New Ideas and Common Themes at Addiction Medicine Conferences

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This blog is about some of the common themes covered at the three recent Addiction Medicine conferences.

Overdose drug deaths:

All three conferences presented general statistics about how the rates of drug overdose deaths increased during 2020, coinciding with the COVID pandemic. Most overdose deaths are polysubstance; that is, decedents are found to have opioids and some other class of drug in their systems at the time of death. Many of these overdose deaths have opioids such as fentanyl and stimulants, either cocaine or methamphetamines.

We think of overdose as being a process associated with sedation and gradually slowed breathing until respiratory arrest occurs, with eventual cardiac arrest. However, the stimulants kill more often by causing cardiovascular events: strokes, heart attacks, or fatal cardiac arrythmias, even in young people without previous medical problems.

We know that stress is a common trigger for drug use, and the statistics show increased consumption for all types of drugs, including alcohol, during the COVID 19 pandemic.

Medications for opioid use disorder during incarceration:

All three addiction medicine conferences had sessions on this topic. In the past, prisons and jails have refused to allow patients to continue their medications to treat opioid use disorder. However, with recent successful lawsuits brought by inmates demanding appropriate medical care, jails and prisons are being forced to re-think their procedures. I sense that jail and prison medical staffs see the writing on the wall and are starting to consider changing their usual anti-methadone/buprenorphine protocols.

There are several ways to get treatment to patients who are incarcerated.

During the ASAM conference, I went to a session where the speaker, a provider of medical care in a prison facility, described how their facility got certified as an opioid treatment program. She outlined all the steps required of her facility and said it was a tremendously difficult process. Though SAMHSA and national agencies have asked jails and prisons to be able to treat patients with opioid use disorder with medications, she said it is those very institutions that make it so difficult to get the approvals needed to become an opioid treatment program.

I heard other sessions about how a mobile clinic, based out of a brick-and-mortar existing opioid treatment program, can be a novel way to dose incarcerated patients. Other people at the conferences talked about having OTP staff transport medication to a jail facility and leave it with medical staff there, using a chain-of-custody form to document in the approved fashion.

There are many possibilities and opportunities to get creative about how to provide methadone or buprenorphine to existing patients and to start these treatments for new patients.

Oh, and by the way…jails should NOT refer to clonidine and clonazepam and other comfort medications that they give for opioid withdrawal as “medication-assisted treatment.” That’s not medication assisted treatment, though it can be of some value to some patients.

Micro-dosing of buprenorphine:

Some providers are interested in a process intended to make it easier to transition patients from full opioids to buprenorphine. This would be helpful because it would eliminate the need for patients to go into withdrawal before buprenorphine could be started. For most short-acting opioids, twelve to twenty-four hours of abstinence from opioids are required to be in enough withdrawal to start buprenorphine. If buprenorphine is started too soon after a full opioid it can cause precipitated withdrawal.

This year at the conferences, lectures and discussions about a procedure known as “micro-dosing” was discussed to achieve transition more easily.

This involves starting buprenorphine at small doses and gradually increasing until the patient it at a full dose of buprenorphine, at which point the patient can stop using other opioids. I’ve read about several difference “recipes” for micro-dosing, but most schedules involve giving .25 to .5mg on day one, then increasing to .5 to 1 milligrams on day 2, and so on, slowly increasing the dose over the next five or so days until the patient is at the 12mg range. Supposedly the patient won’t feel precipitated withdrawal if buprenorphine is started in this way.

Providers also want to try using micro-dosing to help patients get off methadone and on to buprenorphine in an easier manner. Traditional methods of transition require patience and planning. For example, a patient on methadone 100mg per day would be reduced by 5mg per week until he is on 40mg, stay on that for a week, miss two days of dosing, and start buprenorphine on the third day if COWS  (Clinical opioid withdrawal scale) score is at least a 12. I’ve transitioned many patients this way over the past ten or so years.

But micro-dosing is reportedly a faster way to achieve transition. That may be appealing to certain patients who are facing situations where they need to transition quickly.

Micro-dosing appeals to some office-based buprenorphine prescribers who want to accept patients on methadone from opioid treatment programs. It’s possible this could be used, but the office-based physician still must coordinate care with the medical director of the opioid treatment program.  I’ve heard a few office-based practitioners talk dismissively about getting the OTP involved, saying the providers are hard to reach. That might be true in a few cases, but all OTPs are mandated to have 24-hour telephone accessibility. This number is recited on the voicemail options. Usually when a provider says he or she couldn’t reach me on the phone, it’s because they never tried, assuming I could not be reached.

I’m open to the idea of micro-dosing. But I also wonder about the practicality of this quicker procedure. How well does it really work? The initial studies say it works well, but why take the risk of precipitating withdrawal when we already have reliable methods of transitioning from methadone to buprenorphine? I do understand that sometimes patients are inpatient and want the transition to go more quickly than with the traditional method.

Also, what about the nuts and bolts details of micro-dosing? The lowest commercially available sublingual films or tablets are 2mg dose units. The manufacturers counsel against cutting their products because they’ve never done studies to show the active ingredient is evenly distributed over the entire film/tablet. Of course, our patients cut both the films and the tablets all the time. However, what might be fine for a patient already on a stable buprenorphine dose might not be OK for a patient doing a micro-dosing induction, where more precision is desired.

One of the papers I read about micro-dosing said they had a pharmacy with a sharp cutting device cut the tablet form of medication into .25 and .5mg doses.

I’m going to wait for more studies before I undertake any micro-dosing.

Racial inequities in medical care including addiction medicine care:

Minority populations have worse health outcomes than the general population, and substance use disorders are no different. The ASAM national conference had one whole morning plenary session dedicated to racial inequalities in healthcare.

The AATOD conference had sessions discussing racial disparities in the course of illness in minority patients with substance use disorders compared to non-minority patients with the same.

At one session, a psychiatrist presented data collected 2013-2015 that overdose deaths among blacks showed the highest rate of increase in overdose deaths than any other group. This increase was largely driven by increases in metropolitan deaths. A more recent study by Furr-Holden et. Al., published in March of 2021 in Addiction, showed the steepest rate of increase in opioid overdose deaths was greater for African Americans than any other ethnic group, from 2013 -2018. Preliminary data shows even worse data through the COVID pandemic.

Outcome data shows that access to life-saving treatment medication improves survival in patients with opioid use disorder, but access is limited by various factors among African American patients. These factors could include location of the closest treatment facility, transportation problems, affordability, and the like. In other words, if treatment is available geographically but other obstacles get in the way, the patient may still not be able to access treatment.

All of this was good information and it prompted me to have a discussion with our OTP’ program director about how much we are doing to reach minority communities in our area, and what possible obstacles to treatment might exist that we haven’t considered. We decided the best way to determine what obstacles exist was to ask our existing minority patients. We plan a confidential survey, asking their opinions about how are doing and what we could do better to reach and engage minority communities.

We’ve got a few things in our favor. We have reasonably diverse staff, with a wide range of ages and prior work experiences. Five of our twelve counselors are members of minority groups. Nursing staff has less diversity, with no racial minorities and only one male.

Next week: I will write about the extent of law enforcement interference with buprenorphine prescribing in Tennessee, using a recent case as an example.

Conference Season

Each spring we have several addiction medicine conferences. This year was the same; we had our regional North Carolina Society of Addiction Medicine Conference, followed closely by the national AATOD (American Association of Treatment for Opioid Dependence) meeting. Next week is the national ASAM (American Society of Addiction Medicine) conference.

This year, all of them were/are virtual.

I learned a great deal from the first two conferences and look forward to the third as well.

For a regional meeting, this year’s NC spring Addiction Medicine conference was impressive. I wasn’t expecting too much from the virtual meeting, so I was surprised at the ease of access to the sessions, and the graphics for the conference. This conference is supported by the NC Governor’s Institute on Drug Abuse, along with the state’s Department of Health and Human Services. They have been able to get speakers of prominence from the state and national levels. For example, Dr. Paul Earley, current president of ASAM, gave one of the opening keynote addresses.

