said, OK come in, and we can evaluate you, and after a week you’ll be down to this, and after a month you’ll be down to this.

This was in 2005. And when I asked them what their success rate is, it wasn’t very high. It was something like twenty percent of the people who were doing it [succeeded]. So when I’d finally gotten a hold of “X,” [receptionist for Dr. H], she saved my life over the phone. Because she said, you can come tomorrow, and she said that whatever it takes, they’ll work with you. And I felt good about going to a place where it wasn’t already determined how long it would take. Because I already knew how I was feeling after I would come off of opiates. I didn’t want to do that again.

I saw Dr. H. and felt better within twenty-four hours, although it took a little while to get the dosage right. I think we started off at a lower dose, then we went up on the dose and it kept me so level. I had no symptoms. It cured my worst withdrawal symptoms, my stomach and my bowels.

There’s always a kind of stigma in the rooms [12-step recovery meetings] because I’d been in NA for a little bit of time then [he’s speaking of stigma against medication-assisted treatment]. You realize who [among addicts in NA] is die-hard, one way to do recovery, and who is willing to be educated about some things and understand that there’s more than one way to skin a cat. And I was fortunate that I had a sponsor at that time, and still do, who was willing to learn about what exactly it was, and not make me feel guilty about it. It wasn’t necessarily the way he would do it, but he was a cocaine addict, so he didn’t understand that whole part of it.

He said, “Your family’s involved, you’ve got a doctor that’s involved, your doctor knows your history. If all these people, who are intelligent, think this is an OK thing, then who am I to say it’s not going to work?” He was open-minded. And there are not a lot of people I would trust right off the bat [in recovery], that I would tell them. [that he’s taking Suboxone]. I’ve shared it with some people who’ve had a similar problem, and told them, here’s something that might help you. I always preface it with, [don’t do] one thing or another, you’ve got to do them together. You have to have a recovery program and take this medicine, because together it will work. Look at me. I’m a pretty good success story.

One of my best friends in Florida called me, and I got him to go see a doctor down there, and he’s doing well now. He’s been on it almost eleven months now and no relapses.

To me, it takes away the whole mental part of it, because you don’t feel bad. For me, it was the feeling bad that drove me back to taking something [opioids] again. Obviously, when you’re physically feeling bad, you’re mentally feeling bad, too. It makes you depressed, and all of that, so you avoid doing fun things, because you don’t feel good.

Once I trained myself with NA, how to get that portion of my life together, to use those tools, not having any kind of physical problems made it that much easier to not obsess.

JB: So, how has your life improved, as a result of being on buprenorphine?

XYZ: Well, the most important thing for me is that I’ve regained the trust of my family. I was the best liar and manipulator there was. I’d like to think of myself as a pretty ethical and honest person, in every aspect of my life, other than when it came to taking pills.

JB: So, you regained the trust of your family, felt physically better…

XYZ: I gained my life back! Fortunately, I had enough of a brain left to know it had to stop. Once I started on buprenorphine, it gave me back sixteen hours a day that I was wasting. That’s when I decided I really don’t want to jeopardize my recovery, by going out and looking for a job again [he means a job in corporate America, like he had in the past], because I’ve got this thing, this stigma…they’re going to check a reference and I’m screwed. I’m not going to get a job doing what I was doing for the same amount of money.

My brother had enough faith in me that it was worth the risk of starting this business [that he has now] together. My wife and I started on EBay, making and selling [his product], and slowly grew it to the point that, three years later, I’m going to do over two million dollars in sales this year, I’ve got [large company] as a client, I’ve got [large company] as a client, I’m doing stuff locally, in the community now, and can actually give things back to the community.

JB: And you employ people in recovery?

XYZ: Oh, yeah. I employ other recovering addicts I know I can trust. I’ve helped some people out who have been very, very successful and have stayed clean, and I’ve helped some people out who came and went, but at the same time, I gave them a chance. You can only do so much for somebody. They have to kind of want to do it themselves too, right?

