Update

 

 

 

 

 

 

I have an update to my blog of September 16. The patient, who was hospitalized with life-threatening endocarditis (infection of the heart valve), was finally granted the right to have visitors – about fourteen days into his hospital stay. Mission Hospital administrators gave no reason for the change of policy, but I have reason to believe they were feeling some heat from the many people advocating for the patient.

Since this was the patient’s second admission for endocarditis, the chart said cardiovascular surgeons were not going to do a second heart surgery, per hospital policy, because the patient had continued to use drugs intravenously. The patient was told no other hospital would accept him in transfer because he had no insurance. The palliative care team was called in to manage his case, which appears to mean his physicians thought he was going to die without surgery.

Thanks to the efforts of several very tenacious providers at the opioid treatment program where the patient had just been admitted, this case got the attention of many people. Emails flew about the state. The outrageousness of this case got people involved, who got other people involved. Besides the patient’s providers at the OTP, advocacy efforts were undertaken by personnel at the NC State Opioid Treatment Authority (SOTA), the Medical Director of DHHS in NC, the General Counsel for DHHS, and out-of-state help from a lawyer with the Legal Action Center in New York. Patient advocacy groups were helpful, and several other people whom I won’t list by name but know who they are.

Thanks to advocacy efforts, the patient was transferred to Chapel Hill last week, to be evaluated for surgery of his infected heart valve.

I have good reason to believe Mission Hospital had complaints filed against it with the Joint Commission. The Joint Commission is an independent, not-for-profit organization that gramts accreditation to hospitals if they meet certain standards. Accreditation is important, because it affects payment from payers, including Medicare and Medicaid.

I have also heard that a complaint was filed with the Department of Justice, reporting that the hospital violated the patient’s rights under the Americans with Disabilities Act.

A big meeting was scheduled for October 2, with hospital administrators and the patient’s many advocates, people who were upset with their handling of this patient’s case. Unfortunately, the day before the meeting, Mission administrators canceled, saying it hadn’t been put on their schedule, by some oversight.

By this time, I felt those administrators lacked credibility.

I hope this case gets the attention of hospital leaders. I hope the time has come where hospitals will be held accountable for their mis-treatment of patients with opioid use disorder (OUD). OUD is a completely treatable chronic illness, not bad behavior that deserves the death penalty.

 

 

Advertisements

What I Do With My Day

Dr. Cat

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Some of my friends and family still don’t understand what I do for a living. When I was working in primary care, they understood. Now that I work with patients with substance use disorders, they are unsure. I tell them I do the same thing I’ve always done: I take care of sick people.

“Yeah, but they’re not sick sick, right? Not like people who usually go to the doctor.”

“Um, sometimes they are.”

For them and anyone else who wonders what an addiction medicine doctor does all day, this blog entry is a summary of a recent workday at the opioid treatment program where I work.

This was a Wednesday, which I dedicate to established patients. On Wednesdays, I talk to patients who are established in treatment about numerous issues, including adequacy of their dose, other medical problems, new medications, and other things. I also do yearly history and physical exams on patients who have been with us for a while.

In the following, I have changed the patients’ characteristics to protect their identity, while still conveying the essence of our interaction.

My first patient has been with us for several years and has done very well. She was seeing me for her yearly exam. First, I asked about her if her dose was still working well for her, and she said yes. She has been on methadone 105mg for more than a year, and her drug screens have been positive only for only methadone and its metabolites, since shortly after her admission.

This is a nice quality of methadone. Most patients don’t develop a tolerance to the anti-withdrawal effects of their dose, allowing them to remain comfortable on the same dose for months or even years. Other patients have fluctuations in their dose requirements, for assorted reasons: changes in other medical problems, changes of other medications, or changes in activity level, to list a few.

My patient looked at her picture on our electronic record, taken at her intake nearly two years ago. “I hate that picture! It looks awful. Can I get a new picture?”

“Sure, just ask the receptionist or your counselor. You do look different now. You look like that person’s younger, happier sister. But maybe it’s good to keep that old picture, at least in your mind, to remind you what opioid use disorder took from you – your joy.”

We proceeded with her history and physical, and at the end, I told her I thought her biggest health issue was smoking cigarettes. She was now abstinent from illicit drugs for nearly two years, but was still smoking nearly a pack and a half per day. I asked her if she had considered trying to quit. She said she would like to quit but wasn’t yet ready to try. I told her I thought she could quit, because she was doing so well in her recovery already. I asked her if it would be OK for me to ask her about smoking cessation in the future, and she said yes.

It’s important to hit the right tone with patients on this issue. I don’t want to pressure her and demand she try to stop smoking right now, because – of course – that approach doesn’t usually lead to behavioral change. Instead, I wanted her to think about why quitting smoking would be best for her, and to support her efforts in any way I can.