Federal and state updates on various topics were given, and I particularly enjoyed several talks given by our state’s public health experts on overdose data in our state. We had excellent presentations by several of the most prominent psychiatrists in our state, which is always informative. Dr. Anthony Dekker, renowned for his work with Native American populations, gave interesting updates on the populations he treats.

Every other year, this conference recognizes outstanding work in the field of Addiction Medicine at the state level by giving the Frederick B. Glaser award. It’s awarded to people who have shown ongoing commitment and effort in our field in the areas of treatment, education, research, and leadership.

I (probably along with many other people) nominated Dr. Eric Morse, and was pleased that he won, in addition to Dr. Blake Fagan

I’ve worked most with Dr. Morse, who is tireless at providing advice and guidance to physicians and others working in our field. He chairs our regular OTP physicians meeting, among other activities.

We’ve had teleconference monthly meetings starting around 2008. This last year, due to COVID uncertainties and physicians’ demands, the meeting was held weekly. Dr. Morse moderated all of them. That’s a big commitment of time, especially in the middle of a workday. I find these sessions very helpful, but some weeks I’m too busy with patients to attend. Some weeks I tune in for at least a half hour. Anyway, I really appreciate Dr. Morse’s consistent efforts.

He also started a handful of opioid treatment programs in our state. Many people won’t recognize what a financial challenge this is. With all the regulations around the operation of an opioid treatment program, it usually takes more than a year to get through the approval process to open. Most physicians don’t have the capital to make this happen, but somehow Dr. Morse has been smart and savvy enough to open a handful of OTPs.

This means his OTPs are truly run by a physician, instead of a corporation.

Don’t get me wrong. I work for a for-profit corporation, and the state is fortunate to have these OTPs, because otherwise we couldn’t come close to meeting the needs of patients with opioid use disorders. But I really like the idea of a physician-owned & operated opioid treatment program.

But I digress.

I don’t know Dr. Blake Fagan quite as well, since he doesn’t work at an opioid treatment program but rather as a family physician in the Mountain Area Health Education Center (MAHEC) in Asheville, NC. He is a professor in the Department of Family Medicine at the University of North Carolina and has taught many residents in primary care fields about opioid use disorder and its treatment with medications. This is so important, because it ensures a fresh army of medical workers to help with the opioid use epidemic. He’s educated new providers about how to treat patients in office-based settings with buprenorphine products.

Both physicians richly deserved the award and I’m happy they both won.

The AATOD conference was a little different. I found it to be more difficult to navigate the online meetings; it was a little daunting for me, but I’m not very tech-savvy. It took me some time to figure out how the sessions worked; sessions were pre-recorded, and participants needed to view these presentations, then join a live question and answer session with the presenters. I also had to account for the three-hour time difference, but I made it to all of the plenary sessions in the mornings, and a fair number of the pre-recorded sessions in the afternoons (evenings for those of us on the east coast).

The AATOD plenary sessions are by their nature more about the big picture of opioid use disorder, and AATOD had some great speakers. I was interested in the talk given by Anja Busse, from the United Nations Office on Drugs and Crime. We can sometimes forget that the opioid epidemic taking place in the U.S. isn’t the only thing going on in the world of substance use disorders.

The AATOD meeting had speakers talk about the intersection of the justice system and opioid use disorder treatment, which appears to be a hot topic at present. They had a Justice from the Nevada supreme court and Nevada’s governor Steve Sisolak spoke as well.

With the attention now focused on inmate health, I am hopeful that soon we’ll see incarcerated patients have access to treatment medications for opioid use disorders.

The individual sessions were interesting. I particularly loved being inspired by Dr. Loretta Finnigan, who did the pioneering work on treatment for pregnant women with opioid use disorders, about the compassionate and effective treatment of women with opioid use disorder, followed by Dr. Mishka Terplan, with focused information. I’ve heard them both speak before, and always find it rewarding to hear them.

One of the most interesting sessions was about the changes in the privacy standards for patients getting care at opioid treatment programs. There’s been many people pushing to allow opioid treatment programs enter data about their patients to their state’s prescription monitoring program. Indeed, I’ve blogged about this before (see my blog on September 2, 2020). Presenters made great points. Their best argument against easing confidentiality standards was that prospective patients may be discouraged from seeking help for opioid use disorder if they know their information will be made available to anyone with access to the prescription monitoring program. In some states, law enforcement can access this data, and some states have loose controls around this. The potential for misuse of that information is worrisome.

Next week is the national ASAM meeting, and I’m anticipating it too.

Virtual meetings are great in some ways, not so great is other ways. I appreciate the convenience and cost savings of virtual meetings, aside from reducing the risk of COVID transmission. And I can work on my craft projects while listening to presenters. But a great deal of the “feeling” (for lack of a better word), is lost. I miss that sense of comradery and common purpose I get sitting in a room of my peers, all dedicated to improving our knowledge and skills to better treat our patients. That feeling isn’t reproduced virtually, for me.

I believe that next year we will be back to actual meetings, and I vow not to take that for granted.

Blog Anniversary and…. I Win an Award

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Eleven years ago, I started this blog to provide a dependable source of information for people seeking to learn more about opioid use disorder and its treatment with medication. Back in 2010, there wasn’t as much talk about the festering opioid use disorder epidemic in our country. Back then, pain pill mills still flourished in some parts of the country, pouring fuel on the fires of this illness.

Not many people outside the field of Addiction Medicine endorsed the use of buprenorphine products or methadone as a treatment choice back then, and I felt aggrieved by that. Here was this treatment with more evidence to support its benefits than practically anything else in all of medicine, yet there was much misinformation and stigma against it.

“If people just knew of the benefits,” I thought, “If they just knew and understood, they would feel differently about these medications and this treatment.”

I set out to educate as much of the world as I could.

My blog didn’t always get it right. When I read early blog posts now, I sometimes cringe. I use more person-centered language now, and I like to think I’ve become less judgmental towards critics. Trading insults doesn’t really help anyone and perpetuates bad feelings.

I’m an odd person to be writing such a blog. I did my medical residency in Internal Medicine. I didn’t get any training in Addiction Medicine during my residency, though I did learn about 12-step recovery in medical school. At The Ohio State University, every medical student was required to attend at least one Alcoholics Anonymous meeting.

After residency, I worked for seven years in primary care before I developed my own substance use disorder. I took time off work to seek treatment. Like most physicians, I was lucky to receive high-quality treatment with prolonged monitoring after acute treatment. As part of that treatment, I was asked to participate in 12-step recovery.

For me, it worked well. It filled a void in my life by forcing me to re-connect with people without the title of “physician.” During 12-step meetings, I was like all the others seeking help.

I found a great deal of benefit from the Twelve Steps and Twelve Traditions, and from my sponsor, who remains a dear friend these nearly twenty-three years later. I grew as a person and re-connected with a neglected spirituality.

After my treatment, I went back to work in primary care, and found it just as distasteful as before. I was looking for something different when a doctor friend asked me to work for him at a treatment center while he went on vacation.

I thought I’d be doing admission physicals on patients entering their inpatient (abstinence-based) program, which sounded like fun. I did NOT know I’d be seeing patients on methadone and starting patients on methadone. By the time I found this out, I’d already made a commitment to my friend so I couldn’t back out.

I felt like this methadone thing was shady, a “fringe” area of medicine, and decided that when my friend returned, I’d tell him I didn’t “believe” in putting addicts on drugs like methadone. My opinions were based on mistaken preconceptions, certainly not on science.

The patients I saw started my education process. They told me how methadone (buprenorphine was not yet available) had changed their lives for the better and helped them stabilize into the person they were always meant to be. “How can this be true?” I thought. What the patients were saying, and the positive changes I was seeing with my own eyes, contradicted what I thought I knew about treatment and recovery.