JB: Have you ever had any bad experiences in the rooms of Narcotics Anonymous, as far as being on Suboxone, or do you just not talk to anybody about it?

XYZ: To be honest, I don’t broadcast it, obviously, and the only other people I would talk to about it would be somebody else who was an opioid addict, who was struggling, who was in utter misery. The whole withdrawal process…not only does it take a little while, but all that depression, the body [feels bad]. So I’ve shared with those I’ve known fairly well. I share my experience with them. I won’t necessarily tell people I don’t know well that I’m taking buprenorphine, but I will let them know about the medication. Even though the information is on the internet, a lot of it is contradictory.

It’s been great [speaking of Suboxone] for someone like me, who’s been able to put a life back together in recovery. I’d tell anybody, who’s even considering taking Suboxone, if they’re a true opioid pill addict, (I don’t know about heroin, I haven’t been there), once you get to the right level [meaning dose], it took away all of that withdrawal. And if you combine it with going to meetings, you’ll fix your head at the same time. Really. I didn’t have a job, unemployable, my family was…for a white collar guy, I was about as low as I could go, without being on the street. Fortunately I came from a family that probably wouldn’t let that happen, at that point, but who knows, down the road… I had gotten to my low. And that’s about it, that’s about as much as I could have taken.

It [Suboxone] truly and honestly gave me my entire life back, because it took that away.

JB: What do you say to treatment centers that say, if you’re still taking methadone or Suboxone, you’re not in “real” recovery? What would you say to those people?

XYZ: To me, I look at taking Suboxone like I look at taking high blood pressure medicine, OK? It’s not mind altering, it’s not giving me a buzz, it’s not making…it’s simply fixing something I broke in my body, by abusing the hell out of it, by taking all those pain pills.

I know it’s hard for an average person, who thinks about addicts, “You did it to yourself, too bad, you shouldn’t have done that in the first place,” to be open minded. But you would think the treatment centers, by now, have seen enough damage that people have done to themselves to say, “Here’s something that we have proof that works…..”

I function normally. I get up early in the morning. I have a relationship with my wife now, after all of this, and she trusts me again. Financially, I’ve fixed all my problems, and have gotten better. I have a relationship with my kids. My wife and I were talking about it the other day. If I had to do it all over again, would I do it the way I did it? And the answer is, absolutely yes. As much as it sucked and as bad as it was, I would have still been a nine to five drone out there in corporate America, and never had the chance to do what I do. I go to work…this is dressy for me [indicating that he’s dressed in shorts and a tee shirt]

JB: So life is better now than it was before the addiction?

XYZ: It really is. Tenfold! I’m home for my kids. I wouldn’t have had the courage to have left a hundred thousand dollar a year job to start up my own business. I had to do something. Fortunately, I was feeling good enough because of it [Suboxone], to work really hard at it, like I would have if I started it as a kid. At forty years old, to go out and do something like that…

JB: Like a second career.

XYZ: It’s almost like two lives for me. And if you’re happy, nothing else matters. I would have been a miserable, full time manager, out there working for other people and reaping the benefits for them and getting my little paycheck every week and traveling, and not seeing my wife and kids, and not living as well as I do now.

I joke, and say that I work part time now, because when I don’t want to work, I don’t have to work. And when I want to work, I do work. And there are weeks that I do a lot. But then, on Saturday, we’re going to the beach. I rented a beach house Monday through Saturday, with just me and my wife and our two kids. I can spend all my time with them. I could never have taken a vacation with them like that before.

JB: Do you have anything you’d like to tell the people who make drug addiction treatment policy decisions in this nation? Anything you want them to know?

XYZ: I think it’s a really good thing they increased the amount of patients you [meaning doctors prescribing Suboxone] can take on. I’d tell the people who make the laws to find out from the doctors…how did you come up with the one hundred patient limit? What should that number be? And get it to that number, so it could help more people. And if there’s a way to get it cheaper, because the average person can’t afford it.