I can’t ignore the smoking issue. Tobacco-related illnesses are one of the most frequent killers of people in recovery, and I would not be doing my job if I ignored such an essential health issue. I like my patients, and I don’t want them to suffer illness and disability from a preventable condition, especially since their lives have changed so dramatically already.

My next three patients all wanted dose increases. Two were on methadone, and both were on sub-therapeutic doses, as evidenced by late-day withdrawal symptoms. I examined both before they dosed, so I could see them when their symptoms were at their worst. Both had large pupils and sweaty hands, and I ordered dose increases for both.

The third patient was a little trickier. He was dosing on buprenorphine at 16mg, and said he felt withdrawal symptoms of sweating with muscle aches and runny nose, which started at around 1pm each day. Since he doses at around six-thirty in the morning, his withdrawal symptoms started around six hours after dosing.

I didn’t think increasing above 16mg would cover the patient for a full twenty-four hours. I talked to the patient about switching to methadone, since unlike buprenorphine, there’s no ceiling on its opioid effect. As a full opioid, the more you take, the more withdrawal blocking effect.

He was reluctant to switch. He said he heard bad things about methadone, about how it gets in your bones and rots your teeth, and he didn’t want that to happen.

Inwardly, I sighed. Such ideas are still all too common in this region of the country. There’s still more stigma against methadone than against buprenorphine. While I’d love it if all my patients felt normal while dosing with buprenorphine, that’s not the case. There will never be one medication that’s right for everyone, and methadone is a life-saving medication too.

I corrected his mistaken impressions about methadone, without downplaying the real risks of methadone. I told him it was easy to overdose on methadone if he used benzodiazepine or alcohol while on it. I acknowledged that methadone does appear to be more difficult for most people to taper off of, but since he was early in treatment, we weren’t anywhere near close to considering any kind of taper.

He agreed to the switch, and I wrote an order to stop buprenorphine and start methadone. When patients switch from buprenorphine to methadone, I usually start methadone at a lower dose, at around 20-25mg on the first day. If they are older, on many medications, or have serious medical conditions, I may need to start lower than 20mg on the first day. I planned to see him again in a few weeks to see how he was doing.

My next patient had been admitted to the hospital for exacerbation of COPD, and the day I saw her was her first day back at our OTP. She usually doses on methadone at 80mg per day. The hospital didn’t call to confirm her dose with us, so I was very worried that she had gone without methadone for the five days she was in the hospital, on top of the COPD exacerbation.

When I (finally) got her records, I saw she was dosed at 80mg per day, because that’s what she told them she was taking.

I’m glad they dosed her. But it seems to me they should confirm that with her treatment facility before dosing her at that amount. Nearly all our patients will tell their other physicians the truth, but what if the patient, in a misguided attempt to feel better, exaggerated her dose and said she was on 110mg per day?

What if this patient wasn’t even currently in our treatment program? Dosing a patient at 80mg per day who wasn’t already on methadone at that dose would be deadly. When the stakes are that high, why take that risk? I know our phone system has byzantine voicemail, but the 24-hour number is given at the beginning of the voicemail, so they should be able to reach an administrator at any time, who can get all needed information for them.

Anyway, my patient was feeling better, and had no gap in treatment since she’d been dosed while in the hospital. I made note of some new medications and applauded that she had five days without cigarettes and encouraged her to continue the nicotine patches she’d been started on.

I had asked to see my next patient for an odd reason: we got a call that this lady was injecting her methadone dose each day. The caller remained anonymous, which always makes me suspicious of the caller’s motives, but I felt I needed to check it out anyway.

It’s rare for anyone to inject methadone. For one thing, methadone has a high oral bioavailability, due to excellent oral absorption. With methadone, you can get around 90% of an intravenous dose just by swallowing that dose. But injection drug use is about more than just the physiology. Often there’s a psychological component. Patients accustomed to injecting drugs can get a rush of dopamine just with the ritual of injecting.

I didn’t think this patient I was seeing would be doing that, since she’d been in treatment for over a year. All of her urine drug screens were positive only for the expected methadone and its metabolites.

When I saw her, I told her we received reports that she was injecting her methadone, and that I was sorry to inconvenience her, but I needed to check for myself, for safety reasons. To my great surprise, I found track marks. I asked her about what caused the marks, and she denied any IV drug use of her methadone or anything else, but there was no mistaking what I was looking at.

I told her I was afraid to give her further take-home doses, and that she needed to dose with us on site from now on.

She was furious, and while I understood her anger, I was in a pickle. There was no way I was could give her take home doses, given what I saw. It wasn’t safe. Her explanations of how the tracks came to be there didn’t sound realistic at all (cat scratched her in the same place multiple times, repeated injury from a fishing hook in the same area multiple times). I tried to be frank with her, and told her I knew tracks when I saw them.

