Education of New Physicians

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I read an interesting study in the May/June issue of the Journal of Addiction Medicine. This article, by Shuey et al, described Internal Medicine residents’ knowledge and attitudes towards treatment of opioid use disorder with buprenorphine.

This study reports on results of survey questionnaires sent to Internal Medicine residents in Florida residency programs.

The study showed that Internal Medicine residents cared for patients with opioid use disorder frequently: 73% of the survey respondents said they cared for such patients more than once per month. But only 82% reported having substance use disorder educational curricula. Specifically, 75% said their program didn’t provide training in the treatment of opioid use disorder with buprenorphine.

Respondents’ answers to questions about buprenorphine as used to treat opioid use disorder were uneven. While 88% correctly answered that buprenorphine was a partial opioid agonist, only 16% knew that buprenorphine has a higher affinity for opioid receptors than methadone, morphine, and naloxone. Seventy-six percent were aware of the dangers of precipitated withdrawal, and 69% knew that methadone cannot be prescribed from an office-based setting for the purpose of treating opioid use disorder.

However, only 17% knew that weeklong tapers of buprenorphine are not supported by medical evidence, and 56%, more than half, mistakenly thought resident physicians can’t prescribe buprenorphine.

Residents who indicated an interest in treating patients with buprenorphine scored better than those not interested in getting a buprenorphine waiver to prescribe.

Of the Internal Medicine residents who answered the study, only 2% already had waivers to prescribe buprenorphine. However, the vast majority, at 89%, felt deregulation of buprenorphine to allow any physician with a DEA license to prescribe buprenorphine was a good idea. (This study was done prior to the change in rules earlier this year that allows just that.)

The surveyed residents were also asked about their attitudes towards barriers to prescribing buprenorphine. When asked if they were willing to get trained and prescribe buprenorphine if it was offered by their hospital, 82% agreed. When asked if they felt they had been adequately educated about treatment of opioid use disorder, only 19% said they had, and 48% said they didn’t feel educated, while 33% felt neutral about the question. When the residents were asked if they agreed that opioid misuse and addiction was a serious national crisis, over 80% strongly agreed.

When the respondents were asked about obstacles to the prescribing of buprenorphine, by far the most common response was limited knowledge about diagnosing and managing opioid use disorder. Other answers were a lack of awareness of medication, laws preventing residents from prescribing buprenorphine, and limited understanding of the legal process to obtain a buprenorphine waiver. Less than 5% of survey respondents said they lacked interest in prescribing buprenorphine, around the same percentage who feared legal action against residents who prescribe buprenorphine.

Let’s talk about some interesting things about the study. For example, only around sixteen percent of the residents who were sent this survey responded. That’s a low rate of participation. However, the Internal Medicine (IM) residents who did responded to this survey were relatively diverse. More than half were female, and evenly divided over the three years of residency. Ethnicity was 42% white, 24 % Hispanic or Latino, 23% Asian, and 7% Black or African American.

That’s more diverse than my Internal Medicine residency, way back in 1987. We were 28% female and 85% white, with 15% black, with no Asian or Hispanic residents. And we were the most diverse class to date. The IM residents in the two years prior to mine were 100% white and 7% female. I’m glad residents are more diverse now.

Were minority residents more likely to respond to the survey for some reason? And were residents already interested in treating patients with opioid use disorder more likely to answer the survey? There’s no way to know.

This study indicated IM residents are not getting valuable information about treatment of opioid use disorder. We are now several decades into the opioid epidemic. It’s been over two decades since DATA 2000 was passed, allowing patients to be treated with buprenorphine in office-based settings. That’s a whole generation of physicians.

Why have medical schools and residencies been so slow to teach young doctors about opioid use disorder and its treatments? I used to think it was only because treatment with buprenorphine was so new, but it’s not new anymore.

