Risk Factors for Long-term Opioid Use


The Centers for Disease and Control and Prevention published an important article in their Morbidity and Mortality Weekly Report on March 17, 2017, titled, “Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use – U.S., 2006-2015.”

You can read the article here: https://www.cdc.gov/mmwr/volumes/66/wr/mm6610a1.htm

To summarize for my readers, this article describes a study from a very large pool of patients. This study, felt to represent the U.S. population with commercial health insurance, was done on patients with records in IMS Lfelink+database. With nearly 1.3 million subjects, this was a large study, giving it power to detect even small differences.

The study included patients over age 18 who received at least one opioid prescription during the time frame of June 1, 2006 through September 1, 2015. To be included, the patient had to have been free of opioid prescriptions for at least six months prior to receiving an initial opioid prescription. This patient pool was followed over time, to see what risk factors were associated with continued opioid prescriptions. The patient left the study if they de-enrolled from their insurance, or when the patient went for more than 180 days without any opioid prescriptions, or when the study ended.

Patients with cancer were excluded, as were patients with a substance abuse disorder, and patients who were prescribed buprenorphine for the treatment of substance use disorder, since those patients could be expected to have opioid prescriptions lasting longer than patients without those diagnoses.

The duration and dose of the first prescriptions were examined to see which patient or treatment factors were associated with longer opioid use and ongoing opioid prescriptions.

Out of all of the 1.3 million patients, 2.6% continued on opioids for more than one year. These patients were more likely to be female, have a pain diagnosis prior to the first opioid prescription, be older, and have public insurance such as Medicaid or Medicare. They also tended to be started on higher doses of opioids compared to the patients who used opioids for less than one year.

Of all of the patients who were prescribed opioids, 70% were prescribed opioids for seven or fewer days. Only around 7% were prescribed opioids for more than a month. The rest of the patients were prescribed opioids for one to four weeks.

Of the people initially prescribed seven or fewer days of opioids, only around 6% were still on opioids a year later. But 13% of the patients with an initial opioid prescription for eight or more days were still on opioids a year later. Actually, at around the fifth day, the study showed the biggest spike in likelihood of chronic opioid use. For patients with an initial opioid use episode of more than a month, around 30% were still prescribed opioids a year later.

The amount of opioid prescribed influenced risk of continued opioid use. Authors of the study found that a cumulative dose of more than 700 morphine-milligram equivalents were several times more likely to become chronic opioid prescription users than those patients prescribed less than this amount.

The study looked at regional differences too. Of the patients who continued prescription opioid use for more than three years, 38% lived in the South. Only 19% lived in the East, and Midwestern patient accounted for 31% of users of opioids for more three years. Western patients accounted for around 9% of these patients, and the rest couldn’t be classified as to area of the country for some reason.

I doubt this regional variation is from differences in medical issues of the patients. I suspect these differences are due to physician prescribing practices. I could be wrong. The study authors didn’t elaborate on this data. Maybe doctors in the South are getting it right, and doctors in other areas are undertreating pain. However, many southern states have high opioid use disorder rates, and high opioid overdose death rates. And relative to the entire world, the U.S. takes more than its share of opioid medications, as shown in the graph at the beginning of this blog.

Of course, this study doesn’t show cause and effect, just an association. Longer initial opioid prescriptions are associated with continuation of opioid prescriptions for more than a year; however, perhaps the conditions being treated in that group of patients were more severe.

This study looked to see if there was an association between which opioid was prescribed and the risk of long-term opioid use. Patients given prescriptions of long-acting opioids were more likely to have long-term use. That’s no unexpected, but the second most likely medication to be associated with long term use was tramadol.

Tramadol is still mistaken thought by many physicians to be a benign pain medication, unlikely to cause physical dependence or substance use disorder. But in this study, more than 64% of patients who were started on tramadol were still taking some sort of opioid one year later.

As an aside, I’ve seen a fair number of patients present for treatment of their opioid use disorder who used tramadol, usually with other opioids. And some of the worst withdrawals I’ve seen have been with tramadol, with high fevers along with other more typical opioid withdrawal symptoms.

This study’s authors recommended limiting the initial opioid prescription to less than seven days when possible, to reduce the risk of continued opioid prescription and use. Since their data found that a second opioid prescription roughly doubled the patient’s risk of being on opioids for more than a year, the authors also recommended serious consideration of the second prescription.

