Skin Lesions from Injecting Buprenorphine: The Sign of the Cross

Skin lesions from injecting buprenorphine

Skin lesions from injecting buprenorphine

 

 

Trapped in my house due to nine inches of snow and a slick driveway, last weekend I worked to catch up on my medical journals. An article in the January 2017 issue of The American Journal of Medicine caught my eye.

The article was titled “Curious Crosses: Injection-Induced Lesions” and it described the clinical course of a patient on buprenorphine monoproduct who sought care for recurrent, painful nodules. These nodules would erupt, exuding bloody pus. The article’s author described a fairly extensive work up of these lesions.

This patient was checked for all sorts of exotic diseases which can lead to skin eruptions of this sort, including tuberculosis, sporotrichosis and other fungal diseases, Sweet’s syndrome and Behcet’s disease.

Finally, one of this patient’s blood cultures grew Pantoea species. This was an important clue, because this bacterium is thought to be the cause of “cotton fever,” a syndrome of severe body aches, fever, and intense fatigue.  Cotton fever occurs in some drug users because cotton used to filter injected drugs often harbors Pantoea bacteria. Once the bacteria are injected along with the drug, they release an endotoxin, which produces the symptoms of cotton fever.

With this information, the patient was again questioned about injection drug use. The physicians already knew the patient had a history of intravenous drug use, but this patient told them he was doing well in medication-assisted treatment on buprenorphine.  The patient denied any ongoing injection drug use.

All pills and tablets meant to be taken orally contain fillers. These are usually inert substances that stabilize the active drug, and help the pill or tablet keep its shape. Substances that are formed with the active drug and serve to stabilize it are called “excipients.”

Buprenorphine sublingual tablets contain an excipient called amidon. As near as I can tell by internet search, this is a starch-type substance. This amidon, when injected, causes skin reactions and gives a distinct finding under the microscope.

Under polarized light microscopy, some substances refract light in a distinct manner that can help identify the substance. This property is called birefringence. Amidon is birefringent. Under polarized light microscopy, amidon crystals have the distinct shape of a Maltese cross.

Physicians treating the patient described in the article obtained skin biopsies of some of the patient’s sores. Polarized light microscopy showed the Maltese crosses from the amidon filler in buprenorphine, which more or less confirmed the diagnosis. Other substances can also cause Maltese crosses in skin biopsies, but of course, the most obvious cause in this patient was injection use of the prescribed buprenorphine monoproduct.

I got interested in this finding, and looked online to see if this had been reported before. It has.

In France, where injection use of buprenorphine monoproduct has been problematic, doctors have reported this distinct finding under light microscopy.

In fact, I copied the picture at the beginning of this blog from one of those articles (Schneider et al, “Livedoid and Necrotic Skin Lesions Due to Intra-arterial Buprenorphine Injections Evidenced by Maltese Cross-Shaped Histologic Bodies,” Archives of Dermatology, 2010;145(2):208-209.) In this case report, the patient was injecting into an artery, which is much riskier than into a vein, but the appearance of the Maltese cross in the same.

At the end of the report I found in the American Journal of Medicine, the authors said the patient continued to deny injecting his buprenorphine. All of the lesions he had upon admission were in locations where track marks are usually seen. During his hospitalization, no new lesions appeared on his skin.

The article’s authors state they reported their findings to this patient’s buprenorphine prescriber, who planned to discontinue buprenorphine in favor of other treatment options.

This case was interesting, informative, and reminds me to monitor patients closely when prescribing the buprenorphine monoproduct, often better known under its past brand name, Subutex.

I do prescribe the monoproduct buprenorphine, mostly for patients at the opioid treatment program where I work. In that setting, we do observed daily dosing. After getting their dose, the patients sit and are observed for however long it takes to dissolve the medication, and must show a staff member under their tongue prior to leaving the facility. We do this to help reduce diversion and promote proper use of the medication. We don’t grant take home doses unless and until patients have a degree of stability.

I have also prescribed buprenorphine monoproduct for some of my long-term patients in my office-based practice. If one of these patients, doing well for years, loses their medical insurance, I will switch them to the cheapest form of medication, which is the buprenorphine generic monoproduct. I do this only because I know them so well, and don’t want them to relapse, or have to switch to methadone at an opioid treatment program.

In other words, I have to judge that the benefits far outweigh the risks.

Even with the medical problems illustrated in this interesting article, buprenorphine monoproduct has a place in the treatment of opioid use disorder. And this article reminds physicians we must use the monoproduct medication thoughtfully.

Many of the new patients I see entering treatment at the opioid treatment program have injected buprenorphine pills. I’ve seen some really terrible looking tracks, and now I suspect the scarring and inflammation may be due to these Maltese crosses from amidon crystals.

Medical Board Action Against Telemedicine Buprenorphine Physician

Telemedicine

 

 

 

Telemedicine is all the rage these days. For medically underserved areas, telemedicine could help reduce physician shortages and provide care to people without medical specialists in their area.

As appealing as the idea may be, physicians must be careful to conform to their states’ medical board regulations.

Of course, buprenorphine can now be prescribed in the office setting to treat opioid use disorders. Even with the increased prescribing capacity DATA 2000 gave us, less than a quarter of people who need treatment for opioid use disorder receive it. In fact, modifications to DATA 2000, passed last year, allow buprenorphine prescribers to have up to 275 patients at a time, if they fulfil various criteria. Also, physician extenders can now get certification to prescribe buprenorphine after taking proper training.