I’m proud of North Carolina’s efforts to change this. We are fortunate to have the Governors Institute of Substance Abuse, a non-profit foundation that seeks to prevent, identify, and treat substance use disorders. Starting four years ago, they helped to convince and encourage our state’s medical schools and primary care residency programs to teach about opioid use disorder and its treatments. As a result, four (UNC at Chapel Hill, Wake Forest, East Carolina, and Campbell University) of our state’s medical schools already offer eight hours of training on opioid use disorder. Nurse practitioner training programs in NC now mandate a 24- hour training course on opioid use disorder.

This present study of survey responses by IM residents points to significant gaps in the education of young physicians, even twenty years into the opioid epidemic. That’s disappointing. Usually I’m not a fan of governmental mandates in education, but it’s starting to look like some states will need that to change. It’s important. The lives or many people depend on this.

Imagine a chronic illness that causes disability and death. Now imagine there’s a new drug developed that reduced the risk of dying by three-fold. Not by three percent, but it reduces the risk of death three times over.

Now imagine a patient who dies from this chronic illness. Imagine that this unfortunate patient was never offered the life-saving medication. In fact, this patient’s physicians never even told the patient about this l medication, which had been approved twenty years earlier.

It would be a travesty. Malpractice lawyers would salivate to get such an easy case. The negligent physician would be called to account for his actions and possibly investigated by the medical board. There would be consequences.

That’s where we are now, except the chronic illness is opioid use disorder, and there are no lawyers, no consequences for all the missed opportunities to treat this deadly illness.

Why do we allow this to happen, this many years into the opioid epidemic?

Book Review: Empire of Pain: The Secret History of the Sackler Dynasty

This book, by Patrick Radden Keefe, will make you angry, especially if you’ve lost anyone to opioid use disorder or have suffered from it yourself.

The entire book is about how the Sackler family, owners of the pharmaceutical company Purdue Pharma, ruthlessly marketed OxyContin in the face of growing opioid use disorder and opioid overdose deaths. The book details the legal maneuvers undertaken by the Sacklers and their lawyers to avoid taking responsibility, either by financial means or an admission of guilt, for OxyContin sales. Those sales primed the pump for our epidemic of opioid use disorder and death in this country.

The first one-hundred and eighty or so pages describe the family lives of the family patriarch and his three sons, along with their descendants. This background is necessary to understand their motivations, but it’s a bit boring. Basically, the immigrant patriarch worked hard and succeeded on two fronts: he became a physician and he became an excellent salesman. The second generation consisted of three sons, all of whom became physicians, but their primary occupation became making money by owning the drug company that made OxyContin. This second generation created many offspring through multiple marriages. Some members of the third generation of U.S. Sacklers went into the family business, but most went in different directions, funded by the money from the family businesses.

Back in the middle of the last century, Sackers owned the drug company that sold Librium and Valium. The latter was marketed as a non-addicting medication for anxiety and sleep.  That was a harbinger of things to come.

Other books have related the tale of how opioids came to a place of dominance in the last part of the twentieth century, with all the hubris spread about opiophobia. But this book is a tour de force about OxyContin’s role. The author has documented painstaking detail what the Sackler family and their privately-owned drug company, Purdue Pharma, did to sell OxyContin.

IN 2007, John Brownlee, a U.S. attorney for the Western District of Virginia, brought a suit against Purdue Pharma. This book describes how Purdue Pharma lawyers tried to out-maneuver Brownlee at the beginning of his investigation (and the end) by going over his head to his bosses at the Department of Justice. That failed, to some degree, and Brownlee was able to find documents showing damning evidence.

He found evidence that the company knew OxyContin could be injected, but they instructed sales reps to tell doctors that it could not be injected. Brownlee found that Purdue executives had been cozy with the FDA employees charged with keeping the public safe. The FDA employee working with Purdue was later offered a job with Purdue for a mid-six-figure salary.

Brownlee found that sales reps were routinely trained to say things to the doctors they were detailing that were known to be untrue, even finding training videos to prove it. Sales reps were required to call on doctors known to have shady prescribing practices (running pill mills) even when they voiced reservations about calling on such doctors.