This study makes intuitive sense. It showed that the longer the number of days of the initial prescription, the greater than risk of the patient still being on opioids one year later.

But what surprised me was the degree of increased risk, even with only a second prescription, and even with only more than seven days prescribed.

Readers may ask, what’s the big deal about being on opioids for more than one year? That doesn’t necessarily mean the patient has opioid use disorder. That is correct, and this study isn’t saying these patients who became chronic users of opioid pain medication developed opioid use disorder.

However, as the authors say in their summary, previous research does show an increased risk for harm in patients on long-term opioid therapy.

In view of our current opioid overdose death problem, it would seem prudent to limit risk to patients. We can use this information, and be cautious about prescribing more than seven days of opioids. We (physicians) should carefully consider whether to give second opioid prescriptions, and be more cautious about prescribing tramadol and long-acting opioids.

Naloxone in Action


At the recent American Society of Addiction Medicine (ASAM) conference, I read a poster describing a study entitled “Lives Saved with Take-home Naloxone for Patients in Medication Assisted Treatment.” The article, by Katzman et al., from the University of New Mexico School of Medicine, described the outcomes from providing naloxone overdose reversal kits to patients enrolling in medication-assisted treatment of opioid use disorders

The study subjects were admitted to medication-assisted treatment over three months in 2016. The poster didn’t say whether they started buprenorphine, naltrexone, or methadone, but I’m guessing the patients were admitted to methadone maintenance.

In the end, 244 subjects enrolled and had education about opioid overdose and how to use a naloxone auto injector kit.

Twenty-nine subjects were lost to follow up, leaving 215 subjects available for inclusion in the study. Of these 215 subjects, 184 didn’t witness or experience overdose.

That means 31 subjects either experienced or witnessed at least one opioid overdose episode.

The scientists conducting the study interviewed these 31 subjects, and discovered that 39 opioid overdoses had been reversed and all of those lives were saved. Thirty-eight people were saved with the naloxone kits distributed by the opioid treatment program, and one study subject was revived by EMS personnel.

When study authors looked at who was saved by these study subjects, they discovered 11% of people saved were acquaintances of the study subjects, 16% were family members, 58% were friends, 6% were the significant others of study subjects, and 13% were strangers.

The study authors concluded that “a significant number of lives can be saved by using take-home naloxone for patients treated in MAT [medication assisted treatment] programs.” The authors also felt the study showed that naloxone isn’t usually on the patient who entered treatment, but more frequently on friends, relatives, and acquaintances that the MAT patient encounters.

I was intrigued by this study because it mirrors what I’ve heard in the opioid treatment program where I work. We are fortunate to get naloxone kits from Project Lazarus to give to our patients. It’s rare that one of our patients enrolled in treatment needs naloxone for an overdose, but much more frequently, I hear our patients say they used their kit to save another person’s life.

If anyone doubted the abilities of people with opioid use disorders, and felt they couldn’t learn to give naloxone effectively, this study should put that idea to rest. If anyone mistaken thought people with opioid use disorders wouldn’t care enough about other people to put forth an effort to save another person, this study should put that idea to rest, too.

In fact, I’ve seen a real enthusiasm among our patients to make sure they have a kit, in case they get the opportunity to save a life. They are eager to help other people, and I find that to be an admirable attitude that’s nearly universal among the people we treat.

Sometimes I get into discussions with patients about what they think about the naloxone kits, and where they think the kits can do the most good. I’ve heard some good ideas. One patient said every fast food restaurant should have a naloxone kit, since she knew many people with opioid use disorder inject in the bathrooms of these facilities. Actually, I just an online article discussing something similar: http://www.wbur.org/commonhealth/2017/04/03/public-bathrooms-opioids  

This article expresses the problems that injection drug use has become for public restrooms, and makes a case for safe injection centers. This is presently illegal in the U.S.

Even Massachusetts General Hospital armed its security guards with naloxone kits, so they could give this life-saving medication to people they found who had overdosed in the hospital’s public bathrooms.

Another patient suggested giving naloxone kits to people living in trailer parks.

I know that feeds into a kind of stereotype of those who live in trailer parks, but apparently there is some basis for saying such residential areas have high density of people with opioid use disorders. It’s worth looking at.

Several patients said that all people receiving opioid prescriptions for chronic pain should also be prescribed naloxone kits, and I think that’s been recommended by many health organizations too.