Some physicians might not be so confident. Early on in my career as a physician treating opioid use disorders, I might have been a little unsure. After seventeen years of doing this job, I know track marks when I see them.

She asked when she could get her take home levels back, and again I was stumped. How could I ever be confident this patient wouldn’t inject take home medication? I could keep a check on her arms, but of course she could use other sites, and do I really want to have to ask a patient to strip so I can be sure there’s no injection drug use? No, I’m not going to do that.

If I knew what happened, it would give us something to work with, but my patient was unwilling or unable to tell me, so she will have to dose with us daily.

The rest of the day continued like this, with patients asking for dose increases, some asking for recommendations about how to go about decreasing their dose, and others checking in because they were medically fragile. I like to see patients with significant medical issues every three to four months, so I can stay current about any new medications, and remain updated on the status of their other medical issues.

This is what I do during my work day. I love my job and feel like I can help people and make a difference in their lives. I’m better able to do that where I work now than I ever could during the years I worked in primary care.

I’ve got the best job in the world.

 

The Rights of Patients with Opioid Use Disorder

 

 

I’ve been notified of an alarming development that’s come to pass at Mission Hospital in Asheville, NC.

Recently Mission Hospital decided that patients with opioid use disorder will be unable to have visitors while they are hospitalized, and they will also be unable to have any electronic devices with them. The hospital will provide “sitters” to stay in patients’ rooms at all times, for patients with opioid use disorder. It’s unclear to me if this policy also applies to all patients with substance use disorders. It’s also unclear if their policy applies to all patients with opioid use disorder, or just those in early recovery.

These measures have been imposed to prevent hospitalized patients from using illicit drugs.

The first edict – that patients with opioid use disorders can’t have visitors – isn’t absolute. Apparently potential visitor candidates must be pre-approved by the Chief Medical Officer of the hospital.  I don’t know what criteria this CMO uses, but it would seem this policy would have the effect of isolating a hospitalized patient.

I’ve only been hospitalized once, with a broken leg, but without the presence and support of my fiancé, I would have been distraught and more frightened than I already was (and I’m a doctor!). And that’s just a broken leg, completely fixable. Imagine how much worse it would be for patients hospitalized with severe or life-threatening medical problems. Isolating patients at such a time is cruel, even if it may be legal.

Banning electronic devices also has the effect of isolating the patient. Think of it – no email, no cell phone calls, no Facebook, no surfing the net to pass time…this measure also seems unnecessarily harsh.

Mission Hospital’s administrators probably instituted these actions because visitors brought drugs to patients in the past. Of course this happens, and it’s vexing to staff and dangerous to the patients. But surely some sort of common-sense measure can be taken short of barring all visitors and banning electronic devices.

As far as having a sitter in the room – I, for one, would be most annoyed if the hospital where I’m paying to get treatment decided I needed the constant companion of an utter stranger.

Frightened hospital patients with life-threatening illness need to discuss treatment options with loved ones. A random person sitting in the room will not serve as a substitute. The wrong kind of person could even increase patient anxiety.

These new measures taken by Mission are likely to increase the risk of a patient leaving against medical advice (AMA). The cynical side of me wonders if that’s the hospital’s intent. Many people with substance use disorders don’t have insurance, and often need long hospital stays. Are these new measures, which isolate patients with substance use disorders, intended to get rid of these “bad” patients?

I hope not.

As good as their intentions might have been, Mission’s actions might be a violation of the Americans With Disabilities Act (ADA).

I saw a presentation at the spring American Society of Addiction Medicine (ASAM) conference, given by Elizabeth Westfall, an attorney who works at the Department of Justice (DOJ). The topic of her lecture was the new Opioid Initiative started by the DOJ. Right now, there’s a push to investigate and eliminate unnecessary and discriminatory barriers for patients with opioid use disorder who are in treatment and recovery. She said the DOJ was doing an outreach to stakeholders to spread information about what counted as discrimination, and to offer technical support when needed.

She said the DOJ works with U.S. Attorneys across the country to look at these cases of discrimination. She says they can usually negotiate settlements where part of the agreement is to make sure discriminatory practices are ceased. If settlements can’t be agreed upon, the DOJ assists with litigation when needed.

Ms. Westfall told the ASAM audience that the ADA prohibits discrimination based on disability in different areas: employment, services from state and local governments, and public accommodations. She said that patients with opioid use disorder are protected under the ADA if they are not currently using illicit drugs.

That last part is what makes ADA claims tricky. Who is to say what is “current use?” Clearly, she told us that patients in medication-assisted treatment are not considered to be current users. These patients are taking medications prescribed by a physician for a specific purpose. These patients are covered under the ADA, so long as there is no current illicit drug use.