Brownlee was up against some powerful attorneys for Purdue Pharma. In the end, Purdue Pharma and three executives, Friedman, Goldenheim, and Udell, pled guilty to fraudulently marketing OxyContin. Purdue paid over $600 million in fines, and the executives got three years’ probation and community service. It was a large fine, but small in relation to the billions in profits Purdue was making. And the Sackler family had no charges brought against them.

It was a valiant attempt to hold Purdue Pharma accountable, and probably a miracle that any guilty plea at all could be gotten with the degree of influence that the Sackler family appeared to have over the government. But it was a disappointing finish.

And if you thought the legal problem was enough to make the Sackler family and Purdue Pharma change their ways…you would be dead wrong. They did not.

The Sacklers and their lawyers continued to trot out tired old lies and half-truths about their part in the opioid use disorder epidemic, while continuing to aggressively market OxyContin.

This present book presents information debunking all the excuses made by the Sackler family to shroud their involvement in the U.S. opioid epidemic

First, defenders of OxyContin, Purdue Pharma, and the Sacklers still claim that OxyContin sales accounted for a small percentage of the vast amounts of pain pills prescribed early in the opioid epidemic. They say it’s unfair to place all the blame on their shoulders. Like most of their arguments, there’s a scrap of truth to their claims, but they ignore inconvenient facts. For example, as the author points out, OxyContin contained much higher doses of oxycodone than other pills made by other companies. Therefore, Purdue Pharma’s OxyContin, though only accounting for a minority of total prescription opioid pills sold, represented a much higher percentage of total milligrams sold. Each OxyContin tablet packed up to eight and even (before the 160mg tablet was taken off the market) sixteen times the opioid firepower compared to short-acting oxycodone tablets. Besides that, the Sacklers bought another drug company, Rhodes Pharmaceuticals) to make generic oxycodone just months after the 2007 verdict in Virginia. According the book, the family wanted a “landing pad” in case they ever needed a fresh start. This facility made generic versions of OxyContin, and well as immediate release oxycodone. It became the seventh-largest manufacturer of opioids in the U.S. But the Sacklers didn’t acknowledge this to the public.

Second, the Sackler family has claimed in the past that their liability for the crimes of Purdue Pharma should be limited, since they had no role in running the company. But this book points out, repeatedly, that not only did many family members sit on the board of Purdue Pharma, but evidence shows that family members directly micromanaged sales and exhorted sales reps to use tactics to sell ever more OxyContin. Records show the Sackler family members were directly involved in running Purdue Pharma and regularly pressured sales reps to sell more OxyContin.

Third, the Sackler family and top officials at Purdue Pharma repeated said that some rogue pharmaceutical representatives of the company aggressively marketed their drug, without company knowledge or approval. OxyContin was falsely advertised as having a lower risk of addiction than other opioids. However, training videos obtained from Purdue Pharma show drug reps were trained to give inaccurate information. Indeed, that what the 2007 conviction was for: false advertising and false claims of safety.

Even when drug reps feared some physicians were running pill mills, they were told to continue calling of these doctors and to keep selling the OxyContin.

The Sacklers and their associates invented IMS, a company that collects data on doctors about what medications they prescribe, along with the quantities. This data is sold to pharmaceutical companies so they can direct sales pitches about their medications. And of course, Purdue Pharma used this information. They didn’t use it to identify bad apples, doctors who were perhaps inappropriately prescribing, though they certainly could have. They could have used their data to report overprescribing doctors to the DEA for investigation. Instead, they used their IMS data to identify areas with high rates of worker’s compensation injuries, where pain medication might be prescribed by naïve family physicians. The company felt these doctors should be targeted for OxyContin sales pitches.

The most enraging part of the book comes near the end, when the author describes more recent lawsuit settlement negotiations.

Eventually, so many states, cities, counties, hospitals, tribes, and school districts brought suits against Purdue Pharma that the Sackler family wanted to settle them all at the same time. Purdue offered to relinquish control of the drug company to a public trust and the family would donate money if they were guaranteed to be immune from future lawsuits. The total settlement would be $10-20 billion.