Most communities have at least talked about arming law enforcement and first responders with naloxone kits, and hopefully that’s a trend that will continue to spread.

Naloxone isn’t a permanent solution for opioid use disorder, but it can keep the people alive until they can enter opioid use disorder treatment. Because dead addicts don’t recover.

 

ASAM Conference

 

Twenty-one hundred people registered to come to this meeting, the biggest yearly event of the American Society of Addiction Medicine. In the vast grand ballroom, row after row of chairs, in section after section, are occupied with medical professionals eager to learn more about their chosen field. Leaders in the field are scheduled to speak.

On this first morning, distinguished and learned people are ready to speak.

But first…a poet spoke to us.

Joseph Greene is a spoken word artist. I didn’t know what that was until he started, but then I discovered I liked it.

He performed his poetry. First, he reminded us to shed our cynicism and pessimism, symptoms of burnout. He reminded us to remember the people we have already helped, and to allow their energy to revitalizes us. Right away, I felt a wave of enthusiasm.

I admired the positivity his poetry evoked in his audience. We are not so easily moved, we doctors who toil on the front lines in the war on the people who use drugs. We can become cynical, and he moved us out of our pessimistic ruts.

The plenary speakers who came after him presented information and had mixed news.

Patrice Harris, MD, MA, Chair of the American Medical Association Board of Trustees, gave us alarming updated information: ninety-one people die from opioid overdose each day in the U.S., according to data from 2015, the last year for which we have data. That’s up from seventy-eight opioid overdose deaths per day in the previous year. That’s depressing news, especially since the amount of opioids prescribed in this country has been dropping since 2014, a little before the American Medical Society’s call to action. From 2013 to 2015, the total amount of opioids prescribed dropped by about 10%.

Mortality grew despite many more physicians signed up to use their states’ prescription monitoring programs, pushes to prescribe more naloxone to reverse overdoses, more medication drop-off so controlled substances don’t fall into unintended hands, and a push to increase treatment availability.

Despite an eighty-one percent increase in physicians trained to prescribe medication-assisted therapies in the years 2012 to 2016, still only twenty percent of U.S. citizens with opioid use disorder got treatment.

Dr. Barbara Mason, PhD, winner of the R. Brinkley Smithers Distinguished Scientist award, spoke next. She reminded us that despite all the attention paid to opioid use disorder, alcohol still causes many more deaths per year. In the U.S., about eighty-eight thousand deaths per year are attributable to alcohol. Alcohol is the fourth leading cause of preventable death in the U.S. Dr. Mason gave us information about new studies on medications which may be approved for use in alcohol use disorder treatment.

At present, we have only three medications approved by the FDA: disulfiram (Antabuse, acamprosate (Campral), and naltrexone (Revia, Vivitrol). Only around ten percent of people with alcohol use disorders are prescribed any of these three medications.

Next we heard from Vivek Murthy, MD, MBA, Surgeon General of the U.S. He planned to talk to us in person but due to airplane delays, had to join us via internet. We also had plenary sessions with talks from George Koob, PhD, Director of the National Institute on Alcohol Abuse and Alcoholism (NIAAA), and from Wilson Compton, MD, MPE, Deputy Director of the National Institute on Drug Abuse (NIDA).

All of the speakers were good, and most of them were great.

I’ve learned much, socialized a little, ate some great food, and relaxed.

Being around this many people who are all excited about helping people with substance use disorders change their lives is exhilarating. Even better than the data I learned is the enthusiasm I’ve re-discovered.

Thank you, American Society of Addiction Medicine, for another great conference!

New Way to Dose Buprenorphine

FluidCrystal technology

 

 

We all know that Probuphine in now available. It’s a depot preparation of buprenorphine that can be implanted beneath the skin to release buprenorphine for six months. It finally came to market last year, and we are awaiting news of how well it is working.

Soon we may have another choice: weekly and monthly depot injections of buprenorphine. I blogged about this in an entry posted July 30, 2013.

In essence, this new subcutaneous injection of buprenorphine was invented by Camarus Pharmaceuticals, a small Swedish company that invented a nanoscale drug delivery system, as they say on their website. This “Fluidcrystal” injection containing buprenorphine comes in preparations of varying doses, and can be dosed once per week or once per month, depending on the preparation.

The liquid substance containing buprenorphine is injected subcutaneously (under the skin), where it forms a gel. Then a capsule-type substance surrounds it, allowing buprenorphine to be released into the body over time. Started weekly, the dose can be adjusted to meet patient needs. Eventually, the patient can move to once-monthly injections. The matrix of material is biodegradable, and eventually completely absorbed by the body.