The main thing I’d tell them is I know it works. I’m pretty proud of what I’ve achieved. And I wouldn’t have been able to do that, had I not had the help of Suboxone. It took me a little while to get over thinking it was a crutch. But at this point, knowing that I’ve got everybody in my corner, they’re understanding what’s going on…it’s a non-issue. It’s like I said, it’s like getting up and taking a high blood pressure medicine.

I originally interviewed this patient in 2009, for a book that I wrote. Since that time, he and his family have moved to the west coast, but I’ve stayed in contact with him. He’s been in relapse-free recovery for over eight years, he’s still on Suboxone, and still happy. He has excellent relationships with his wife and children, and his business has thrived and continues to grow.

He’s an excellent example of how a recovering addict’s life can change with the right treatment. For this person, Suboxone plus 12-step recovery worked great.

 

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

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

This was a tough blog to write. I want to thread the needle; I want to relate some solid help from 12-step recovery sources without angering some of my faithful readers who become angry with any mention of 12 step recovery.

So you’ve been warned.

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. If not, try again next week because my topics fluctuate.

I talk to many recovering addicts 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 is still regarded as a sin by some religious groups. Other groups know addiction 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, which are also sound psychological advice. However, the twelve steps provide 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.

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 now for over 16 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.

Addiction taught harsh lessons that came at exorbitant prices, so we should 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 an addict stole money from a drug dealer, it should not be paid back, especially if it puts the recovering addict at risk. In some situations, the best amends may mean having no contact with the other person.

Some recovering addicts have long lists of bad behavior to make amends for, and other recovering addicts’ lists may contain only a few people. Many addicts 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.

Addiction, 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.

 

U-47700

Illicit U-47700

Illicit U-47700

 

 

 

My patients are sometimes my best teachers, so when one of them mentioned a new opioid drug, I searched for information online. This new drug is called Pink, or Pinky, but its chemical name is U 47700.

This drug was first developed in the 1970’s by a scientist at Upjohn, a pharmaceutical company. This drug has never been studied in humans, but produces a strong opioid-type effect due to its action at the mu opioid receptor. It’s quite powerful, with estimated potency at seven or eight times that of morphine.

Last year, forty to eighty overdose deaths in the U.S. were attributed to this drug, depending on which source you read. As a man-made research drug, it was legal to obtain until late last year, when the DEA placed U-47700 on Schedule 1 status. This means it is no longer legal to buy online, and that it has a high potential for causing addiction and harm.

Rolling Stone did an article on this drug last fall, saying it was one of the drugs that contributed to Prince’s death, found in his blood at autopsy along with fentanyl. When Rolling Stone published their article, it was still an unscheduled drug. According to that report, there had been around 80 deaths attributable to U 47700, which is usually combined with fentanyl or other drugs. [1]

In some areas, fake Norco tablets were peddled by drug dealers. These pills actually contained U-47700, or a combination of U-47700 and fentanyl. At least a dozen people died from these fake pills, because they believed they were buying hydrocodone, but actually ingested the much more powerful opioids U-47700 and/or fentanyl.

When I listened to an online lecture from last year’s American Society of Addiction Medicine’s fall conference, one of the speakers, Robert DuPont M.D., said the drugs of the future will be synthetics. We’ve already seen this in the rise of synthetic marijuana products, and now it appears we are seeing synthetic, novel opioids hit the streets.

These drugs are cheaper to make by the big drug labs in China and Mexico than traditional heroin, as I said in a former blog post.

It’s impossible to tell how big a problem U-47700 is at this time. Routine toxicology may not detect this substance, unless the lab is told to test for it specifically. It’s quite possible this drug could be a component of much of what is sold as heroin. We already know heroin is frequently mixed with fentanyl because it’s cheaper to manufacture. If U- 47700 is cheap to make, it’s also likely to become a common component.

Synthetic drugs present legal problems. A chemist who is experimenting may come up with a new psychoactive product, and it can hit the market before any law can be passed against its use.

These novel drugs aren’t illegal until after they appear on the streets and cause harm. Then governmental agencies like the DEA rush to change laws to cover these drugs.