Intrigued, I started reading about opioid use disorders, called “opioid addiction” at that time. I went to local addiction medicine conferences and eventually joined the national American Society of Addiction Medicine and our state chapter. I discovered a ton of data clearly proving the benefits of methadone in the treatment of opioid use disorder. I was amazed to read that starting methadone dramatically reduces the risk of patient death.

Not dying…that alone makes this medication worthwhile.  How could I not have heard about this before? As we know now, medical school and residencies paid little attention to addiction and its treatment, so no wonder I had not learned about the use of medications for opioid use disorder.

I gradually transitioned from primary care to addiction medicine, and by 2004, I was working exclusively at opioid treatment programs.

Meanwhile in my own recovery, I continued to go to 12-step meetings. Of course I never spoke about my work at meetings, knowing how most people there felt. But gossip exists in those rooms as it does in every human organization. A few times I was approached after a meeting and told what I was doing professionally was wrong, and against the policies of that 12-step group. Fortunately, by then I knew no person could speak for the entire organization. I also knew these misguided people didn’t have all the facts. They were like I had been, which was uninformed.They didn’t know the science behind treatment. They were relying on opinion and not fact, so their opinions didn’t matter too much to me.

I knew what the science said, and I leaned on that. I also talked to other people in recovery who worked at opioid treatment programs. They also went to 12-step meetings and worked with patients being treated with methadone. They didn’t see any conflict. Those wise people didn’t see one form of treatment opposing another. They felt different treatments should be complementary. That is, rather than an “either/or” approach, recovery could be “both/and.”

That’s what I think now. I hear abstinence-only proponents criticize medications for opioid use disorder, and I think to myself, “If you only knew how much some people benefit from methadone/buprenorphine, you would change your mind.” When I hear people who support medications for opioid use disorder talk badly about 12-step recovery, I think the same thing. If you could only see the great benefits some people get from these recovery meetings, you wouldn’t be so harsh. Meetings aren’t perfect, and the people who attend them certainly aren’t, either, but they can be so helpful.

This year, I have the honor of receiving the Holden/Lane award for Patient Advocacy from the American Association for the Treatment of Opioid Dependence. I believe it is mostly for my efforts writing this blog, and for some other advocacy things I’ve done at a local level for my own patients.

I am thrilled to receive this honor, and a little embarrassed, too. I feel like there are hundreds of people like me working in our field, toiling to do our best job for the patient sitting in front of us, day after day, week after week, etc. My efforts seem puny when compared to professionals who lobby congress and work on changing laws in our nation.

But I do feel a fire to defend and promote adequate treatment for all patients with opioid use disorder, and it’s turned into kind of an obsession for me. I understand how medical professionals lack education about opioid use disorders. And when I offer information to other people including professionals, I expect them to care about the science. When they don’t…I can write snarky things about them in my blog, which is still kind of fun.

I get angry when my patients, mostly all nice people who happen to have a bad disease, are treated poorly. When they endue prejudice and stigma, I get a little obsessed with correcting mistaken impressions and assumptions. I’ve written letters and made phone calls to all sorts of medical and dental professionals, to judges and lawyers, and to law enforcement personnel.

I’ve given many talks locally and around my state about opioid use disorder and its treatment with medications. I’ve talked to probation and parole officers, to EMS workers, and other members of the community. I’ve spoken at churches, university conferences, to community groups, and with DSS workers. I’ve talked to groups of doctors and to nurses. I hate talking in front of people, but after I get started, I lose myself in trying to communicate the important message that medications used to treatment opioid use disorder do work.

I am deeply grateful to be chosen for this distinguished award. The winners in previous years are most impressive people, so these are big shoes to fill.

I plan to continue to advocate as I can, by letter writing, giving talks when asked, and…by continuing this blog.

Primary Care Difficult to Find for OTP Patients

This area where I now live is odd in some ways. It’s beautiful country, but odd. Around here, people must “apply” to become patients of local medical practices. This isn’t because of COVID; it was like this before too.

Many of my patients tell me they keep getting turned down when they apply to be patients at local practices. Some of these patients have no insurance, some have Medicaid, and some have private insurance. Sometimes they wonder aloud to me if they were turned down because they truthfully revealed they had opioid use disorder and were being treated with either methadone or buprenorphine.

There’s just no way to know. It would be illegal, of course, for practitioners to turn down a patient for primary care because they have opioid use disorder, whether they are in or out of treatment. But usually these patients aren’t given an exact reason why they are being turned down for care. They are usually told something vague, like, “Our providers don’t have the expertise to treat your medical conditions.”

I’d love to do a little undercover investigation of this situation, but just don’t have the time.

But last week, I saw a new patient seeking treatment for her opioid use disorder. She had other medical issues that had long been neglected. This is not unusual, because active substance use disorders often push other health issues into the background of a patient’s attention. However, this patient told me she had gone to a local medical clinic for help, both for her drug use and for other medical issues. She was turned away without being seen. She was told she had to get help with her drug use first.

She went to an FQHC, an abbreviation for Federally Qualified Health Clinic.

It isn’t easy for a medical clinic to get FQHC designation. These clinics need to meet certain standards, including making medical care easier to obtain by using a sliding scale for payment. That is, the less money a patient has, the less they are charged for care. The benefit of being an FQHC is that they get paid more for Medicaid and Medicare patients, because they are providing affordable care for low-income people.

But my patient got no care.

As she told it, at her first visit she disclosed her regular illicit opioid and methamphetamine use and asked for help with those problems along with other medical problems. She had severe joint pains of her hands and a few other common medical symptoms. She says she was told she could not receive care until she got her addiction under control. The patient sensed this wasn’t right, and asked to talk to the office manager, who told her the provider didn’t feel comfortable treating any of her medical problems because her drug use would interfere. Again, she was told she could return when she got her addiction “under control.”

She says she received no referral for treatment of her addiction.

I asked the patient if she wanted me to call this office to tell them she’s now in treatment, and she said yes, but please wait until she could see if our treatment was going to work. I agreed.

On her seventh day of treatment, she looked and felt much better. She felt stable on her dose of buprenorphine 16mg per day and she had no cravings for opioids or opioid withdrawal. She had not used any heroin since admission, though she did smoke a small amount of methamphetamine on her fifth day of treatment. This is not unusual, and she was talking to her counselor about her triggers for methamphetamine use.

I asked again if she wanted me to call the FQHC, for her to get her needed primary medical care done there. She said yes, she had to go there, since they were the only care available for low-income patients near her home.

So I called them. I was angry for the way she had been treated, and truth be told, spoiling for a verbal fight. Fortunately, I had a pharmacy student shadowing me that day.

As an aside, pharmacy students who rotate through our local hospital for part of their training have asked to come one day a week to shadow me, to learn about opioid use disorder and its treatment with medication. I’ve been delighted to be given a chance to blather on about my favorite topic. I always make sure to have a few willing patients tell the students their stories of recovery, and about how treatment benefitted them. The students are always amazed, and a few have asked if there’s any place for pharmacists at opioid treatment programs. I say yes, some programs do use pharmacists, though currently ours does not. I’ve been happy with their enthusiasm and willingness to learn.

Anyway, a student was with me that day, and I tend to be better behaved when people are watching me. As I made the phone call, I kept repeating to myself, “Be collaborative, be collaborative…”

I got the receptionist, and described who I was, and which patient I was calling about. Immediately I was put on hold and the office manager came on the line. As I remember, our conversation went something like this:

“Hi, I’m Dr. Burson and I’m seeing Mrs. X.  I understand she was seeking medical care at your office and was told she needed to get help with her addiction issues prior to seeing a provider there. I’m calling to let you know she is getting care with us and has made a great deal of progress with…”

“We absolutely did not refuse to provide care for her. I remember her very well. She was hollerin’ in our lobby about us denying her care. We only told her that we couldn’t treat any of her medical problems until she got off the drugs. That’s not unreasonable. That’s all we told her. We did NOT deny her care.”