This subcutaneous injection of medication has a very low viscosity, meaning it can be given with small needles that cause less pain to the patient. The medication is already pre-mixed, making it convenient for medical providers, and it is stable at room temperature for up to three years.

Initial trials of this medication have been intriguing; they show a fast delivery of medication, giving rapid onset and a steady blood level over one week or one month, depending on the preparation given. Safety data was pretty good; other than some headache and a low rate of inflammation at the injection site, it was well-tolerated. Because of the Fluidcrystal technology, if an addict attempts to inject this substance into a vein, it will form a deposit at the injection site, blocking the vein.

I’m excited by this medication. First, with daily buprenorphine dosed sublingually, some patients relapse. They may decide to stop taking the buprenorphine for a few days so that they can use their opioid of choice and get high again. True, they have to do a little more planning to relapse than if they were not on buprenorphine, but relapse rates are still too high. The depot forms make relapse less likely, I think, because compliance is assured once the medication is injected.

Second, with the depot forms of buprenorphine, the patients don’t have to think about taking something to treat their addiction. They don’t have to think about their medication at all, and their addiction doesn’t have the chance to urge them to take more of their medication than prescribed. Thankfully with buprenorphine there is a ceiling to its opioid effect, so that patients already on a blocking dose of sublingual buprenorphine won’t usually feel any intoxication from taking more of their medication.

Third, we’ve seen increases in the amount of buprenorphine being diverted to the black market, as the total amount prescribed has increased. Politically, this diversion threatens buprenorphine availability. One only need to look at regulations like what was passed by Virginia’s medical board to see the limits being placed on this life-saving medication, due to concerns about diversion. Law enforcement officials and politicians believe buprenorphine is a desirable street drug. Of course, research shows most people using illicit buprenorphine are trying to prevent withdrawal, and not using it to get high.

With this subcutaneous injection, I think it’s highly unlikely to be diverted, or at least much less likely that film or tablet to be diverted.

Because the dosing interval is every one week to every one month, medical providers can still see the patient once per month, and can provide counseling as a condition of continued treatment. With the six-month depot placement of Probuphine, it’s unlikely the patient will voluntarily return monthly for counseling visits, once they get the medication implanted. The more frequent and simpler administration of this form of buprenorphine appears ideal to me.

According to the Drug Addiction Treatment Act of 2000, the FDA must give approval to any form of buprenorphine that’s to be used to treat opioid addiction. At present, the sublingual form of buprenorphine and the implantable form of buprenorphine known as Probuphine have FDA approval. Other forms of buprenorphine in patch (Butrans) or injectable form are illegal for a doctor to prescribe to treat opioid addiction. this new subcutaneous injection of buprenorphine therefor must be approved by the FDA before it can be legally used to treat patients with opioid use disorder.

According to the manufacturer’s website, Phase 3 trials are concluded. According to a company press release, a double-blind, double dummy controlled trial of the weekly and monthly injections were found to be “non-inferior” to sublingual buprenorphine. That phrase is something drug manufacturers have to prove before a new drug is allowed to be approved by the FDA. The new drug must show it’s at least as good as the old drug. Additional data is rumored to show that it’s superior to sublingual buprenorphine, though I haven’t been able to find and read the original data yet.

This is a medication I would be excited to use in my practice. Instead of a surgical procedure, all I would need to do would be give a subcutaneous injection of this new product. How easy! My patient could see me as often as needed, and could see her counselor the same day she gets the injection, thus remaining established in a counseling program, too.

I am eager for the FDA to review this drugs study and approve it, if appropriate.

Comorbidity and a Sad Update


 

 

In 2011, I posted the following blog entry, and described an example of a patient from my office-based practice to illustrate:

Addicted patients are twice as likely as non-addicted patients to have mental illnesses such as mood disorders, anxiety disorders, schizophrenia, and attention-deficit hyperactivity disorder. The converse is also true: patients with mental illness diagnoses are twice as likely to have an addictive illness in addition to their mental illness.

Why is this? Is there a common factor underlying both types of disorders? Does one cause the other? For years, doctors and therapists have argued about this, and there are still no definite answers. However, why these diseases occur together isn’t as important to me as how to treat them most effectively.