Elizabeth Westfall also gave information about how to file a claim with the DOJ. Of note, employment discrimination claims need to go to the EEOC, but even if you send them to the DOJ, she said they would be forwarded to the appropriate agency.

There is a specific case at issue right now. I will change some data to protect patient identity, but here’s the story: A patient entered medication-assisted treatment on methadone about two weeks ago. He did well, and got up to a dose at which he stabilized. Then he became ill with malaise and fever, and went to Mission Hospital’s emergency department. He was found to have a potentially life-threatening medical disorder, and was admitted for treatment.

He has not been permitted to have visitors, and his mother was apparently refused permission to visit him. He’s been isolated from any support network he might have, due to Mission’s new policies in place to prevent illicit drug use among their hospitalized patients.

Is this a violation of the ADA? Since I’m no lawyer (despite having watched every single “Law and Order” episode from the twenty years it aired), I don’t know.

Bu it doesn’t seem right to me, separating the patient from critical support during a life-threatening illness. I know the medical staff at the OTP he goes to has been talking to hospital officials, trying to negotiate a compromise.

Here is the information given at the ASAM meeting, should any of my readers know of a case of discrimination against patients with opioid use disorder:

File a complaint:
http://ada.complaint@usdoj.gov

Great website for further reading/information:
http://www.ada.gov

Pregnant Women with Opioid Use Disorder

 

 

 

 

Before I launch into my blog entry for today, I’d like to remind readers that my intent with my blog is to offer general information. My blog isn’t a substitute for real medical advice based on a face-to-face evaluation by a medical professional. In medicine, the devil is in the details, meaning one patient’s case could vary in some small way that would indicate a completely different approach to treatment. I have people write me for specific and personal medical advice, which I cannot provide. You will be disappointed with my answer, which is nearly always to see your own doctor.

Having said that, this blog entry is about my general recommendations to pregnant women with opioid use disorder:

Medication-assisted treatment with methadone or buprenorphine is still the gold standard of treatment for pregnant women with opioid use disorder. Despite some recent studies which indicate medically-supervised withdrawal in the fetus may not be as dangerous as we previously thought, relapse rates for the mother are still high.

There’s no conclusive evidence that medically supervised withdrawal of opioids during pregnancy reduces the incidence of neonatal opioid withdrawal (NOW), also called neonatal abstinence syndrome (NAS). [1]

That’s right…tapering a pregnant patient off methadone or buprenorphine doesn’t reduce the risk of NAS, probably due to high relapse rates.

In keeping with that information, at our opioid treatment program, our pregnant patients are continued on their life-saving medication. If a pregnant patient demands a taper, even after hearing all the current expert recommendations, I’ll honor her wishes, but only after she signs a form saying she’s been informed about possible harmful outcomes.

Due to the enormous stigma pregnant women with opioid use disorder face, I like to see these patients once per month. I can offer them support and remind then they are doing the right thing for themselves and their babies despite what other people tell them. I can also more closely monitor their medical issues and the adequacy of their dose of methadone or buprenorphine.

I try to address certain issues each month when I a see these pregnant women in our treatment program, to make sure they have all the data needed, and to make sure we have good peripartum planning.

In no particular order, here are the items I review at each visit. If I forget one, since I’m seeing the patient repeatedly, I’ll address it at the next visit.

1. Recommendations for pregnant patients with opioid use disorder have not changed recently. The gold-standard, best treatment choice is medication-assisted treatment with either methadone or buprenorphine.

Many pregnant women are urged by their family, with the best of intentions, to taper off methadone or buprenorphine while pregnant. Sadly, even some obstetricians still recommend taper off medication-assisted treatment, lacking the information from experts in their own field.

Sometimes I can gently educate these physicians…and sometimes it doesn’t help.

Sometimes I ask the patient if they’d like to bring their significant other, or other relative, to one of our visits so that I can explain the importance of staying in treatment. Often, once the relative has more information, they don’t try to discourage my patients from remaining in treatment. I can only do this with patient consent, though.

2. The risk of withdrawal in the newborn isn’t related to the dose of the mother during pregnancy. It’s counterintuitive, but studies done over the past three to four decades don’t show a clear relationship between dose and risk of NAS. Given this fact, there is no reason to keep the mom’s dose lower than she needs. Since we know that the mother will be healthier and have a better outcome with adequate dosing, we need to titrate the mom’s dose to the point withdrawal symptoms are suppressed.

3. We expect a pregnant patient’s dose to need to increase during pregnancy. This is particularly true with methadone. Because of plasma volume expansion and faster methadone metabolism, the pregnant patient’s methadone blood level will drop during pregnancy, mostly during the last three months. Sometimes splitting the mother’s dose (giving half the dose in the morning and half in the evening) works better than increasing the overall dose. We also have some evidence that splitting the dose may reduce the risk of withdrawal in the newborn, so it’s win-win. Splitting the dose isn’t possible if the patient has an unstable home situation, or if she struggles with other drug use. It’s always a matter of balancing risk and benefit.