That’s a big number, until the details revealed that the Sackler family would only be paying from $3 billion up to a possible $4.5 billion. Given the billions the Sacklers had made over the years from the sale of OxyContin, this agreement didn’t sit well with many of the negotiators. Basically, the family said take this agreement or we will declare bankruptcy. Bankruptcy would freeze litigation against Purdue Pharma.

Talks broke down and true to their threats, Purdue Pharma declared bankruptcy. The bankruptcy judge’s rulings favored the Sacklers, particularly when he ruled that the Sacklers would also be protected by Purdue’s bankruptcy. This decision outraged many people. Our own state’s Attorney General Josh Stein said aptly, “Multi-billionaires are the opposite of bankrupt.” But the judge’s ruling stood, protecting the family from liability.

There’s so much more in the book, such as how the Sackler family’s philanthropic gifts to universities, libraries, and museums were retuned and refused, due to public outcry about where their money came from. The author suggests members of the Sackler family were upset about their charitable gifts being declined and returned. That’s truly a problem of the very wealthy.

The book contains information about brave protesters who brought the Sackler’s association with OxyContin to light and pushed venerable institutions into re-thinking gifts from such sources.

Towards the end of the book, the author asks why the Sackler family couldn’t or wouldn’t admit to their complicity in creating the opioid use disorder challenge we now face. How could they be so blind? Even if they were motivated solely by greed, at some point they must have known their lies were now brought into the sunshine. Why have they never taken a more conciliatory tone, at least pretending to have empathy for the millions of families affected specifically by OxyContin abuse?

The author said the Sackler family wouldn’t talk to him. He also said that during interviews with former Purdue Pharma employees, from executives down to sales representatives, he was struck with their “fog of denial.” He wonders if acknowledging complicity in Purdue’s and the Sackler family’s destructive acts would be too much for human conscience to bear, and so they continue to parrot the same old lies: only drug addicts abused OxyContin, only a few wayward drug reps mis-marketed OxyContin, and the company was driven only by a desire to help patients, and not by greed.

At several places in the book, the author compares the Sacklers to Big Tobacco both in their legal strategies and their refusal to admit their part in marketing a dangerous product.

After reading the book I was left feeling discouraged, disillusioned, and tired. It appears that justice for the very rich happens on a different plane, if at all. I couldn’t help but think about the physician (my blog post of May 11, 2021) indicted by the Department of Justice for – among other things – failing to do random drug screens on the patients he was treating for opioid use disorder.

None of the Sacklers have been criminally indicted for anything. Justice for the Sacklers versus justice for this physician feels…uneven…to put it mildly.

Medication Interactions with Methadone and Buprenorphine

Patients being treated for opioid use disorder with methadone or buprenorphine often need other medications to treat chronic and acute medical conditions. When our opioid treatment program patients fill other prescriptions at retail pharmacies, the pharmacist might not know that the patient is on methadone or buprenorphine. Due to privacy laws, OTPs don’t report patient data to state prescription monitoring programs. That puts the burden on opioid treatment providers to watch for potential drug interactions.

I take that burden seriously.

Methadone, for various reasons, is more likely to have drug interactions than buprenorphine. Buprenorphine’s various pharmacologic properties reduce the risk of drug interactions. It has a high affinity for the opioid receptor, which means it’s not easily displaced off the receptor. Also, buprenorphine has a ceiling effect, so fluctuations in blood levels are less likely to cause sedation than methadone. Drug interactions can still occur, but not with the frequency or severity as with methadone.

Many medications interact with methadone, too many for me to reliably remember. I use a smart phone app to supplement my aging memory with up-to-date data. And if I can use these smart phone apps, believe me…anyone can. I prefer the Medscape app, though it’s only one of many. Other providers like Epocrates or others. If you work at an opioid treatment program and make dose decisions, I strongly recommend you get one of these apps, because there’s no way to remember or keep up with all new data.                                                                                                                  

Here are some of the main ways methadone interacts with other medications.