“Yes, that’s why I’m calling,” I said, smooth and unruffled as silk, “She found help for her opioid use disorder and stimulant use disorder, so I was wondering if I can tell her to make another appointment with your provider. And by the way, anytime you have a patient with opioid use disorder, please refer them to us. We want them. We can help them.”

A bit of a pause ensued. I sensed – or perhaps imagined –  she didn’t really want my patient in that practice but was smart enough to know she’d be breaking the law if she refused.

“Of course. Tell her to call today, we’ll be happy to see her.”

“Thank you so much for your help. I’ll tell her.”

The student, having heard the whole conversation, said something to the effect of how is that not denying care? I said I thought it was the same thing too, but didn’t want to argue or offend, since I get more cooperation with politeness and cooperation.

The Americans With Disabilities Act, known as the ADA, makes it illegal to discriminate against someone due to their medical conditions. It is illegal to refuse to provide medical care to a person only because they have substance use disorder.

How should this FQHC have handled my patient? Of course, drug use can influence other medical problems. But the answer isn’t turning the patient away. The answer is to see the patient, form a therapeutic alliance with the patient, and assess her needs. Start treatment of medical problems and include referral for treatment of substance use disorders, while also addressing her other medical problems.

Instead, it feels to me – and her – like they said to her, “You’ll have to take your nasty bad habit somewhere else and stop your bad behavior before you are allowed to see our providers.”

They absolutely bungled it.

Out of curiosity, and to try to see who their medical director was, I went to their web page. Ironically, splashed in large letters over their home page was this statement: “We promise not to deny services based on a person’s race, color, sex, national origin, disability, religion, sexual orientation, or ability to pay.”

Well OK.

One nurse practitioner was listed as a provider, but I didn’t see a medical director listed. I plan to call this nurse practitioner soon, when I am calm and cheerful, in the hopes of doing some gentle education.

I’ll let her know about our opioid treatment program, and that we are happy to receive referrals for patients with opioid use disorder, and that she can refer them any weekday. (Just as COVID hit, we started doing admissions five days per week). I also hope to convince her to refer patients with substance use disorders for treatment, just as she would for any other illness, and to give her my cell number to call if she ever has any questions about what to do for a certain patient with substance abuse, even if they don’t have opioid use disorder.

Treatment of Opioid Use Disorder During Incarceration

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Change is coming, but slowly.

In the past, many county jails and state prisons refused to allow patients prescribed methadone or buprenorphine to remain on their medication during incarceration. Most experts felt this was denying medical treatment to inmates, something which – we thought – was not allowed in the United States. But due to the stigma against opioid use disorder and the medications commonly used to treat it, our patients were denied treatment repeatedly.

Now there’s hope on the horizon.

Last month, a patient with opioid use disorder, successfully being treated with methadone, was sentenced to thirty days in jail in DuPage County, Illinois. The Chicago Tribune covered the story, but you can also read pertinent details on the website of the Legal Action Center (LAC). [1]

This patient, instead of resigning herself to a miserable thirty days of methadone withdrawal, decided to petition the court system to allow her to be able to take her prescribed medication as usual. I probably don’t have to point out to my regular readers that methadone treatment for opioid use disorder reduces the risk of death by at least three- fold. Remaining on her usual medication would prevent relapse once she’s released from jail, commonly a time for overdose death. And of course, continuing her medication would prevent agonizing withdrawal syndrome.

This patient had been in treatment for her opioid use disorder since 2019 but got a DUI back in 2016. It took five years for her to be sentenced to jail time for her DUI. In her lawsuit, the patient asked a federal judge to make sure she was allowed to take her usual medication as prescribed. The complaint stated that depriving inmates of needed medical treatment for opioid use disorder is cruel and unusual punishment and violates the Americans with Disabilities Act. The complaint correctly stated that the refusal to continue the patient’s treatment placed her in grave and immediate danger.

She brought her lawsuit with the help of the LAC, working with the American Civil Liberties Union. DuPage County, where she would serve her sentence, was alleged to have an unwritten policy of prohibiting people from dosing with methadone or buprenorphine, even when prescribed by a physician. The county denied this, saying that each patient’s needs were evaluated on a case-by-case basis after a physical exam. However, no non-pregnant inmate was ever allowed to remain on methadone or buprenorphine in the jail’s history.

Based on that last fact, it strains credulity to believe this patient would have received her methadone as usual had she not brought her case.

From what I understand by reading internet reports, the federal judge said this patient had not yet been denied her medication, so she needed to wait until it was denied before she could bring her lawsuit to court.

County jail officials, likely sensing the shitstorm that would descend upon them if they denied this patient her medication after attention her lawsuit had received, finally decided to do the right thing, and give the patient her medication.

County officials made some sort of laughable statement that a “headline-grabbing lawsuit” wasn’t needed for this patient to get proper care, and that they would have done the right thing without a lawsuit…but I doubt that. I am judging DuPage County’s attitudes and actions by the ones I’ve encountered at rural North Carolina’s county jails.

In May of 2019, a federal judge ruled that a patient in Maine, sentenced to forty days in jail, must be allowed to remain on her usual daily dose of Suboxone. She was in recovery on this medication for five years before she was sentenced to this term. The judge said that denial of medication-assisted treatment would cause serious and irreparable harm to the patient, and that denial would violate the Americans with Disabilities Act. The patient asked Maine’s division of the ACLU to assist her attorneys in bringing her suit against the county jail.

Attorneys for the county jail had argued that medical personnel at the jail are able to manage opioid withdrawal symptoms, apparently meaning withdrawal could be managed without Suboxone. But they lost the case, and the patient remained on Suboxone during incarceration.

I was very happy with the outcome of this case, and a few others like it, scattered around the country these last two years.

In my state of North Carolina, there are now around five counties that will allow patients in treatment for opioid use disorder to remain in treatment. These counties are to be congratulated for their progress. However, in my county, patients prescribed methadone or buprenorphine products for opioid use disorder are NOT ALLOWED to dose in our county’s jail while incarcerated. The jail medical personnel have some sort of a detox protocol that involves clonidine (which may help a little) and clonazepam. The latter medication, of course, serves to place inmates at even higher risk of death if they relapse back to opioid use once they leave jail.

Use of clonazepam is not part of any legitimate opioid withdrawal protocol that I’m aware of. Plus, it is a controlled substance. If the jail is willing to dose controlled substances, why not just dose the patient with the evidence-based, life-saving medication that the patient is already on?

I have tried talking to county jail medical personnel. The nurses who work there are sympathetic, for the most part, but medical policy about patients on methadone or buprenorphine seems to be set in stone by someone above them. I once talked via phone to the jail doctor, but it went very badly. He was like other doctors of a certain age, who feel they must talk much, much more than they listen. I had to interrupt to get any time to speak at all, and he then became derisive towards medication-assisted treatment in general and dismissive toward me personally. So much for my attempt at gentle education in the name of cooperation. Not everyone remains teachable throughout life.

I’ve been trying to get patients at our opioid treatment program to reach out to our state’s ACLU branch when it’s obvious they will be sentenced to a jail term and denied their usual medication for opioid use disorder. So far, none have taken this step. I’ve tried to call the ACLU for them, but was told I don’t have standing, and it must be the patient who calls to ask for their help.

Understandably, many patients worry that filing a lawsuit to be able to get their usual medications may backfire. If they don’t win, they fear angering the prosecutor or judge. They worry they may face more severe punishment if they attempt to advocate for themselves.

I understand their fears, and I can’t tell them it’s unfounded. If they bring a suit and lose, perhaps they would be treated more harshly. The law enforcement and judicial system in this county is not as forward-thinking as I would prefer, though it is improving.