There’s another big danger to synthetics. Sometimes the chemists making drugs aren’t that careful. Not all chemists are Walter White, the character on “Breaking Bad.” Walter was an educated chemist who wanted to make the purest product possible, in order to please his customers and maintain his reputation. I dare say most chemists aren’t as educated as Walter, and aren’t as meticulous with details.

There’s always the risk that these people will inadvertently make a similar drug with completely different properties and side effects.

MPTP is a great example of a drug manufacturing error.

MPTP, chemically known as 1-Methyl-4-phenyl-1,2,3,6-tetrahydrophyridine, can be accidently manufactured instead of MPPP, a closely related drug with opioid-like effects. In the 1980’s a handful of people injected what they thought was MPPP, and developed severe Parkinson’s disease. This happened because the chemist accidently made MPTP, which destroys cells in the brain that control movement of the body. MPTP caused Parkinson’s disease in these drug users. This error, though tragic for the people affected, led to useful information to better understands Parkinson’s disease and its treatments.

And some of what I read online seemed overblown. For example, one section of the Rolling Stone article said the drug could cause rectal bleeding. Upon closer reading of the article, the rectal bleeding was reported by people who had used the drug rectally. So yeah, that might cause problems down there.

In another online article, the police chief of Park City, Utah, is quoted as saying, “This stuff is so powerful that if you touch it, you could go into cardiac arrest.” [2]

I am skeptical about that statement. Unless there’s something in it allowing it to pass through the barrier of the skin, that’s doubtful.

Making speculative statements without proof can lead to hysteria, and can undermine the credibility of people who are trying to inform drug users of some very real dangers.

For me, the message is “buyer beware” with heroin. It may or may not be heroin. It could be fentanyl, it could be U-47700, and it could be a whole lot of other things.

This means it’s even more important for drug users to try “tester shots,” meaning use a fraction of drug to assess its potency. It’s important not to use alone, and to stagger injection times, so that there’s always someone able to call for help if needed. Drug users of opioids should have up-to-date naloxone kits on hand in case the worst happens and someone overdoses.

And above all, consider getting into opioid use disorder treatment: https://findtreatment.samhsa.gov/

  1. http://www.rollingstone.com/culture/news/u-47700-everything-you-need-to-know-about-deadly-new-drug-w443344
  2. http://www.inquisitr.com/3600359/new-drug-pink-causing-deaths-nationwide-opioid-u-47700-easily-purchased-online-despite-federal-ban/

Trump and the Opioid Grants: What Will Happen Next?

"Du-oh!"

“Du-oh!”

 

 

 

 

 

The front page article in the January 9, 2017 issue of Alcoholism and Drug Abuse Weekly is the jumping-off point for this blog entry. This excellent article outlines in plain language how the $ 1 billion Cures Act allocations were supposed to be used.

But on January 20, 2017, President Trump placed a sixty-day freeze on regulatory actions and executive orders that have been published but not yet taken effect. I scoured the internet to try to figure out if Obama’s Cures Act falls into this category. I’m still not certain it does.

The Cures Act, passed in late December as one of President Obama’s last actions had strong bipartisan support. Under this act, the Substance Abuse and Mental Health Services Administration (SAMHSA) is to administer funding for grants to each state. These grants are called State Targeted Response to the Opioid Crisis Grants, or Opioid STR for short.

The amount allotted to each state isn’t based on opioid overdose death rates, but rather on treatment gaps in each state. “Treatment gap” is a term for how many people need addiction treatment in a state compared to how many people are actually getting it. The bigger the gap, the more money that state will be allotted out of the $1 billion pot, to be disbursed over two years.

The states with the biggest treatment gaps are California, due to receive nearly $45 million, and Texas and Florida, both to receive around $27 million.

If dollars were spent based on per capita overdose death rates, the three top states would be West Virginia, New Hampshire, and Kentucky. This, of course, led to some criticism of the way money allocations were decided. Some people feel that the states that need money most desperately won’t get a big enough piece of the money pie.