But what about telemedicine? Can it be used to meet the demand for opioid use disorder treatment in underserved areas? We now have clearer guidance, thanks to a recent ruling by the NC Medical Board.

Here’s the condensed story:

A physician, who lived and practiced in the middle of the state, also prescribed Suboxone via telemedicine for patients in the Western part of the state. The medical board was displeased this physician didn’t examine his patients in this second location in person, prior to initiating the Suboxone. The physician stated he felt buprenorphine could be prescribed safely without an in-person exam, but the board didn’t agree.

The medical board faulted the physician for not giving adequate attention to patients’ use of other drugs, and their mental health history. The board said patients were not examined for track marks or withdrawal signs, and that the physician accelerated their doses too quickly. Patients were seen every four weeks from the start, and the medical board opined that was not frequent enough in early treatment.

In other words, there were clearly other issues besides the lack of initial face-to-face contact, but this lack was cited as a departure from the standard of care.

I’ve been contacted by at least a half dozen mental health agencies who wanted to hire me to start treating patients with opioid use disorder with buprenorphine, using telemedicine. I’ve turned them all down, mainly because it wasn’t good medical care, and also because I didn’t want to do anything to violate medical board’s telemedicine policy. They have had published guidelines surrounding telemedicine since 2010, and update it periodically. You can read it here: http://www.ncmedboard.org/resources-information/professional-resources/laws-rules-position-statements/position-statements/telemedicine

You will note that the policy says “This evaluation need not be in-person if the licensee employs technology sufficient to accurately diagnose and treat the patient…”

So it is a little confusing, in view of their recent ruling against a doctor prescribing buprenorphine.

In September of 2016, another Addiction Medicine physician got a public letter of concern from the NC Medical Board, for using the telephone to stay in contact with a patient who had moved out of state. I only know the circumstances of the case from what the medical board listed in their public letter of concern, but I do know the physician. He is well-trained, cautious, and has excellent judgment.

His patient of over three years moved out of state and couldn’t find a new buprenorphine prescriber. So his NC doctor agreed to continue to prescribe for him, and did phone sessions with this patient every two weeks for thirty minutes at a time. He issued buprenorphine prescriptions for only two weeks at a time. This happened over several years without a face-to-face visit. Apparently the physician enlisted the aid of a local pharmacist to do medication counts, and the medical board opined this was “insufficient.”

Wow. This ruling should give every physician a reason to avoid telemedicine. Because I think that doctor did a good thing. Every patient should have such a doctor, willing to go the extra mile to help. I don’t think the physician’s actions were “insufficient” in any regard, though I’ll admit I’m probably not what our NC medical board considers an expert.

I’ve used pharmacists to do pill counts for me if the patient says he is out of town when called for a pill count. Sounds like I’m going to have to stop doing that, given the medical board’s statement.

At least once at an opioid treatment program, I was pressured to admit patients using telemedicine.

Several years ago, I had surgery for a broken leg. At the time, I worked for two opioid treatment programs. One was located an hour away, and the other was two hours away. Driving was going to be cumbersome, of course.

As soon as I was able, I called the program managers of each to let them know I might be out of work for the next week or two. At the first OTP, the program manager said I should take all the time I needed, and intakes could be postponed. Obviously, this is not an ideal situation, since we want to admit patients as soon as possible, but this was one of those things that were out of our control. I was still available by phone, of course.

At the second, the program manager said being out of work for several weeks was “not acceptable.” The program manager pushed me to admit patients via Skype or other technology. I refused, citing quality of care issues. In retrospect, I made the right decision.

I hear about “Doctor on Demand,” advertised by Dr. Phil on his show, and I wonder how these doctors get around this telemedicine issue. These doctors aren’t examining patients face to face on the first visit. Also, to practice medicine in NC, you must have a NC license, and surely all these doctors don’t have NC licenses.

I sent an email to Doctor on Demand asking about these issues. They sent me an email back, saying someone would be in contact with me. This was about four weeks ago and I haven’t heard anything else. I’ll let you know what they say in the unlikely event that they do contact me.

In the meantime, I think all physicians, and specifically buprenorphine prescribers, need to be very careful with telemedicine. Given these two recent rulings by the NC Medical Board, we could be cited for improper medical practice. Telemedicine seems like it could be a wonderful way to get care to people with opioid use disorders who live in remote places, but physicians need to protect their medical licenses first, or we won’t be able to prescribe anything to anybody.

 

 

Harm Reduction versus Abstinence Only

aaaharm

 

 

I’ve heard the harm reduction versus abstinence -only debate about addiction treatment many times, not only at addiction medicine conferences, but also in my own head. In the past, I thought abstinence from all addictive drugs was the only true recovery from addiction. As I’ve aged, I’ve traveled far into the harm reduction camp, having seen people with addiction die from their disease when perhaps more could have been done to save them.

A wise mentor of mine once said try not to argue with people who aren’t actually in the room with you, so I’ve committed the debate to writing.

Following is an imaginary debate between two addiction treatment professionals. One professional believes harm reduction measures are worthwhile because they can keep drug users alive and healthier, even if they never completely stop using drugs. The other professional feels harm reduction cheats a drug user out of full and happy recovery, which she believes is seen with complete abstinence from all drugs.