Our opioid treatment program participated in a three-year grant that paid for treatment for patients involved with the criminal justice system. This grant just ended last August. Our staff worked with local probation and parole officers, who got to see first-hand the dramatic improvements in patients’ lives when evidence-based treatment with medication for opioid use disorder is available. Some of those officers still refer their clients to us, even after the grant ended. But other officers remain cool towards our treatment program, though at least they have stopped telling our patients they must get off of methadone or buprenorphine to remain on probation. Small victories.

Many jail systems, large and small, say they can’t allow methadone or buprenorphine dosing of inmates already prescribed these medications because of diversion risks. Staff say such medications would be diverted from the patient for whom it is prescribed, presenting overdose risks to other inmates.

That argument suggests that jail personnel are unfamiliar with observed dosing protocols that OTPs use every day. We could teach jail staff these simple techniques. And again, if the jail is already giving out doses of clonazepam, what steps are they now using to make sure the dose goes to the patient for whom it is intended?

And from what I see and hear from patients who have been incarcerated, plenty of drugs are already circulating in some jails and prisons. Availability seems to vary a great deal at different facilities, for whatever reason, but these places don’t allow methadone or buprenorphine through approved channels.

It’s possible to find creative solutions to all the issues that make methadone and buprenorphine administration difficult for incarcerated patients.

Jail systems say they don’t have the manpower to bring each patient to the opioid treatment program to be dosed each day. However, that would not be required in every case.

Most patients could be issued take home doses for whatever time frame the medical director feels in appropriate. For example, a relatively stable patients could be brought to our OTP for observed dosing every two weeks, with daily take -home doses issued for the thirteen days in between visits. These doses could be given, via chain of custody forms, to jail personnel to be taken to the county jail and stored in a locked container. Chain of custody is a method where there is documentation of which personnel are in possession of the medication each step of the way. When a dose if given to the patient, jail personnel watch to make sure it is consumed and can document this.

Or perhaps OTP staff could bring the medication to the local jail and do observed dosing there, then, when appropriate, leave daily doses of medication in the care of medical personnel to be stored in a locked safe until the next dose is due.

For patients on sublingual buprenorphine products prescribed by office-based providers, the methods could be much simpler. The patient could bring in their bottle or box of medication with them when they report for incarceration, and the medication can be stored under lock and key. It can be dosed daily, with jail personnel watching to make sure the medication dissolves and no residue remains under the tongue or in the mouth, to prevent diversion.

Sublocade could be an excellent option for buprenorphine patients. This is an injection that can be given once monthly, so that the jail personnel would only need to bring that patient from the jail to the provider once per month for their injection, instead of worrying about daily dosing. And with the injection, diversion of medication would not be an issue. Soon, we may have weekly injections available, also eliminating fears of medication diversion.

My point is that I believe we can work together to find solutions to every possible problem raised by continuing patients on life-saving methadone and buprenorphine, if only we have the will to do so.

These half-assed, county jail “detox protocols” must stop. They are insufficient to prevent withdrawal, not evidence-based, and they place patients at unnecessary risk of overdose death once the patient is released. They interrupt a legitimate medical treatment that has more evidence to support it than nearly anything else we do in the field of medicine.

Medically fragile patients can die from improperly treated opioid withdrawal during incarceration. I’ve blogged about this before. Who can forget the case of David Stojcevski, who died from benzodiazepine and methadone withdrawal, sixteen days into his incarceration? He lost forty-four pounds and suffered from hallucinations and seizures during his time in this county jail. The family brought lawsuits against the county jail, which still has not been resolved. The county jail employees pointed their fingers to Correct Care Solutions, a company that was supposed to have provided medical care to their inmates. Of course, Correct Care Solutions pointed their fingers at county jail employees. Since all this happened, Correct Care Solutions was bought by another company and merged into Wellpath LLC. This new company is also plagued with lawsuits alleging improper care of inmates. [2]

I’m going to continue to tell my patients facing incarceration about recent lawsuits, and I’m going to continue to point them towards the Legal Action Center in New York, and our state’s chapter of the ACLU. I’d love for one of my patients to make a little history in the cause of patients’ rights.

And I’ll testify for my patients for free, with pleasure, if I am asked.

1. https://www.lac.org/news/dupage-county-sheriff-sued-for-access-to-life-saving-medication-to-treat-opioid-use-disorder
2. https://www.metrotimes.com/news-hits/archives/2020/03/12/lawsuit-targets-billion-dollar-company-making-life-and-death-medical-decisions-in-michigan-jails

The Future of COVID Take Home Doses

This may be a controversial blog post. I’ve been mulling over the ideas I’m presenting in this blog for many weeks and have changed my mind several times. So don’t get too upset with what you read, because I may have changed my mind again by the time you read it.

The events of this past year have given us experiences and information, and it seems prudent to learn what we can from them.

In the spring of last year, state and federal authorities moved quickly to allow patients enrolled in opioid treatment programs to receive more take homes doses than usual. They did this to reduce the risk of patients’ exposure to the COVID virus. Most opioid treatment programs were able to give many more take home doses of buprenorphine or methadone than ever before. This cut down the number of patients physically present at OTPs at any one time, thus creating more social distancing than ever before.

Now patients – and providers – are wondering what will happen after our country no longer has a high risk of COVID transmission in crowds. Will the previous regulations snap back into place? Will patients receiving extended take home doses now be asked to come more frequently and give up the convenience of extra take home doses?

In my state of North Carolina, as I understand it, once the state is no longer under a “state of emergency” declaration, the permission to give extra take homes to patients will no longer exist.

I’m not sure what state and federal authorities will advise, but I have some thoughts.

As I see it, we have two sets of questions. The first is what to do about patients presently receiving extra take homes. The second is deciding if information from events of the past year should cause us to change regulations about methadone take home doses.

At my opioid treatment program, we have about half our patients dosing of buprenorphine and half on methadone. Because of its better safety profile, buprenorphine patients already get take homes more quickly than methadone patients. So, my next paragraphs will be about patients being prescribed methadone at opioid treatment programs.

Let’s take the first question: what shall we do about patients who are getting extra take homes now? This has been an unusual time in history – I hope – and we have a cohort of patients who were suddenly given many more take homes than they were accustomed to getting.

Some patients had problems with those extra take homes. They came back to the opioid treatment program early, saying they didn’t know what had happened to the extra doses, or that the nurse hadn’t given them extra doses, or that some other person stole their medication. These problems almost always came to light within the first few months. Those patients were not ready – at that time – for extended take homes, though they may be able to do so in the future.

However, most patients with extra methadone take home doses did well. We’ve done bottle recalls (like pill counts done at pain management clinics) and most patients brought their bottles back in with the correct number of bottles untouched, with the appropriate amount of medication contained in them. This reassures us that these patients can take only one dose per day and are able to store it safely where it won’t be stolen or tampered with. Most of these patients have been reachable by their counselors for weekly in-person or telehealth meetings, showing further evidence of stability.

For patients who have proven their ability to manage their take home doses, it seems counterproductive to reduce the number of take- home doses again after the COVID emergency passes. Why would we want to do this? So long as patients have been making appropriate contact with their counselors at their programs and are doing well, I will advocate for them to stay at their advanced take homes. I might have to submit an exception to get permission for this from state and federal authorities, but that’s easy to do, and would seem a reasonable request.

Then comes the question of what to do with these patients if they have drug screens positive for illicit drugs. Should these patients move back to daily dosing? What if the only illicit drug they use is THC? Before the extra COVID take homes, our state said patients who remained positive for THC couldn’t advance past a level 1, which means they had to come every day but Sundays. In the past, I agreed with this policy. I reasoned that people using THC weren’t as stable as those not using it.

Now I have changed my mind.