After delivery, we usually need to decrease the dose slowly, as the pregnant patient’s body gradually goes back to its pre-pregnancy state.

4. I try to help the mom stop smoking during pregnancy, since there’s good evidence to show smoking cessation reduces the risk of withdrawal in the newborn. This isn’t an easy thing, but very important for the baby’s health – and the mom’s.

5. It’s OK to breast feed while on either methadone or buprenorphine. Studies show only tiny amounts of either medication in the breast milk. Experts say the benefits of breast feeding clearly outweigh the risks. And it’s OK if the patient does not want to breast feed. Let’s not be “breast-bullies” and shame women who decide not to breast feed. Let’s support their decision no matter what.

However, if the pregnant patient has used other substances, particularly during the two months prior to delivery, the neonatologist may make a recommendation not to breast feed. Most commonly, the drug in question is marijuana. I tell my patients to heed the advice of the neonatologist.

6. I make sure the patient understands the plan for pain control during hospitalization. I want to continue the patient’s same dose throughout her hospitalization for the delivery of her baby. Patients can still have epidurals which will work well. After delivery, they can be prescribed short-acting opioids like any other pregnant patient, since the daily methadone or buprenorphine won’t be enough to treat acute pain.

I also make sure patients know the names of medications that are contraindicated with methadone and buprenorphine. If they are given one of the mixed agonists/antagonists like pentazocine (Talwin), butorphanol (Stadol), or nalbuphine (Nubain) they will go into immediate withdrawal. This is more problematic for patients on methadone than buprenorphine. Lately I’ve written the name of all three on a piece of paper and given it to the pregnant patient, determined to avoid therapeutic misadventures that have occurred in the past.

Several years ago, a new-ish obstetrician called me, concerned about one of our patients who had elevated blood pressure after delivery. She wondered if there was something in the methadone that caused this, as she had seen it in several other deliveries.

I was mystified. No, I said, I didn’t know of any data saying that methadone raised blood pressure. Worried, I combed the literature but didn’t find anything.

Then I got a copy of the patient’s hospital record. Shortly before the patient had elevated blood pressure, she got a dose of Nubain.

Mystery solved. The Nubain put the patient into immediate withdrawal, resulting in very high blood pressure and other miseries. I hadn’t considered this possibility before, because I had talked to this OB in the past about the need to avoid the mixed agonists/antagonists. She must have forgotten this.

So now, I give all pregnant patients a piece of paper on which I write the three medications, and tell the patients to tell their providers that they are allergic to all three medications. I hope this will prevent further episodes of precipitated withdrawal in patients.

7. I make sure our pregnant women know their babies will need to stay in the hospital for monitoring for six or seven days. I want them to be prepared for this, since it’s upsetting not to be able to bring the baby home immediately.

The baby must stay to be evaluated for withdrawal. Because of the very long-acting nature of both methadone and buprenorphine, the infant won’t have withdrawal as soon as it is born. Withdrawal, if it occurs, can be delayed up to six days. I tell the moms-to-be that the prolonged admission is for the baby’s safety.

Lately, more hospitals are encouraging “rooming-in” which means the infant and mother have a room assigned to them where the mom can keep the room dark and quiet, and either breast feed or cuddle with skin-to-skin contact that soothes the baby.

This newer way uses non-medical means to reduce the infant’s withdrawal symptoms. Sometimes it isn’t possible, obviously, if the baby has other major medical issues, and may have to be admitted to the intensive care unit. But when possible, rooming in is a wonderful option.

8. All drug use is of special concern during pregnancy. Ironically, we have more data about the harm caused by alcohol during pregnancy, yet it’s legal, and part of many social activities. If the mom struggles with use of alcohol or other drugs, we try to refer her to inpatient treatment programs, for more intensive treatment of her substance use disorders.

Our first choice is the state facility in Greenville, NC, called Walter B. Jones Alcohol and Drug Use Treatment Center. They do a terrific job, and admit pregnant women as a priority. They can provide prenatal care as well as maintaining the patient on methadone or buprenorphine. And they can address whatever other drug use has been a problem, providing a much higher level of support. Soon, that standard of care may be offered at other North Carolina ADATC programs, as they become certified as opioid treatment programs too

.Pregnant women on medication-assisted treatment can’t be admitted to many inpatient residential programs, because these programs won’t “allow” patients to dose daily with methadone or buprenorphine. This severely limits our choices for pregnant patients. I hope this will change soon, since those programs aren’t observing the standard of care for pregnant women.

Let me say a little about stigma and bias. We’ve seen too many sensationalistic stories in the media about “drug-addicted babies.” As a point of fact, babies aren’t born with addiction. They may be drug-dependent, but they aren’t addicted, since the definition of addiction requires mental obsession with the drug, and craving. Newborns obviously can’t formulate that mental preoccupation for substances.