First, they chat about needle exchange:

HR: I fully support needle exchange programs. They have been proven to reduce transmission of infectious diseases, including HIV and hepatitis. Why wouldn’t we want to help people avoid getting these potentially devastating diseases?

AO: Because giving out needles sends the wrong message. It says we are OK with people injecting drugs, and that we are willing to make it easier for them to do so. Appearing to condone drug use in any way sends the wrong message to young adults, who may be considering using drugs for the first time. Stigma towards drug users can be harmful, but perhaps stigma serves a good purpose if it discourages people from doing dangerous things like injection drug use.

HR: Studies do not show needle exchange increases the likelihood that people will start using drug intravenously. Easily available clean needles are not enough to convince a person to start injecting drugs. Besides, even if you have little compassion for the drug user, for every case of HIV we prevent with needle exchange, we save our society countless dollars in medical care. That’s just one disease. When you consider the health burden and medical costs of transmission of hepatitis C, it’s even more reasonable.

Even the ultra-conservative Mike Pence, the former Governor of Indiana and our future Vice President, changed his mind on needle exchange after an outbreak of HIV occurred in a rural community among people injecting opioids.

Besides being morally right, needle exchange makes financial sense.

AO: No, it doesn’t. It sends a message to drug users that we’ve given up on them. It says we don’t think they will ever be able to live without injecting drugs. In a way, it infantilizes them. By making drug use easier, we may cheat them out of trying to become clean and sober.

AO and HR move to the topic of medication-assisted treatment of opioid addiction with methadone and buprenorphine:

HR: First of all, medication-assisted treatment (MAT) is harm reduction only so far as all treatment should reduce harm. MAT is a good treatment in itself, and isn’t necessarily just a stop on the journey of recovery.

I fully support medication-assisted treatment. We have fifty years of studies that show people who are addicted to opioids are less likely to die if they enroll in methadone maintenance or buprenorphine maintenance. It is one of the most heavily evidence-based treatments in all of medicine, and it is endorsed by many professional agencies, such as the Institute for Medicine, Substance Abuse and Mental Health Services Administration, the World Health Organization, and the American Society of Addiction Medicine.

We have study after study showing how opioid addicted people have a better quality of life when on medication-assisted treatment with methadone. We have more information about methadone because it has been use in the U.S. much longer than buprenorphine, which was approved by the Food and Drug Administration in 2002, after the Drug Addiction Treatment Act of 2000 was passed.

Opioid-addicted people enrolled in methadone treatment are more likely to become employed, much less likely to commit crime, and more likely to have improved mental and physical health. They receive addiction counseling as part of the process of treatment.

We think buprenorphine has the same benefits, though there have been fewer studies than with methadone. We do know the risk of opioid overdose death is much lower when an opioid addicted person is treatment with buprenorphine, too.

Because medication-assisted treatment is so effective, it should be considered a primary treatment of opioid addiction, and not only a harm reduction strategy.

AO: With MAT, opioid-addicted people may be harmed more than if they continue in active addiction. It is no different from giving an alcoholic whiskey. Methadone is a heavy opioid that’s difficult to get off of. The opioid treatment programs that administer methadone don’t try to help these people to get off of methadone, because they make more money by keeping them in treatment. These patients are chained to methadone with liquid handcuffs forever. It’s also expensive over the long run, and patients have to agree to many restrictions put on them by state and federal governments.

HM: Methadone and buprenorphine treatments are not like giving an alcoholic whiskey, because the unique pharmacology of these medications. Both medications have a long half-life, and when patients are on a stable dose, they feel normal all day long without cravings for illicit opioids. This frees them from the unending search for drugs that occupies much of their days. Instead, they can concentrate on positive life goals.

Also, even after an opioid- addicted person stops using opioids and endures the acute withdrawal, he will usually feel post-acute withdrawal. This syndrome, often abbreviated PAWS, can cause fatigue, body aches, depression, anxiety, and insomnia. It’s unpleasant. Many people in this situation crave opioids intensely. We think this occurs because that person’s body no longer makes the body’s own opioids, called endorphins.

Endorphins give us a sense of well-being, and without them, we don’t feel so good. When humans use opioids in any form, our bodies stop making endorphins. In some people, it takes a very long time for that function to return. In some cases, it may never return. We can’t yet measure endorphin levels in humans, so this is a just theory, but one borne out by years of observation and experience.

Methadone and buprenorphine are both very long-acting opioids. Instead of the cycle of euphoria and withdrawal seen with short-acting opioids, these medications occupy opioid receptors for more than twenty-four hours. It can be dosed once per day and at the proper dose, it eliminates craving for opioids, and eliminates the post-acute withdrawal, which is so difficult to tolerate.

We often compare opioid addiction to diabetes, because in both cases, we can prescribe medication to replace what the body should be making.

And yes, methadone is difficult to taper off of, but most of the time it is in the patient’s best interests to stay on this medication, rather than risk a potentially fatal relapse to active opioid addiction. Some patients are able to taper off of it, if they can do it slowly.

Do you think of a diabetic who needs insulin as being “handcuffed” to it? Do you think the doctor who continues to prescribe insulin is just trying to make money off that patient? Why is it wrong to make money from treating addiction, but not other chronic diseases?

AO: What about all of the former opioid-addicted people, now in 12-step recovery, who are healthy and happy off all opioids? Why are these people doing so well, even though they had as severe an addiction to opioids as the patients in opioid treatment programs?