Don’t misunderstand. I am no fan of marijuana. I think it can hold patients back in some insidious ways. It’s not harmless, as some people think, but neither is it a toxic substance, like alcohol is. Some day we may have beneficial medications derived from the marijuana plant, but at present, lighting the plant on fire to inhale the smoke isn’t a medically safe way to ingest those chemicals. We know marijuana use affects adolescent brains adversely, but even in adults, it can shave off IQ points, and may interfere with motivation to make life changes.

However, regular marijuana doesn’t cause the chaos that other illicit drugs cause.

 Since COVID, I’ve seen many patients, long-term smokers of marijuana, managing their additional take-home doses quite well. They appear as stable as non-smokers of THC. I don’t see that it would help anyone to revoke those take-home doses, and it may benefit some of these patients to be able to give even more take homes. At present I am more open to such ideas than I ever have been in the past.

Patients using alcohol and other sedatives are not getting extra take homes at the opioid treatment program where I work, due to the dangers of mixing methadone with sedatives. I have not changed my mind about that.

What about stimulant use? We’ve seen an uptick in methamphetamine use over the past several years, and some of those patients are getting extra take homes now. Some are not, depending on an assessment of each patient’s overall stability. I have not been consistent with decisions about take home doses for such patients, because stimulant-using patients can differ widely.

For example, one patient has tested positive for methamphetamines for about a year, but she has a job, a stable relationship, and no apparent clinical decline, at least thus far. But another patient tested positive for methamphetamines for two months. Since then, his family committed him once to a mental institution for a few days, for auditory hallucinations related to drug use. He’s lost twenty pounds in two months and is twitchy and easily distracted when I try to talk to him.

I was generous with take homes for the first patient and denied take homes to the second one. Of course, the second patient feels like this is unfair towards him. After the COVID take-home exceptions end, should both patients be moved back to daily dosing?

Let’s move on to the idea of changing existing take home regulations. There are eight criteria that patients ordinarily need to meet to get take home doses of medication. In an abbreviated form, these are:

1. No ongoing drug or alcohol use
2. Regular attendance
3. No serious behavioral problems at the OTP
4. No recent criminal activity
5. Stable home environment
6. Ability to store medication safely
7. Benefits of take homes outweigh risks of diversion
8. Time in treatment

I agree with all these requirements, except perhaps the last one, which I feel is the most restrictive. Federal and state authorities have firm regulations about how soon a patient, doing very well otherwise, can be granted take home doses, based only on how long that patient has been in treatment. New patients can receive up to one take home dose per week for the first three month, then if all is going well, can get three take home doses per week for the next three months, then four doses per week for three months, etc. At the one-year mark, even an extremely stable patient will need to come once per week for a year.

That’s a long time, and perhaps unduly restrictive for many patients.

Before readers criticize me for risking lives due to putting methadone at risk for diversion, let me explain that I do know how much harm methadone take homes can cause in the wrong hands. I can tell you horror stories about diverted methadone, but I won’t do that now.

But on the other side, more patients thrive with extra take- home doses, able to feel less stress about getting to their OTP in time to get dosed and get to work on time. They can spend more time with their families in the morning hours. That’s worth quite a lot.

If we decide to revisit our present methadone take home schedule regulations and ultimately relax them a bit, it will fall to treatment center staff and ultimately the medical director to decide if a given patient is stable enough for take homes. That means the medical director will need to know her patients well. This requires time at the opioid treatment program and involvement with the patients. That should already be happening, but I know that’s not always the case.

Here are a few of the warning signs we’ve seen that can indicate problems forming: coming in a day or two early to dose, even when the patient should already have take-home doses; being unable or unwilling to give urine drug screens; giving falsified urine drug screens; counselors being unable to reach the patient for telehealth counseling sessions; poor attendance or repeatedly coming at the last minute to dose; new mental health issues or new physical health issues, and unexplained change in appearance or affect.

Since the medical director is ultimately responsible for the consequences of methadone take-home doses, the medical director needs to be made aware of any warning signs seen in patients, aside from positive urine drug screens. The medical director needs to know the patients well, and have input from counselors, nursing, and even front office staff when making these important decisions. Therefore, time for case staffing, sometimes also called treatment team meetings, is so important.

At the OTP where I work, we usually have case staffing twice per week, and it includes medical and counseling staff. We make decisions about take home doses at these meetings. Sometimes we disagree, and that’s good. It means differing opinions are being voiced. Sometimes emotions run high, a reflection of the importance of our decisions to patients. It’s often a difficult process.

But because of the importance to patients, perhaps take-home regulations should be re-evaluated at national and state levels, in the light shed by our recent experiences with the extra COVID 19 take home doses.

Never mind….

You know that blog I posted a few weeks ago, about DHHS’s decision to allow any physician with a DEA license to prescribe buprenorphine products for their patients with opioid use disorder? That idea has been nixed. SAMHSA said HHS’s decision to announce the change of regulations to have been “premature.”

I have no idea what political machinations were behind all of this, but Medscape’s webpage said loosening the restrictions was an idea put forward by Trump’s administration, and Biden’s administration cancelled that plan.

Many addiction medicine specialists were wary about the idea of loosening restrictions, fearful of the consequences if any physician could prescribe buprenorphine without the mandatory training course. That eight-hour course teaches providers about opioid use disorder in general and specifically about how to prescribe buprenorphine products from an office-based practice to treat that disorder. They say prescribers need this education, since for decades it was illegal to treat opioid use disorder from an office setting. Consequently, most physicians don’t know much about treating addiction, and may mistakenly think it’s the same thing as treating pain.

On the other hand, eliminating the need to take this course could encourage more doctors to prescribe buprenorphine products to treat opioid use disorders, thus expanding access to treatment.

I’m not sure what I think.

 On the one hand, I’ve seen providers with no training or “X” number prescribing all sorts of buprenorphine products for years, and not always with the diligence I would hope for.

For example, several months ago I reviewed a new patient’s data from the North Carolina prescription monitoring program. I saw the local pain clinic had been prescribing an extended- release full opioid agonist, along with a short-acting full agonist for breakthrough pain for many months. Then I saw the Butrans patch (contains buprenorphine) was added to this regime of medication.

I asked the patient what happened when they started the Butrans patch.

“Oh I found out I was allergic to it. It made me very sick. I felt like I was back in withdrawal. I can’t take that medication.”

Of course, that was no allergic reaction. That was precipitated withdrawal, predictable to providers familiar to the pharmacology of buprenorphine. But now this patient is convinced that buprenorphine in any form will make her sick under any circumstance. She was started on methadone and has done very well, but it is a shame she had to be put through that nightmare.

However, another prescriber, this one who took the eight-hour course and who has a DEA “X” number, starts all patients at a dose of buprenorphine/naloxone 32/8mg per day (four of the 8/2mg tablets) and tapers down over a period of several months until the patient is off the medication completely. Apparently this prescriber wasn’t paying attention to instructions given at the 8-hour training course about how to do induction. Or how to do maintenance. Or that most patients need much longer than several months on the medication to remain in recovery, and few need any higher dose than 16 to 24mg per day.

Then there’s another prescriber in town, also with her DEA “X” number, who accepts methadone patients from our opioid treatment program and starts them on buprenorphine without asking for any data from us. We only find out about the patient’s medical misadventures when their counselor calls them, to find out why they’ve missed days of treatment with us. The patient says he told the prescriber what dose of methadone he was currently on, and but prescriber asked the patient to miss one or two days of methadone before she started a sublingual buprenorphine product.

If they patient was on a dose of 40mg or less for at least a week, everything will go well. But if the patient’s been dosing at 110mg per day, per example, and missed a few days…things usually don’t go well. The patient ends up in precipitated withdrawal, which is completely predictable. If we are lucky, we can get them back into treatment right away.

At our opioid treatment program, we switch patients all of the time, though much more slowly. My usual “recipe” for switching involves tapering by 5mg per week, down to 40mg, where they dose for at least a week. Then the patient misses two days and sees me on the third day. If they are in sufficient withdrawal, with a COWS greater than 12, I feel safe starting them on buprenorphine. I usually end up dosing them with between 4 to 8mg on that first day.