Pregnant moms face a great deal of stigma for having substance use disorders. These disorders are defined by loss of control over the substance, yet if one of these women become pregnant, they are suddenly reviled for their lack of control. They are sometimes judged severely, and told they must not care about their babies or they would quit using drugs.

Substance use disorders are so much more complicated than that.

In fact, harsh confrontation of a pregnant woman predicts treatment failure, with worse outcomes in both mom and baby.

Best results are seen when the woman is treated with compassion, and motivated by hope.

All mothers want to have healthy babies, and moms who use drugs are no different. They want to be good moms, and they want to do the right thing for their babies. Sometimes pregnancy can be a positive thing, since it can be a strong motivator for patients to ask for help. Let’s support them in any way that helps.

1. Jones et al, 2017 “Medically Assisted Withdrawal (Detoxification: Considering the Mother –Infant Dyad,” Journal of Addiction Medicine, Vol. 11, No. 2, March/April 2017)

 

A Bridge to Treatment

 

 

 

 

 

In my last blog, I lamented the lack of communication and cooperation between medical professionals involved in the care of patients with opioid use disorders.

Opinion about medication-assisted treatment has split the field in half. Most old-school, 12-step-based, abstinence-only programs discourage patients with opioid use disorder from seeking treatment with medication like methadone and buprenorphine. Some providers at opioid treatment programs rail against the lack of knowledge and open-mindedness of these programs, yet don’t inform stable patients on buprenorphine about their office-based options, which may be more appropriate and less restrictive (an option usually not available to methadone patients). Office-based providers accept patients from opioid treatment programs without bothering to get records that could give essential information that could make treatment safer.

Hospitals lack information about appropriate referral sources to treat opioid use disorders, and emergency departments let patients leave after a near-fatal overdose with only a list of phone numbers to call for help.

It’s time to break down barriers and put the welfare of patients first.

At the American Society of Addiction Medicine (ASAM) conference this year, I heard a possible solution.

Dr. Sarah Wakeman and Dr. Laura Kehoe, both associated with Harvard Medical School, talked about their Bridge Clinic. This program is set up to be a bridge between acute hospital or emergency department care and long-term primary care for patients with substance use disorders.

This model is “low barrier” or “low threshold” care, which means eliminating obstacles between the patient and appropriate care. The clinic’s mission is to provide on-demand, compassionate care to patients in all stages of addiction.

Most of their patients have opioid use disorder, and around 77% are treated with buprenorphine products. Around 11% are treated with naltrexone. I assume the others are treated for alcohol use disorder or other substance use disorders.

The Bridge Clinic serves as an immediate access clinic for Massachusetts General Hospital patients with substance use disorders who don’t have a primary care provider. This clinic provides both drop- in and scheduled appointments for patients. It’s been in operation for the past several years and has grown quickly, indicating a need for their services. In some cases, patients elect to remain in treatment at this Bridge Clinic rather than go on to primary care, office-based medication-assisted treatment.

This clinic is opened seven days per week, from 9am to 5pm. The physicians who staff this clinic are very aggressive with starting same day pharmacotherapy for substance use disorders, not only MAT for opioid use disorder. They refer to opioid treatment programs when that level of care is most appropriate, or if the patient needs methadone rather than buprenorphine.

They also work with families, and connect patients with other needed services.

The clinic staff includes an addictionologist, family practice physician waivered to prescribe buprenorphine, recovery coach for peer support services, resource specialist who finds other programs to help patients with their needs (food, housing, etc), and administrative assistant and a patient service coordinator. Extended care in the overnight hours can be provided by the colleagues at the emergency department.

Patients are referred from Massachusetts General Hospital, where patients with substance use disorders are offered induction onto medication-assisted treatment while hospitalized.

That’s right. I said that. Patients with opioid use disorder are started on methadone and buprenorphine during hospitalizations for other medical ailments. For example, a patient with endocarditis from IV opioid use disorder can be started on treatment with methadone or buprenorphine before ever leaving the hospital, and the Bridge Clinic can take care of the patient during the gap between hospitalization and arrival at an office-based or opioid treatment program.

This is treatment nirvana!

Patients with near-fatal overdoses can be started on buprenorphine before they even leave the emergency department, and use the Bridge Clinic to link them with care.

This wonderful new idea has substantial evidence to show it works. D’Onofrio et al., [2] published results of a randomized study of patients with previously untreated opioid use disorder who presented to the emergency department. In one arm of the study, patients got treatment as usual, which was referral to treatment facilities. In the second arm, patients received brief intervention counseling and referral to care to an outpatient buprenorphine provider. In the third arm, patients were started on buprenorphine and linked directly with outpatient buprenorphine treatment, with no gap in treatment. In this last group, nearly 80% of patients followed up with buprenorphine treatment and had significantly less opioid use than patients in the other two arms.