HR: We don’t have all the answers to this question. One form of treatment, even medication-assisted treatment, won’t be right for every patient. Maybe the support that a 12-step group can provide got these people through the post-acute withdrawal. We don’t have much information about these recovering people, obviously due to the anonymous nature of that program.

If these people feel OK off all opioids, that’s great. They don’t need medication. But don’t prevent other people who do benefit from medication-assisted treatment to be helped with methadone, and buprenorphine.

Besides, not all opioid-addicted people want to go to 12-step meetings. Do treatment professionals have the right to insist everyone go to these meetings, even if patients don’t like them?

AO: Medications cheat patients out of full abstinent recovery. Methadone and buprenorphine blunt human emotions, and make it impossible to make the spiritual changes necessary for real recovery. Methadone and buprenorphine are intoxicants, and they prevent people from achieving the spiritual growth needed for full recovery. You keep these people from finding true recovery, and condemn them to a life of cloudy thinking from these medications.

HR: Various people assert patients on maintenance methadone and buprenorphine have blunted emotions and spirituality, but there’s no evidence to support that claim. How can you measure spirituality? If spirituality means becoming re-connected with friends and loved ones and being a working, productive member of society, then studies show that methadone and buprenorphine are more likely.to assist patients to make those changes.

Physically, studies show patients on maintenance methadone and buprenorphine have normal reflexes, and normal judgment. They are able to think without problems, due to the tolerance that has built up to opioids. They can drive and operate machinery safely, without limits on their activities. Contrary to popular public opinion, patients on stable methadone doses are able to drive without impairment.

However, if that patient mixes drugs like sedatives or alcohol with methadone, they certainly can be impaired. That’s why patients should not to take other sedating drugs with medication-assisted treatments.

People with opioid use disorder are far more likely to make significant and healthy life changes if they feel normal, as they do on medications like methadone and buprenorphine. If they chose abstinence, many times they feel a low-grade withdrawal for weeks or months, and this makes going to meetings and meeting life’s responsibilities more difficult.

Remember: dead addicts can’t recover. Far too many opioid- addicted people have abstinence-only addiction treatments rammed down their throats. Most of these patients aren’t even told about the option of medication-assisted treatment, which is much more likely to keep an opioid drug user alive than other treatment modalities.

Too often, people addicted to opioids cycle in and out of detoxification facilities over and over, even though we have forty years of evidence that shows relapse rates of over 90% after a several weeks’ admission to a detox facility. We’ve known this since the 1950’s, and yet we keep recommending this same treatment that has a low chance of working. And then we blame the addict if he relapses, when in reality he was never given a treatment with a decent chance of working!

Medical professionals, the wealthy, and famous people are treated with three to six months of inpatient residential treatment, and they do have higher success rates, but who will pay for an average opioid user to get this kind of treatment? Many have no insurance, or insurance that will only pay for a few weeks of treatment. For those people, medication-assisted treatment can be a life-saving godsend. It isn’t right for every opioid-addicted person, but we do know these people are less likely to die when started in medication-assisted treatment. After these people make progress in counseling, there may come a time when it is reasonable to start a slow taper to get off either methadone or buprenorphine, but first we should focus on preventing deaths.

AO: Given the time, money, expense, and stigma against methadone and buprenorphine, it should be saved as a last resort treatment. If an opioid-addicted person fails to do well after an inpatient residential treatment episode, then MAT could be considered as a second-line treatment. Let’s save such burdensome treatments for the relapse-prone opioid-addicted people.

HR: It seems disingenuous to claim stigma as a reason to avoid MAT when you are the one placing stigma on this treatment.

I could go on for many more pages, so let’s stop here. You get the idea.

In the past, harm reduction and abstinence were considered opposing views. I’ve heard some very smart people say this is a false dichotomy, and that in real life, these views are complementary.

I like this newer viewpoint.

 

Any form of treatment should reduce harm. If a patient achieves abstinence from drugs, then that’s the ultimate reduction of harm. Also, harm reduction principles can help keep drug users alive, giving them the opportunity to change drug use patterns later in life. As I’ve said above, dead addicts don’t recover. Let’s give people more choice and more opportunities to transition out of drug use, if that’s what they desire.

 

Let’s do a better job of working together in the coming year!

Holiday Guide for Families

Best Christmas Lights

Best Christmas Lights

 

 

Several years ago, I posted a sarcastic holiday post about how relatives can sabotage a loved one’s recovery. One reader commented it could have been more helpful if I’d left out the snark and written something useful. I agreed, and re-wrote my blog post for this year.

So, this post is written for the friends and relatives of people in recovery from substance use disorders.

What to do:

  1. Do invite your loved one in recovery to family functions, and treat her with the same respect you treat the rest of the family. If you have resentments from her past behavior, you can address this privately, not at the holiday dinner table. Perhaps given how holidays can magnify feelings, it’s best to keep things superficial and cheery. Chose another time if you have a grievance to air.
  2. Allow your relative some privacy. If the person in recovery wishes to discuss her recovery with the entire family, she will. Let her be the one to bring it up, though. Asking things like, “Are you still on the wagon or have you gone back to shooting drugs?” probably will embarrass her and serve no useful function.
  3. Accept her limitations graciously and without comment. Holidays can be trigger for drug use in some people, and your relative may want to go to a 12-step meeting during her visit. Other people in recovery may need some time by themselves, to pray, meditate, or call a recovering friend. Allow them to do this without making it a big deal.
  4. Remember there are no black sheep. We are all gray sheep, since we all have our faults. In some families, one person, often the person with substance use disorder, gets unfairly designated as the black sheep. She gets blamed for every misfortune the family has experienced. Don’t slip into this pattern at holiday functions.