We know patients get the best results when both diseases are treated at the same time, preferably under the same roof. That’s not always easy, but it’s the ideal.

To further complicate treatment, many times drug addiction causes the same symptoms as mental illness. For example, a person intoxicated on methamphetamine can look just like someone in the manic phase of bipolar disorder, or even schizophrenia. Another example can be seen in heavy drinkers, who are often depressed from the effects of alcohol, which is a depressant.

I rely on several methods to help me decide if drug use, abuse, or addiction is mimicking mental illness. First, I try to get information about what a patient was like during periods of abstinence from all drugs. If all of the mental illness symptoms went away during abstinence, it’s less likely that there’s an underlying mental illness. However, if the patient was still suffering with significant symptoms of mental illness even during a period of abstinence from drugs, the patient probably has a second diagnosis.

I ask about family history of mental illness, because if relatives have been diagnosed with these disorders, it’s more likely that the patient I’m treating will have mental illness in addition to addiction.

I ask my patient which started first, the symptoms of mental disorder or drug use? Often, symptoms of mental illness and drug use both started around the same time, at late adolescence/early adulthood, so that history often isn’t as helpful as I’d like.

Here’s an example of a case I saw recently: (identifying details have been changed):

A 24 year old female saw me in my office as a new patient. She wanted to be considered for my Suboxone program. She gave a history of illicit drug use for four years, and had used opioids daily for a year and a half, snorting up to 200mg of hydrocodone or oxycodone per day. She used marijuana three times a week, usually two cigarettes per day. She denied use of benzodiazepines or alcohol, and said her father was an alcoholic. She used cocaine heavily in the past, but stopped using it three years ago because of its expense. Besides, by that time, she preferred opioids. She acknowledged recent use of methamphetamine three or four days ago, and said she snorted methamphetamine when she couldn’t find any opioids, only to stave off withdrawal. Her answers about frequency and amount of methamphetamine used were vague and evasive, so I was unsure of her exact history.

When I asked about her mood, she said she was depressed because of all the bad things that were happening as a result of her addiction: she was broke, her boyfriend just broke up with her (he was her drug-using buddy) and her family wasn’t loaning her any money, so she was in withdrawal much of the time. She denied any period of abstinence from drugs since she started using drugs at age 15. Family history was significant for a maternal aunt with severe bipolar disorder, requiring psychiatric hospitalization on multiple occasions.

Her exam was worrisome for a very low body weight. At 5’6” she weighed 103lbs. (she denied any symptoms of eating disorders) She was tense, pleasant, intelligent, and well-spoken. She fidgeted in her chair to an extreme amount. She was in florid opioid withdrawal, with wide pupils that were briskly reactive, obvious runny nose, frequent yawning, sweating, and goose bumps visible on her upper arms.

Her mother, who paid for her treatment, came to the appointment with her. My patient gave me permission to talk with her mother, who had quite a bit to add to the story. Mom said her daughter often seemed paranoid, and last weekend she stayed awake all night on Saturday, peering out one window after another, and checking repeatedly to make sure they were locked. My patient’s weird behavior kept the family awake all night. My patient also claimed to be able to hear people talking just outside the windows, and was sure the government meant to take her from her family for a nefarious reason. The patient’s mother said this last weekend was the most severe paranoid behavior she had seen in her daughter, but she had seen similar conduct in the past.

At this point, I thought there was a good chance we were dealing with more than just addiction. I considered bipolar disorder with psychotic features to be the most likely diagnosis, or schizophrenia. I hoped her use of methamphetamine had caused these worrisome symptoms, since she shouldn’t have them once she stopped use of the drug and got out of opioid withdrawal.

With this new information, I changed my treatment recommendation, and thought an inpatient admission to a detoxification unit was most appropriate. Her psychiatric status could be closely observed, and she could be started on Suboxone. If the psychotic features resolved, great. If not, she could be started on appropriate medications, be stabilized and then come see me after she was discharged. I could maintain her on Suboxone after she was stabilized.

It was a great idea, but unworkable. The detoxification unit wanted a chunk of money up front, before admission, and she didn’t have that kind of money. It was also beyond her mother’s financial capability. This patient had no insurance and didn’t qualify for Medicaid.

The patient pleaded with me to start on Suboxone. She believed all would be well if only she could get out of opioid withdrawal. I had my doubts, but agreed to prescribe one week of medication with telephone contact. Her mother agreed to call me or take her daughter to the psychiatric emergency room if her mood or behavior deteriorated.