For this reason, the Bridge Clinic wanted physicians who worked in the emergency department to get their waivers to prescribe buprenorphine, and accomplished this. When they see patients with opioid use disorder, they either do the induction onto buprenorphine in the ER, or send the patients home to do a home induction by providing a two-day pack of buprenorphine. Since the Bridge Clinic is open seven days a week, such patients can be seen quickly.

This is wonderful, since we know from studies that patients who are started on MAT while in the hospital or emergency department have much higher rates of treatment retention. We also know that higher treatment retention means fewer opioid overdose deaths.

Around half of the patients referred to the Bridge Clinic from the hospital or emergency department are seen within 24 hours of being referred.

The clinic endorses a harm-reduction model, and does not discharge patients for continued drug use. They staff attempt to build trust by offering services without attempting to control the patients’ intake of drugs. The patients are included in the plan of care. They have low no-show rates, and are aggressive at getting patients back in to treatment if they miss appointments.

The Bridge Clinic’s goal is to eventually transition care, after acute stabilization, to somewhere closer to where the patient lives. Sometimes this can be worked out easily, and sometimes there may be problems. Bridge Clinic staff attempt to work out these difficulties.

Some patients need the Bridge Clinic short-term, and others for longer. Their average length of stay is around three months. This program provides help to patients with ongoing drug use, homelessness, pregnancy with substance use disorders, chronic pain patients, and to patients leaving incarceration, eager to find help prior to a relapse.

I was so inspired by the description of this program. It was obvious that these women excelled at gaining the cooperation of their colleagues at their hospital and in the primary care practices. It really sounds like the ideal situation, with everyone working for the good of the patient, no matter what their needs are. There are no waiting lists, and no senseless obstacles for patients to surmount.

Every community needs a bridge clinic, I think. How wonderful that would be, with a warm and friendly place to send patients in crisis, open every day of the week. Patients could be assessed, stabilized, then referred to the best treatment program nearest to where they live.

However, North Carolina isn’t Massachusetts. We have a higher percentage of people with no health insurance, while Massachusetts has expanded Medicaid, which helps pay for this sort of treatment.

But at least we have a model for quick-access, low-barrier care for people in crisis with substance use disorders. If we can ever muster the cooperation and will for such a program, these people can teach us how to do it.

1. Sordo et al., 2017, British Medical Journal
2. D’Onofrio et al., Journal of the American Medical Association, 2015, Apr 28; 313(16): 1636-1644.
3.  

Buprenorphine Prescribed in Two Settings

 

It’s very confusing. Even medical professionals get confused, so imagine how it is for patients.

I’m referring to the different setting where buprenorphine can be prescribed for the treatment of opioid use disorder.

Opioid treatment programs deliver care for patients with opioid use disorder in a much more structured setting. OTPs are regulated by sets of federal, state, and sometimes even local agencies. This limits flexibility when responding to changing patient needs, but provides a much more structured – some would say rigid – treatment setting.

OTPs must do observed, on-site dosing, with established protocols. Take home doses can be given, but patients must first meet a set of eight criteria. Some states, along with the federal agency, dropped the time-in-treatment requirement for buprenorphine, since it’s a safer medication than methadone.

Substance use disorder counseling is built in this system with stricter monitoring. OTPs must do a minimum set number of observed drug screens on patients. Opioid treatment centers offer a more intense, controlled, and hopefully more supportive setting for patients new to buprenorphine treatment, or who are struggling in treatment.

Office-based settings for treatment with buprenorphine aren’t nearly as regulated. Providers in office-based settings have more freedom to customize the treatment to the needs of the patient. The prescriber can decide how often the patient needs to be seen for follow up appointments and for substance use disorder counseling. Drug screen frequency and counseling intensity are left up to the prescriber. Some practices do observed urine drug screening, and some practices do not.

Opioid treatment programs are inspected by a number of state and federal agencies. Office based practices are not inspected at all, in most states. Other states, like Tennessee and Virginia, have more regulation around office-based practices, but overall, office-based practices vary more widely in quality and intensity than opioid treatment programs do.

So which setting is best? It depends on the needs of the patient.

As I said above, opioid treatment programs may be best for new patients, or those patients who use other substances besides opioids. Office-based programs may be better for stable patients because their treatment can be customized, allowing more freedom.

Ideally, office-based programs and opioid treatment programs should work together, collaboratively, to provide the best care to meet the needs of the patients. This idea of continuity of care happens with other chronic illnesses; patients with asthma may see a pulmonologist during a bad flare of illness, then resume care with a primary care provider after the expert has done everything an expert can do.