What not to do:

  1. Don’t ask the recovering person if she’s relapsed. If you can’t tell, assume all is well with her recovery. If she looks intoxicated, you can express your concern privately, without involving everyone.
  2. Don’t use drugs, including alcohol, around a recovering person unless you check with them first. Ask if drug or alcohol use may be a trigger, and if it is, abstain from use yourself. If you must use alcohol or other drugs, go to a separate part of the house or to another location.

Being around drugs including alcohol can be a bigger trigger during the first few years of recovery, but any recovering person can have times when they feel vulnerable, so check with them privately before you break open a bottle of wine.

If your family’s usual way of celebrating holidays is to get “ all liquored up,” them understand why a recovering relative may not wish to come to be with family at this time, and don’t take it personally.

For some of us, remaining in recovery is a life and death issue, so please accept we will do what we must to remain in recovery, even if that means making a holiday phone call rather than making a holiday visit.

  1. If your recovering loved one is in medication-assisted treatment with methadone or buprenorphine, don’t feel like you have the right to make dosage recommendations. Don’t ask “When are you going to off of that medication (meaning methadone or buprenorphine)?

Your loved one may taper off medication completely at some point, or he may not. Either way, that’s a medical decision best made by the patient and his doctor. Asking when a taper is planned is not your business.

  1. Remember your loved one is more than the disease from which they are recovering.

Some people have diabetes and some people have substance use disorders. These diseases are only a small part of who they are.

Refrain from giving hilarious descriptions of your loved one’s past addictive behavior, saying, “But I’m only joking!” This can hurt her feelings, and keep her feeling stuck with an identity as a drug user. She can begin to believe that with her family, being an addict is a life sentence.

I hope this helps.

May all my readers have a Merry Christmas and Happy Holidays!

New Data from State Prescription Monitoring Program

aaaaaaaaaaaaaaaaaapills

 

 

North Carolina’s Health and Human Services published a most interesting data set recently: http://www.ncdhhs.gov/divisions/mhddsas/ncdcu/Prescription-Rates-by-County

This interactive map shows information, by county, of the prescribing rates for opioids, benzodiazepines, and stimulants for the years 2012 through 2015. It also includes the average morphine milligram equivalents, or MMEs.

This data was gleaned from my state’s prescription monitoring program, called the North Carolina Controlled Substance Reporting System, abbreviated NC CSRS.

Quantifying MMEs, sometimes also called MEDDs, for morphine equivalent daily dose, is a way to quantify the potency of the opioids being prescribed. For example, since fentanyl is so potent that it’s prescribed in micrograms rather than milligrams, a prescription of 10mg of fentanyl would be very different than a prescription of 10mg of hydrocodone. So using MMEs, prescribed opioids are “translated” into the potency of that dose if it were morphine.

This data is important, since the risk of opioid overdose death risk increases when patients are prescribed higher MMEs. The Centers for Disease Control and Prevention (CDC) has said MME doses higher than 50mg per day should be used with great caution, since doses above this cut off are associated with higher risk of opioid overdose death.

I looked at my own county first, and found some puzzling data. For 2015, Wilkes County was fifteenth out of one hundred counties for the number of opioid pills prescribed per resident. The table said county residents were prescribed one hundred and two opioid pain pills per resident, giving an average of 1.3 opioid prescriptions per resident.

But when I looked at the 2012 data, Wilkes County averaged eighty-two pills per resident, giving an average of 1.1 opioid prescriptions per resident. In other words, the data showed more pills are being prescribed in 2015 than in 2012.

That’s disheartening.

A new pain clinic opened in late 2014, which could explain some of this data. Also, since this is data collected by the patient’s county of residence, perhaps county residents travel to physicians in other counties for prescriptions, and then bring them to Wilkes County to fill.

Then I looked at the MME, the abbreviation for morphine milligram equivalents.

Wilkes County was number one out of one hundred NC counties for highest total morphine milligram equivalents. That says our county’s residents are prescribed more opioid firepower per capita than any other county in the state.

Really? This data doesn’t feel right to me. My impression from the new patients I admit to the opioid treatment program is that area physicians are prescribing lower doses than in the past.

So I started thinking…the opioid addiction treatment program where I work has been growing, accepting more patients, and our census is a little higher than one year ago. But data from my opioid treatment program is not part of the prescription monitoring data, because we must adhere to a higher standard of confidentiality, given the stigma attached to medication-assisted treatment of opioid use disorders.

Except for the office-based buprenorphine patients. At present, they are not protected by higher levels of confidentiality and their data is part of the prescription monitoring program. I only have thirteen patients in that program in Wilkes County, but the pain clinic also prescribes much buprenorphine, for both pain and addiction.

Buprenorphine is an odd drug, since it is a partial opioid agonist with a ceiling effect at 16-24mg per day.