Anyway, my point is that most of these prescribers, who took the eight- hour course, don’t necessarily do things as I would hope they learned in the course. But perhaps it would be worse if buprenorphine prescribers took no course.

My opinion about this issue rockets from one side to the other faster than a tennis ball at Wimbledon.

I can’t decide what I think. I read opinions from leaders in the field that say untrained prescribers could lead to disasters, and I know they are correct. Then I read from other leaders in the field that increasing access will save lives and I know that’s right, too.

I have no conclusion for this blog post. I’m just acknowledging uncertainty.

My Quest to Get the COVID 19 Vaccine

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In North Carolina, hospital systems are immunizing their staffs for COVID. These systems also own many doctors’ offices and immunize their personnel at those offices too. But local county health departments have been assigned the chore of providing vaccines to the public.

Most opioid treatment programs (OTPs) are not part of health systems. During our weekly state-wide opioid treatment provider teleconferences, we’ve discussed how and when OTP staff can get COVID 19 vaccines.

The medical staff, including nurses, physicians, and physician extenders, are categorized as 1a priority for vaccine, and for counselors and OTP office staff, consensus seemed to be they were also 1a, or 1b according to some county health departments.

Like my co-workers, I got notification that the opioid treatment program where I work, owned by Acadia Healthcare, will not be offering vaccinations to patients or their healthcare workers at the programs. However, they do encourage providers to obtain the vaccine.

So, I was left to find the vaccine on my own.

Our local hospital immunized most of their workers near the end of December. Beginning in late December, our local health department started giving the vaccine to other community members, as they received doses from the government.

I went to our county’s health department website and was pleased to find a form to fill out with my name and data. I was under the mistaken impression that submitting the form meant I was requesting the vaccine. That was not the case. The form was a survey regarding potential interest in getting the vaccine. I got a polite email from the health department telling me to be sure and call if I needed the vaccine.

So I did. Our OTP works with our health department, so we had some contacts there. I called them but could not get through to our contact person or any other human, so I left a message. I was called back by a pleasant woman who told me to call the next week, since they were already out of vaccine, and perhaps some would be available the next week.

Many of my colleagues at other OTPs in other counties already got their vaccines, usually by appointment at their health departments.  I was feeling a bit left out of things.

Last week, I called their number again and got a general message: more vaccine had been received and “appointments were not necessary.” The vaccine would be available on a first come, first serve basis, starting at 10am at a drive-through site, only for people in the 1a and 1b categories. On previous vaccine drive-through days, they have run out of vaccine rather quickly.

I’m usually at work on weekdays, so I had to ask to leave work at 9:30 that morning, to get in line at our health department.

My fiancée, whose schedule is less structured than mine, reconnoitered for me that morning. He went to the old airport where the vaccines were being given at around 8:30am, only to be turned away by a policeman who told him that the vaccines were already all gone, and that people had been camping out there at 2 am to be first in line for the vaccine. Disappointed, he let me know there was no reason for me to leave work that day.

So, I stayed and worked as usual, thinking I wasn’t going to be able to get a vaccine that week. But then at around 11:30 one of the employees told me two of her elderly relatives had just received the vaccine after waiting in line for two hours. They got to the site at 9:30.

This made no sense, since my fiancé had seen many cars being sent back home at 8:30am. I put it out of my mind until after we finished up case staff at around 1pm.

Later, we discovered local police, helping manage crowds, mistakenly sent people back home because they thought the vaccine was already gone when it was not.

As I was leaving work around 1pm, I thought I’d drive the extra ten minutes out of my way home, just to see for myself what was happening – or not happening.

I kept thinking how silly I was to think there would be any vaccine left this late in the day, but I pushed on. I passed a flashing sign giving directions to the vaccine site. That was promising. Surely the sign would be off if everyone was gone. I turned the corner and saw a squadron of flashing police lights and lines of cars.

I pulled up behind one line and after several minutes a helper came to my window and asked if I had the correct forms. I told her I had the forms I downloaded off the Health Department’s website. She took them from me and peevishly told me they weren’t the correct forms. She took my temperature and asked about recent illness including cough and fevers. I answered no to all, and she gave me a card with a number on it.

I was in line to get my vaccine!

Hurriedly, I called my fiancé to let him know to return for the vaccine, since he’s also in the 1a risk group. I also texted other co-workers also wanted to get the vaccine. Thankfully, two other co-workers made it in time to get vaccinated.

The health department nurses couldn’t have been nicer, and the shot was a breeze. I remained in my car the whole time and got a card with the vaccine name and other information with a reminder of when my second dose was due. This whole process took maybe twenty minutes.

Then after the injection, people waited in a line of cars, because we had to wait 20 minutes to see if we were going to have a reaction.

And if you think anyone was leaving that parking area one minute early, you are mistaken. At the eighteen- minute mark, an EMS worker asked me how I was feeling, I said fine, and she said something I mistakenly thought meant I could drive away. Nope. A stout policeman literally jumped in front of my car to block my exit. He shook a finger at me. I obediently stayed four more minutes until I was permitted to leave.

My arm was sore at the injection site for two days, about the same feeling that I get with the yearly influenza vaccine. I did have body aches the day after the vaccine but was able to work as usual, though I took a few Tylenol to ease the aches. I’ve felt fine since.

These county health departments have been poorly funded for years. With relatively small budgets, the health departments have been trying to provide medical care for the many uninsured patients of the county. Now we’ve asked these health departments to perform the most daunting task of the century: get a COVID vaccine to any person who wants one. I admire their resolve to get the job done and I’ll happily overlook any inconveniences presented.

I was happy to see local police and EMS services on the site to help with the task. I thought that was a great idea. They held this drive-through vaccine program on an old airport runway, which was perfect for the purpose

I was thrilled to get this vaccine. I was thrilled the wait was very brief and I didn’t have to miss any work. I was especially happy that my sweet fiancé was also able to get vaccinated. I hope it can be quickly distributed to any person who wants one.

I was surprised that at the opioid treatment program where I work, out of around twenty-five employees, only five of us wanted to get the vaccine. I think that may change with time, as more people are vaccinated.

I still wear a mask to work and to the grocery, the only two places I need to go. I know I can still spread COVID, and it’s still possible to get sick with COVID between the two vaccines in the series, though I’m less likely to get severe illness.

Early on, I wasn’t sure about the vaccine, and told people that I didn’t want to be the first person in line to get it and I didn’t want to be the last one either.

One of my patients helped me adjust my thinking. She participated in the Pfizer vaccine trial, and we talked about this last fall. I told her I admired her courage. She said courage had nothing to do with it. She entered the initial clinical trial because she wanted to be able to tell her grandchildren that she did something to help mankind overcome this threat to us all. Even if the vaccine wasn’t successful, she was willing to take a risk to help other people.

I admire her generosity of spirit. Her outlook is more like, “What can I do to help others?” rather than, “What will be best for me?”

As always, my patients continue to teach me.

Health and Human Services Seeks to Expand Buprenorphine Services

Last week, the U.S. government’s Department of Health and Human Services announced new guidelines intended to expand access to treatment for patients with opioid use disorder. [1]

 My reading of this announcement is that HSS is exempting prescribers from obtaining a waiver to prescribe buprenorphine products from office-based practices. It appears to mean that physicians no long must take the eight-hour training course that is necessary to get a DEA “X” number waiver. Physicians only need a valid DEA license that covers prescribing Schedule III controlled substances. Physician extenders such as nurse practitioners and physician assistants must still go through the extra training already in place, however.

Non-waivered physicians can start prescribing buprenorphine products to up to thirty patients at any one time. The thirty-patient cap doesn’t apply to hospital-based physicians like those working in emergency departments.