But with opioid use disorder, we aren’t there yet. I still sense a spirit of competition rather than cooperation between OTPs and OBOTs (office-based opioid treatment). It’s as if providers think to themselves, “There are only so many patients to go around, and if my patient transfers to that other practice, I will lose money.”

Believe me…there are plenty of patients to go around, unfortunately.

Providers who work at OTPs sometimes make unkind statements, saying OBOT providers are careless, poorly educated about opioid use disorder, and make bad decisions that lead to diversion of buprenorphine products into the black market. Then OBOT providers talk badly about OTPs, saying they are nothing but for-profit juice bars.

I’m as guilty as any – in my blog from last December, I made fun of an OBOT provider who used the cut and paste option of producing notes for office visits, leading to a statement about the patient being 8 months pregnant at each monthly visit for more than a year. (but that was a funny example, no?)

Somehow, we’ve got to start cooperating.

In my next blog, I’ll describe a type of treatment program that was set up to be a bridge between acute care in the hospital or emergency department, and treatment at both settings, OBOT and OTP. It’s inspiring me to be more collaborative and cooperative.

 

ACLU Sues to Allow MAT During Incarceration

 

 

 

I was sent a link to this article that made my day:

https://bangordailynews.com/2018/07/26/mainefocus/aclu-lawsuit-demands-maine-man-get-addiction-treatment-in-jail/

This article reports that the ACLU (American Civil Liberties Union) has taken the case of a man in recovery on medication-assisted treatment who must serve a nine-month jail sentence starting in September in Maine. This man, Zachary Smith, has been in recovery on a buprenorphine product for the past five years. Ordinarily, the jail has a policy of NOT continuing medication-assisted treatment to inmates, leading to forced withdrawal from these medications.

Opioid withdrawal doesn’t (usually) kill healthy adults but can be fatal to people in fragile health. Acute withdrawal does cause significant suffering, and it leaves the person at increased risk of death from overdose upon release from incarceration.

The ACLU says there are two reasons why denying this medical care is against the law. First, denying medical treatment to inmates violates our 8^th amendment against cruel and unusual punishment. Second, the Americans With Disabilities Act recognizes opioid use disorder as an illness covered by that Act. This means denying appropriate medical treatment for this condition is discrimination.

The ACLU filed a preliminary injunction to speed up a hearing of the case prior to the beginning of the jail sentence. This means the case will be heard – hopefully – before Mr. Smith must show up for his sentence in early September.

I was so happy to see this case. I think it could be a watershed moment for this nation, one way or the other. I have never understood how it could be legal for a person to be denied medical care while incarcerated, yet it happens across this country every day. In most jails, patients in treatment for opioid use disorder with medication-assisted treatment are denied their medication.

I’ve blogged about this before. I’ve even called the NC chapter of the ACLU myself, many years ago, to ask for help, but was told I had no standing, and that it needed to be the patient to contact the ACLU for help. But my patients sentenced to jail are often reluctant to bring an action against their local jail, feeling they might receive retribution of some sort – a very realistic concern, at least in my area.

Can you imagine the uproar if any other group of patients with chronic illness were denied medical treatment? What if patients with heart disease were denied life-sustaining medications during incarceration? What if diabetics were denied their insulin? For all I know, this may be happening. If it is, citizens of this country should not stand for this. We shouldn’t stand for it for people with substance use disorders, either.

Since all of this is happening in Maine, I was curious if North Carolina has any similar cases pending. I went to the website of the North Carolina chapter of the ACLU and found nothing advocating for inmates to be continued on medication-assisted treatment for opioid use disorder.

However, I did find that our state chapter of the ACLU filed a federal class action lawsuit against North Carolina’s Department of Public Safety’s policy of denying treatment for Hepatitis C to incarcerated people with the virus. The current class action suit was filed on behalf of all people incarcerated in NC with Hepatitis C.

https://www.acluofnorthcarolina.org/en/press-releases/aclu-incarcerated-people-sue-nc-failure-provide-life-saving-treatment

Current expert recommendations are that all incarcerated people receive Hep C testing, since according to data from the Center for Disease Control, around one-third of all prisoners are infected with Hepatitis C.

In the past, recommendations were to wait until the person with the Hep C virus developed liver damage before treating. Those expert recommendations have changed. The current recommendation is that all people with active Hep C infection should be treated. Experts now also recommend treatment even if the patient has not stopped illicit drug use.

The NC Department of Public Safety’s present policy is that incarcerated people with Hep C infection that’s caught early, when at its most treatable, are forbidden to receive treatment while incarcerated.

This article says there’s no law for universal testing of prisoners for Hep C, and the decision to test is left up to personnel at each jail site.

Both issues are important, though to me, continuing access to medication-assisted treatment appears more pressing, and could prevent more deaths in the short term.

I will follow these cases, and give updates to my readers.