The American Society of Addiction Medicine published a paper giving instructions about how to calculate MME for methadone and buprenorphine. Their position paper on this issue (http://www.asam.org/docs/default-source/public-policy-statements/public-policy-statement-on-morphine-equivalent-units-morphine-milligram-equivalents.pdf?sfvrsn=0 ) says,

  1. When used for the treatment of addiction, methadone and buprenorphine should be explicitly excluded from legislation, regulations, state medical board guidelines, and payer policies that attempt to reduce opioid overdose-related mortality by limiting milligram morphine equivalents (MME). Higher MME of these medications are necessary and clinically indicated for the effective treatment of addiction involving opioid.
  2. State medical boards should not use MME conversions of methadone or buprenorphine dosages used in addiction treatment as the basis for investigations or disciplinary actions against prescribers.

In other words, when buprenorphine is used to treat addiction, translating the dose into MMEs is misleading. I would add that given the ceiling effect of buprenorphine, a partial opioid agonist, overdose is much less likely with this drug than with full agonists for opioid-tolerance people. And really, the risk for overdose death is the purpose for collecting MME data.

My state’s prescription monitoring program does use MMEs for buprenorphine. I’ve seen it on my office-based patient reports, and it annoyed me, knowing ASAM’s position statement about this issue. But I didn’t realize using MMEs for buprenorphine could potentially skew data until now.

What if residents of my county are prescribed more buprenorphine than other counties, both because it’s being prescribed appropriately for the high incidence of opioid use disorder in the county, and also because at least one physician group prescribes buprenorphine off-label for pain?.

To get an idea of how badly buprenorphine MMEs could skew data, I went back and looked at one of my office-based patients. The NC CSRS (our state’s prescription monitoring program) gave a MME of 360mg for a buprenorphine dose of 12mg.

That’s misleading. Morphine at a daily dose of 360mg would place a patient at infinitely more risk than buprenorphine at 12mg.

Just a few days ago, I sent an email to some of the smartest people in my state, asking them to consider this issue. As I was getting ready to post this, I heard back. The NC CSRS plans to separate office-based treatment data. I’ll update readers.

Give Thanks

aaaaaagrateful

 

OK, here is the column I was preparing before I became impaired by turkey tryptophan last week:

I have plenty of things to be thankful for in my personal life, but this column is about my gratitude for what’s happening in my professional life.

  1. I believe stigma against medication-assisted treatment of opioid use disorders has decreased over this past year. With the continued appalling mortality from opioid-related overdose deaths, people in positions of power have been forced to look for solutions. And when you look for solutions proven to help reduce opioid overdose death, there’s more evidence for maintenance use of methadone and buprenorphine for these patients than any other intervention. If you do any research at all, you can’t ignore this evidence. Well, unless you are Dr. Phil, but I digress.

In fact, some of my colleagues feel, and I agree, that abstinence-only treatment programs are committing malpractice if they fail to inform patients with opioid use disorder about the options of methadone and buprenorphine maintenance.

Policy makers and people who decide who gets grant money now look for grant proposals that include medication-assisted treatment of patients with opioid use disorder as necessary to get grant money. Money talks louder than any lecture, conference, or review article, and so some professionals who didn’t “believe” in MAT in the past are now becoming believers. I am fine with that, since patients benefit.

I’m excited to be involved with several grants, as a consultant in two and as a provider in another. This makes me happy, because all I have to do is what I always do – provide care and serve as a consultant if someone wants to pick my brain. I’m enthusiastic to see the final results of how we can improve care with better communication, too.

  1. More people know about naloxone for opioid overdose rescue. As a routine question when I admit new patients, I ask about past overdoses and I ask if they have a naloxone kit and if they know what they are used for. Most people know what the kits are for, and many already have kits. Some returning patients are reminded to tell me their kits have been used – usually on a friend or acquaintance.

Most of our patients got their kits, directly or indirectly, from Project Lazarus, the grass-roots program that started here in North Wilkesboro. It’s been copied in many other places, and does a wide variety of helpful services. This program provides education for law enforcement, physicians, community leaders, and any other interested parties on opioid use disorder, opioid overdose, and how each part of the community is needed to improve the lives and health of these patients.

As the founder of Project Lazarus, Fred Brason was given the Robert Wood Johnson award, and recognized for ground-breaking action in our community that can be duplicated in any interested community.

My state now has third-party prescribing, meaning I can write a prescription for naloxone to a worried parent or friend of someone with opioid use disorder. I did this twice yesterday, after two of my office-based buprenorphine patients, stable for years, talked about their fear a family member was going to die of an overdose from active opioid use disorder. My patients were very grateful, and I felt happy my state felt this was an important law to enact.

Naloxone kits aren’t treatment, but can help keep a person alive until they reach some sort of treatment. As I repeatedly say, dead addicts don’t recover.

  1. More physicians are willing to talk with me about the patients we share. Several months ago, a meeting was scheduled by one of our local OBs which included most of the obstetricians working in our area, all MAT providers in our county, the local health department, hospital representatives, and pregnancy care coordinators. DSS and anesthesiology were also invited but didn’t come. Our hospital’s new neonatologist was there, as was the head hospital pharmacist, who has always been an ally to me.

I was there along with the nurse manager and program manager of our opioid treatment program. We came armed with reams of information and recent studies to hand out to all participants, along with some of SAMHSA’s publications about medication-assisted treatment of opioid use disorder in general.

The meeting was ultimately productive, though it started poorly. In his opening statements, the head of the hospitals OB department accused me of “allowing” patients with opioid use disorders to get pregnant. I fired back at him, and accused him of being difficult to speak with because of his openly hostile stance on MAT.