One week later, a calm, smiling young lady entered my office. She had gained seven pounds in one week, and was no longer restless. The change was remarkable. Her mom came with her and said she hadn’t seen any more paranoid behavior. Her mother started to cry, saying, “I have my daughter back.” I was thrilled at the improvement. I adjusted her Suboxone dose slightly, and made sure she had her first session with the addiction counselor in my office.

I’ve seen her every week for the past month. She goes to three Narcotics Anonymous meetings per week, which is fewer than I’d like, but at least she’s going. She’s met with the licensed addiction counselor in my office each week. She’s had negative urine drug screens for the past three weeks and continues to gain weight. She says her mood is good, and she just went back to work.

For now, I don’t see evidence on mental disorder, but I’ll keep watching for problems.

I have a sad update.

After about two years of doing extremely well in my office-based practice, this patient relapsed. She was taking Suboxone 8mg per day, and appeared to be enjoying a good recovery. She went to 12-step meetings, got a sponsor, worked the 12 steps of recovery, and did service work at her home group.

She also had some sessions with the therapist who works in my office, who is MINT certified and has LPC and LCAS certification. After the first six months, she didn’t see a need for this service, and I didn’t push the issue, since she appeared to be doing so well.

After nearly two years of recovery, she missed an office visit, without calling to re-schedule. When she came the next week, she was positive for opioids on her urine drug screen.

We talked about her relapse extensively. She said she was upset one day, and had taken a few pain pills her mom had around the house.

We talked about what this meant. She already talked to her sponsor and had picked up a white chip at her 12-step meeting. We talked about how relapse is often a part of a person’s recovery. Since she was fortunate enough to survive it, we needed to examine her relapse process in detail, to learn from it.

I was unsettled, since I thought she had been doing great. I could tell she was unsettled too, and I made her next visit in one week instead of our usual one month.

She missed that visit, and I was really worried.

When she did make it in to my office a few weeks later, she falsified her urine drug screen. I told her I was really worried, because that was so unlike her. She admitted to relapsing back to heavy pain pill use.

We discussed treatment options. I wanted her to go to an inpatient program, to become re-stabilized, and then come back into treatment with me. We also discussed transferring her temporarily to an opioid treatment program, where she can go each day to be dosed, and where there’s more accountability.

She refused both of these options, saying she couldn’t miss work, and both would interfere with her work schedule. She was sure she could pull herself out of this relapse, if only I would give her another chance.

She kept her appointment a week later, but she was still illicit opioids. She said she was filling my Suboxone prescription, but only used it if she couldn’t find anything else. She had stopped going to 12-step meetings. Her mom came with her to this visit, and I asked if we could include her mom in her session. My patient not only refused to allow her mom to be a part of the conversation about treatment options, she also revoked the release for me to disclose anything to her mom.

I told my patient it was no longer safe to treat her in an office-based setting. I gave her one more week’s prescription and told her she had one week to decide what option she preferred: inpatient medical detoxification followed by inpatient residential treatment, or transfer to an opioid treatment program. I gave her the number and address of the OTP, where I knew she could continue on buprenorphine while she regained her stability.

I never spoke to her again.

She didn’t keep her next appointment. Three weeks after this missed appointment, she went to an opioid treatment center (not the one I’d recommended), which only used methadone. After she took her first day’s dose, she took a handful of Xanax and died in her sleep that night.

I thought about those last sessions multiple times, and wished I’d handled them differently. I think I believed her when she said she could stop using heroin on her own, since she had done so well while in recovery. Surely, I thought, she doesn’t want to stay stuck in active addiction any longer. Surely she has the tools to get back on the right path.

But this is a deadly disease. Even two years of joyful recovery didn’t save this patient in the long run.

I’m sorry to end on such a somber thought. However, I need to remember the stakes are so very high for our patients, and all relapses are serious.

Those of Us Who Lie


 

 

 

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

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

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

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

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

Lies are part of substance use disorders.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

 

Mandated Training?


 

 

 

 

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

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

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

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

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

Example number one:

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

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

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

Example number two:

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

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

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

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

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

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

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

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

Example number three:

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

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

Now, things are getting weirder.

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

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

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

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

Example number four:

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

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

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

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

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

He was not expected to live.

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

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

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

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

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

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

He was started on sublingual buprenorphine and has done beautifully.

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

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

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

 

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

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

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