As the ADAW article points out, some people feel the method of allocation is unfair to states where action has already been taken to treat substance use problems, out of their own state budget. By proactively treating problems, these states won’t qualify for as much of this federal money as states that ignored their opioid problem.

Other complaints are that states which decided not to expand Medicaid will now be awarded more than their share of this federal money, since their treatment gap is wider due to fewer citizens with substance use disorder who qualify for Medicaid to pay for substance use disorder treatment.

Probably no method of dividing the money can be perfectly fair to all states. I think the Cures Act does as good a job as is possible under the circumstances.

However, I am troubled by one aspect of this money distribution.

Each state can spend their federal money as they see fit.

In the ADAW article, H. Westley Clark, past director of SAMHSA’s Center for Substance Abuse Treatment, said, “State attitudes towards agonist medications will be a controlling factor.”

Oh dear. This could be bad.

States which have held a strong bias against methadone or buprenorphine as treatment for opioid use disorders may decide not to spend money on this evidence-based form of treatment.

But now, with President Trump’s sixty-day moratorium on new legislation, no one knows what will come to pass. There are so many uncertainties.

In the January 23, 2017 issue of ADAW, the front page article outlines how the repeal of the Affordable Care Act (ACA) could adversely affect the treatment of opioid use disorders. As we know, Trump campaigned on a promise to kill this healthcare Act. No one knows what he will decide to do, or how it will affect the 30 million people who have health insurance through the ACA now.

As the ADAW article points out, much of the gains in funding for treatment of substance abuse and mental health illnesses came from the ACA, and from the Mental Health Parity and Addiction Equity Act which preceded it. This last Act made it illegal for insurance companies to cover physical health problems while denying coverage for mental illness and substance abuse. Other laws made it illegal to refuse coverage for pre-existing illnesses. Denial of coverage for pre-existing conditions was common practice until relatively recently. When insurance companies could pick and choose who they wanted to insurance, patients who needed health insurance the most couldn’t get it.

Would canceling the ACA affect patients with substance use disorder who are already in treatment? Yes, of course, though I’m not sure to what degree. I know it would be more of an issue for my patients in office-based treatment with buprenorphine than for my patients enrolled at the opioid treatment program.

In the opioid treatment program setting, I don’t know of any patients with Obamacare who were able to get reimbursed for what they paid to our treatment program. These patients paid out of pocket even if they had insurance. I don’t know what the problem was, but I do know I had some bizarre conversations with physician reviewers. One physician said my patients with opioid use disorder, treated with methadone, needed to go a cheaper route, and get methadone prescribed in a doctor’s office. Of course, this is illegal, and has been since 1914, but that fact didn’t budge the reviewer.

Some of my office-based buprenorphine patients were able to enter treatment only because they got Obamacare. I would estimate I have eight to ten patients on Obamacare at present. They get reimbursed for the office visit and drug screening charges they pay to me, and get their medication paid for at the pharmacy, except for a co-pay.

Some of these patients have high deductibles, and still have to pay out of pocket for part of the year, but once they meet the deductible, have their opioid use disorder treatment paid for.

We’ve had the usual difficulties with prior authorizations with these patients, but it’s been no more difficult than patients with traditional insurance.

What would happen to my patients with Obamacare if it suddenly disappears? I assume most couldn’t afford treatment and would drop out. Data about patients who leave treatment for any reason shows relapse rates in the 85-90% range, so most of these people would go back to active addiction. I’ve become very attached to these patients, and this idea breaks my heart.

About a month ago, I was talking to Kristina Fiore, a reporter for the Wall Street Journal, who has done some outstanding reporting on the nation’s opioid use disorder epidemic. She called me for some background information for an article she was researching. Near the end of our conversation, she said something to the effect that everyone is always talking so negatively about our present opioid addiction situation, and she needed to know about reasons for optimism.

I thought about what she said for a few moments. Then I told her the only positive thing I saw was more money being released for desperately needed treatment.

Now, even this one positive aspect feels very uncertain.