A pregnant pause settled over the meeting, if you will pardon the pun, until cooler heads prevailed. Then we started talking about the actual mechanics of how we all could improve communication and treatment for these patients.

Aside from the opening of the meeting, it went well. We decided on ideas of how better to communicate with each other. Since that meeting, I have been sending updates to OBs of patients’ progress (with permission from our patients, obviously). I’ve been more diligent at asking patients to see their OB or the county health department for family planning if they aren’t on contraception and don’t desire a pregnancy.

The last pregnant patient who delivered at our local hospital was happy with her treatment there, and says she was treated courteously by hospital staff. She had a chance to meet with the neonatologist before delivery and felt comfortable with him, too.

  1. Now for the best of all…our opioid treatment program just moved into a new facility.

It’s great. It feels like a football field compared to the too-snug warren of offices we worked from before the move. Best of all, I am no longer located right beside the patient bathroom. My office smells gently of the scented candle I have on a shelf. And I have my own sink. I can wash my hands between patients without having to make a trip to the nearest bathroom!

 

 

 

I’ve worked over fifteen years in OTPs, at over fifteen separate sites. This is the best physical plant I’ve seen. The company, a for-profit hospital and mental health chain, spared no expense with renovations. All of our computers are new, as is our phone system, and all of our furniture. We have six dosing windows so that once we are up to speed, our patients will have short wait times. Patients waiting to see me have a separate waiting room. New patients, usually not feeling all that well, don’t have to be around the noisy interactions of the main waiting area.

What I like best is exactly what one patient said to me after looking at the facility: “You know, it looks just like any other medical practice.”

Yes. Because it is a medical practice. We provide life-saving, evidence-based medical care. The owners of this company sent an important message with this renovation – that our patients and our staff are deserving of a nice facility where we provide this important care.

I have great expectations for 2017.

My Favorite Patients Have Opioid Use Disorder

dogs-asleep-and-falling-off-couch

 

 

I’m lazy and bloated from too much tryptophan from turkey, so I’m going to post an article today that’s a re-run. I wrote it for a physicians’ magazine, and I’m pleased to say it was published (around six or so years ago). The original title was “My Favorite Patients are Drug Addicts,” but in keeping with newer language, I updated the title:

When I was a fresh faced, newly unleashed graduate from my Internal Medicine residency twenty-three years ago, I never dreamed my favorite patients would be drug addicts.

In medical school, I learned little about drug and alcohol addiction and its treatment, and in residency, even less. I was well trained in the management of acute alcohol withdrawal, acute GI bleeding from alcoholic gastritis, and antibiotic coverage of endocarditis in an injection heroin user, but I couldn’t tell any of these patients how to find recovery from the actual underlying cause of their problems. I could only treat the sequellae, and I didn’t always do that with much grace.

The addicted person caused their own miseries, I thought, and since these were the Reagan years, they should “just say no” when offered drugs. My attitudes mirrored those of the attending physicians in my residency program. When an addict was admitted twice for endocarditis, needing an artificial valve the first admission, and its replacement on the second admission for re-infection, I was just as irritated as the attending and the rest of the house staff. I remember we discussed whether we could ethically refuse him treatment if he came in a third time! We were so self-righteous, though we had offered him little in the way of treatment for his disease of addiction. We might have had a social worker ask him if he wanted to go away for inpatient treatment, he said no, and that’s where our efforts ended.

I knew nothing about medication-assisted therapies for opioid addiction. Now I know better.

I was working part time in primary care when a colleague, the medical director at a local drug addiction treatment center, asked me if I could work for him at this center for a few days while he was out of town. He was a good friend so I agreed. I thought it would be easy money, and fun, doing admission histories and physicals on addicts entering the inpatient residential program, and I was right…but I also saw patients entering the clinic’s methadone program.

This appalled me. It seemed seedy, shady, and maybe a “fringe” area of medicine. It just seemed like a bad idea to give opioid addicts methadone. However, I had made a commitment to my friend, so I told myself I would work those few days, tell my friend politely when he returned that I didn’t “believe” in methadone (as if it were a unicorn or some other mythical beast) and could not work there again.

But when I talked to these patients they surprised and intrigued me. Some patients were intravenous heroin addicts, but most were addicted to pain pills, like OxyContin, various forms of hydrocodone, and morphine. Most of them had jobs and families, and expressed an overwhelming desire to be free from their addiction. I was most intrigued by how the patients talked about methadone treatment. They said such things as “It gave me my life back” and “Now I don’t think about using drugs all the time” and “Methadone saved my marriage and my life”.

Huh? With methadone, weren’t they still using drugs?

My curiosity piqued, I started reading everything I could find about methadone – and to my surprise discovered that the treatment of opioid addiction with methadone is one of the most evidence-based treatments used in medicine today, with forty years worth of solid data proving its efficacy. So why had I never heard of it? I could have referred many intravenous heroin addicts that I saw during my residency, which happened to be during the height of the spread of HIV, for effective treatment of their addiction. Because of methadone’s unique pharmacology, it blocks physical opioid withdrawal symptoms for greater than 24 hours in most patients, and also blocks the euphoria of illicit opioids. At the proper dose, patients should not be sedated or in withdrawal, and are able to function normally, working and driving without difficulty. Therefore, methadone maintenance is not “like giving whiskey to the alcoholic” as some ill informed people – like me – have accused.