This change applies only to buprenorphine products and does NOT apply to the prescribing of methadone for opioid use disorder. That medication must be prescribed from an opioid treatment program, as it has been.

HHS says that physicians can only prescribe buprenorphine products to patients residing in states where the physician is licensed and must keep separate charts for these patients. I think both things are already required. If they want to prescribe for more than thirty patients at a time, they will need to get the usual DEA “X” number. Prescribers must also put an “X” on the prescription to indicate it is being prescribed for opioid use disorder and not for pain.

HSS also says an interagency group will be formed to monitor implementation of these services.

For the past twenty-one years, we’ve tried to convince medical providers that instead of viewing opioid use disorder as a crime, we need to treat it as the chronic medical problem that science shows that it is. Trying to reverse a near-century of bad policy (the time from passage of the Harrison Act until the DATA 2000 Act) has not been easy.

Then our present epidemic of opioid use disorder with its corresponding epidemic of death started at the end of the 20^th century and it grew like cancer into this century.

This has been a tough year for more than just COVID deaths. A record number of people – around 83,000 – died from opioid overdoses over the twelve months ending in June of 2020 in the U.S.

 We know prescribing buprenorphine products (or methadone, by the way) to patients with opioid use disorder is life -saving. Mortality is reduced at least three-fold by the most conservative estimates. I challenge anyone to name any other medical intervention that has such an impact and reduction of mortality. Yet medical providers haven’t been enthusiastic about providing this treatment. Old ways of thinking have been hard to challenge.

The new guidelines intend to loosen restrictions on prescribing buprenorphine products. People in the government fear that the eight-hour course to get a special DEA number is keeping physicians from prescribing buprenorphine products. Many patients with opioid use disorder have a hard time finding prescribers with the waiver to treat, and the Department of Human Services wants to make it easier for these patients.

Both the American Medical Association and the American College of Emergency Physicians praised the change in policy.

Not surprisingly, I have some thoughts about this change in HSS policy.

Weirdly, my first thought was, “Wow, someone is going to have to tell all the CVS pharmacists because they are going to lose their minds about this.” Readers of my blog may recall the comical insistence of CVS pharmacies that providers to include a “NADEAN” number in a specific format before they will fill any buprenorphine product.

Overall, I agree that dropping training requirements may make providers more willing to prescribe buprenorphine products. Providers may not be as educated about buprenorphine before starting to use it, but other than causing precipitated withdrawal, it’s hard to kill anyone with it.

We experts may not like to admit it, but just providing the medication saves lives. Even with no psychosocial counseling and very little provider interaction, lives are saved if patients just take the medication. Ideally, the medication should be provided in concert with counseling, but some patients aren’t interested in counseling, for whatever reasons.

There may be diversion if physicians with little experience miss evidence the patient is selling medication. I hate to see diversion, even as I recognize the benefits of buprenorphine when used off the black market. I also know that every day a person with opioid use disorder takes buprenorphine instead of fentanyl, the risk of overdose is decreased. And that’s worth a lot.

Will dropping the eight-hour training requirement prompt more physicians to prescribe buprenorphine? Perhaps, but as I said above, it’s hard to convince doctors that this is a disease that can and should be treated, and not criminalized.

Here’s the biggest value I see with these new guidelines: hospital-based physicians can prescribe buprenorphine without needed the “X” DEA number.

For years, I’ve wished our local emergency department physicians would start buprenorphine when they see patients with opioid use disorder. They have not, partly because they say they don’t have the required “X” number, and partly because they say they don’t have anywhere to refer patients newly started on buprenorphine products.

This new guideline will eliminate the first problem, and the second problem has already been solved. Our opioid treatment program does intakes five days per week, Monday through Friday. Even if the patient is seen on a Friday night, the emergency department physician could write two days of medications to last until we can evaluate and admit the patient on Monday.

And there are three or four office-based providers of buprenorphine in the community now, as well as another good opioid treatment program. Surely we can all get together to make a plan to admit a patient to treatment very quickly.

I plan to keep pushing for this, because the studies show the reduction in the risk of overdose and death. At some point, it will be malpractice NOT to provide life-saving treatment to people with opioid use disorder.

Hopefully we will continue to make progress. That’s why I started this blog in 2010. I wanted a platform to tell people about the mountain of evidence to support the treatment of opioid use disorder with medications and get patients and providers interested.

Change takes time.

And change also takes patience and perseverance.

1. https://www.hhs.gov/about/news/2021/01/14/hhs-expands-access-to-treatment-for-opioid-use-disorder.html?mc_cid=d21a328f2d&mc_eid=9c7edff92d

Compassion

Maybe with all the suffering around us, it’s easier to feel compassion. I don’t think I’ve had a year when I felt more concerned about other people, to the point I pray more for them, have donated more to charitable organizations, and even started donating blood on a regular basis. I’m not bragging; I’m just happy I’ve felt more like doing these things. I’m at my best when I have that feeling of wanting to be helpful, and I tend to be happier with myself.

I am not, by nature, a very compassionate person. Left on my own, I can be judgmental, the opposite of compassionate. But I don’t want to be that kind of person. Thankfully, over the past twenty-plus years that I’ve been in recovery from substance use disorder, I’ve learned a few things. I’m better at recognizing my own negative attitudes and challenging them.

 It helps me to be around other compassionate people. I’m grateful I have such people in my life; my sister has natural compassion, as do many of my friends and my best friend of all, my fiancé. Spending time with these people helps change my outlook.

 Prayer helps change me. I ask for compassion each day on my way to work. I pray to be able to see people as my Higher Power sees people and to treat them accordingly. I also read books that help me cultivate compassion. Alternatively, focusing on negative content in my conversations and reading can dampen my mood and tip me into more pessimistic attitudes.

Compassion doesn’t always look warm and fuzzy. Sometimes true compassion leads to difficult conversations, odd as that sounds. It can even lead to conflict, if I don’t remember to be respectful. If I didn’t feel compassion for patients, I wouldn’t take pains to talk to them about their lives and their desires for change.

No one is compassionate all the time. I have my early warnings that I’m slipping back into old patterns of thinking. For example, when I start making sarcastic jokes at other people’s expense…not good. I can justify by saying I’m blowing off steam and I’m only joking, but as a close friend pointed out to me, sarcasm is “flesh-eating” humor. It can be damaging to the person who is the butt of the joke and corrosive to me.

When I start muttering negative things under my breath at work…not good.

So, what do I do when I start feeling negativity?

First, I don’t have to express it. Expression of negativity contaminates my workplace. It can make my home life feel heavy. I try to keep it to myself. It’s my issue and I don’t need to make it my co-workers, patients, or friends’ issues.

Next, I try to decide why I’m feeling what I’m feeling. Usually, it’s because I’ve decided other people aren’t acting like I want them to. I’ve slipped into a pattern of thinking that other people, organizations, politicians, whatever, need to conform to my ideas for them. Which brings up the real issue: such an attitude shows I haven’t accepted the basic truth that there are many things in the world that I can’t control and shouldn’t try to control.

When I can accept people as they are, while still being willing to extend myself towards them when they request help, I’m in a good place.

Compassion helps me do my job better. Patients wanting help are more likely to engage in treatment when they sense their helpers are rooting for their success, and willing to go an extra mile to help them. Patients sense these things; a helper who is just going through the motions doesn’t inspire patients effectively.

I started to write this blog thinking that compassion is a difficult subject; the blog post could end up being a self-serving treatise extolling my virtue of compassion. Or it could reveal how much I struggle with compassion because at heart, I’m not a very nice person. I hope this blog post has threaded the middle ground by presenting the message that we can feel and act with more compassion by practicing, like any other habit. We can also refuse to cultivate more negative personality traits, like negative thinking and speaking. I’m not saying we should ignore problems when we see them, but rather try to focus on solutions.

Anyway, I hope 2021 is a better year for all of us. May we all feel more compassion for ourselves and others, and struggle less with negativity.