For the next eight years I happily worked part time with my friend at this drug treatment center, and saw most methadone patients improve dramatically. Certainly methadone did not work for everyone, but it was a good treatment for many addicts. I did see some tough characters, but I was struck by how normal most of the patients seemed; most were not scary thugs as I had imagined, but housewives and construction workers.

Then I began hearing about a second medication to treat opioid addiction, called buprenorphine, better known by its brand name, Suboxone. The principle of this drug is the same as for methadone: it is a long-acting opioid, can be dosed once per day, and at the proper dose removes the physical withdrawal symptoms, and does not impair patients or give them a high. As an added bonus, it can be prescribed through a doctor’s office. In 2000, the Drug Addiction Treatment Act allowed doctors, for the first time in about 80 years, to prescribe specifically approved schedule III, IV, or V controlled opioid for the purpose of treating people with opioid addiction. Shortly after this, the FDA approved buprenorphine for the treatment of opioid addiction, and the drug became available in 2003. In order to prescribe buprenorphine, a doctor must take an eight hour training course, petition the DEA for a special “X” number, and give notice to CSAT, the Center for Substance Abuse Treatment, of her intent to prescribe. Doctors prescribing buprenorphine also must have the ability to refer patients for the counseling that is so necessary for recovery from addiction.

Buprenorphine, a partial opioid agonist, is a milder opioid and there’s a ceiling on its opioid effects, making it a safer and better choice for many patients than methadone. It is particularly good for addicts with relatively short periods of addiction, and fairly stable lives. Since it is a milder opioid, it is relatively easier to taper, if appropriate.

I started prescribing buprenorphine from a private office and loved it from the first. Initially, Suboxone was expensive, but now generic forms have been approved, and prices have come down a little. Opioid treatment programs, formerly known as “methadone clinics” have started offering buprenorphine in addition to methadone.

The opioid addicts I met both in the opioid treatment program and in my private office have not been what I expected. The vast majority are ordinary, likeable people with jobs and families. They are your hairdresser, your grocery clerk, the guy that works on your furnace. They sit beside you at the movies and behind you at church. Because they have built a tolerance to the sedating effects of opioids, they do not look impaired or high; they are able to function normally in society…as long as they have a supply of opioids.

If they are in withdrawal, without a source for opioids, they will be sick. Some people compare opioid withdrawal to having the flu, but it is not. It is like having the flu…and then being hit by a truck. Most addicts in opioid withdrawal are unable to work because of the severe muscle aches, nausea, vomiting, and diarrhea. Many of these patients are blue collar workers with physically demanding jobs who initially used pain pills to mask their physical pain so that they can work harder, better, faster…never guessing that what seemed to be helping was actually causing them more harm than they could imagine.

Some patients seen in the office setting were professionals. Most professionals can afford the more expensive inpatient thirty- to ninety- day rehabs, a luxury for many of the working middle class. But I saw some lawyers, nurses, even policemen with opioid addiction who refused to consider inpatient treatment even if they could afford it. These professionals were concerned about their livelihood if it became public that they had a problem with addiction, or because they were unwilling to take time off work. They were willing to come to a doctor’s office where no one would know why they were being seen, and they did very well on buprenorphine.

I am thrilled when seeing a patient respond positively to treatment with buprenorphine. Many return on the second visit looking like younger and happier versions of themselves. On the second visit, a common phrase is “It’s a miracle!” Many patients say they just feel normal, even though they had forgotten what normal felt like. When an addict begins to recover, the changes are usually dramatic; they begin to smile, to restore relationships, to rejoin their families and their communities. When an addict recovers, the ripple effect extends throughout the community.

We know now that addiction is indeed a chronic disease much like asthma and diabetes. Just like these diseases, there are behavior components that can make the disease worse, and there are genetic and personal factors that put some people at higher risk. Sadly, many addicts are still treated with distain and disgust by their doctors, an attitude we would not tolerate towards any other disease. This causes patients to hide addiction from their doctors, and the disease worsens.

Many people, even doctors, still object to the use of medication assisted therapies for addicts, saying “it’s trading one drug for another,”  when in reality it is trading active addiction for medication, when prescribed responsibly and appropriately. Drug-free recovery is ideal, but with opioid addiction, it does patients a disservice to dismiss the mountains of evidence proving the effectiveness of medication-assisted therapies with buprenorphine and methadone.

Detoxification alone (usually five to seven days) does not work, and shows relapse rates of up to 96%. If detoxification alone worked, the policy of imprisonment for addicts promulgated in the 1950’s would have solved the opioid addiction problem. It didn’t.

For most patients, their big question is: “How soon can I get off of this drug?” Most express a desire to be completely drug free at some point, but I think it’s important to get each patient involved in a recovery program before tapering their medication. This can be an intensive outpatient program at a treatment center, an individual therapist, or through 12-step recovery.

Some patients, particularly those with both opioid addiction and chronic pain, prefer to remain on buprenorphine or methadone indefinitely as the safest treatment for both problems, and these patients also seem to do very well.

As for me, I plan to continue treating addicts of all types. These patients have been among the most grateful that I have encountered in primary care, and show the most improvement. When I treat addicts and see peace return to a face that had been filled with shame, I get a unique feeling of accomplishment. These are events I am honored to witness.