Sedatives

Any sedative medication can have an increased sedative effect when it is administered to a patient on methadone, or any other opioid, for that matter. Sedatives affect that ancient part of our brain that tells us to breath while we sleep. Opioids also affect that brain center, so when opioids and other sedatives are mixed, patients can fall asleep and stop breathing, which is how overdose deaths occur.

By far, the most commonly consumed sedative that my patients use, by prescription or illicitly, are benzodiazepines. However, other sedatives are just as deadly, and alcohol is a sedative drug too. Recently we’ve had more patients prescribe gabapentin (Neurontin) or its mirror-image molecule, pregabalin (Lyrica). These medications are commonly prescribed by primary care providers for just about any complaint of pain, anxiety, or anything else. When misused, or when taken with methadone, it can lead to impairment and even overdose.

I’ve railed against the inappropriate use of benzodiazepines so many times that even I get tired of hearing myself, so I’ll refer to reader to past blog entries. But let me just say that many patients being treated for opioid use disorder with methadone have been harmed by also taking benzos, prescribed or not prescribed. It’s a hazard that should be avoided if possible.

Cardiac Effects: prolonged QT interval

Methadone can prolong the QT interval in the heart. In the interest of not getting overly technical, let’s just say that the QT interval has to do with how the beats are conducted through the electrical system of the heart. If the QT interval lengthens past a critical point, it puts the patient at risk for a potentially fatal heart rhythm.

Many opioids can cause this, but methadone is probably the most well-known. Other opioids, like tramadol and oxycodone, carry some risk of QT prolongation, but usually not to a clinically significant degree. Some sources say buprenorphine can theoretically cause QT prolongation, but most experts don’t feel it’s clinically significant. In fact, if a patient on methadone develops QT prolongation issues, that patient is often recommended to switch to buprenorphine.

While methadone alone infrequently causes clinically significant QT interval prolongation, other factors can increase patient risk. For example, some patients with certain types of underlying heart problems may already be prone to QT prolongation and starting methadone could make this situation worse.

Many other medications also can cause QT prolongation. When these medications are started in a patient on methadone, the combination can cause significant QT interval prolongation.

For a recent list, go here: https://crediblemeds.org/pdftemp/pdf/CombinedList.pdf

As you will see, many common medications are listed. Common antibiotics, like cipro and erythromycin, cause prolonged QT interval and these are often prescribed to our patients. Many commonly prescribed mental health medications can prolong the QT interval.

What should opioid treatment providers do when a patient on methadone gets a new prescription for a medication which could critically prolong the QT interval? I’ve searched the internet and can’t find exact evidence-based solutions. But that’s not uncommon. Physicians often need to weigh decisions of risks and benefits of medications and act based on this.

First, I inform patients if there might be a problem. Next, I decide if the risk presented by the medication is so high that I need to ask the prescriber to change it. Or, if the patient is young and healthy, I might decide to check an EKG to monitor the QT interval. Lowering the dose of methadone can help reduce the QT interval, but at the risk of de-stabilizing the patient, so that’s rarely the best course of action.

Opioid treatment programs vary widely in their abilities to get and interpret ECGs. Thankfully, I’m trained in Internal Medicine and feel comfortable getting my ECG calipers to calculate the QT interval and yes, of course I correct for heart rate too.

Here are two examples of how I handled potential QT situations.

The first patient was young and healthy, and dosing with methadone at 95mg per day. He was started on ciprofloxacin for two weeks for an infection. The other prescriber had done a culture of the infectious situation and cipro was one of few antibiotics that the bacteria was sensitive to, so antibiotic choices were limited. I decided to check an ECG after my patient had been taking cipro for a few days, and the QT was fine. He was able to remain on the cipro until the infection cleared, with no problems

The second patient was older, nearly 50, with several chronic medical conditions including severe mental health diagnoses. A new psychiatrist changed his medication and started him on ziprasidone (Geodon), a medication infamous for causing QT prolongation. My patient was dosing at 115mg per day, and extremely fearful about any dose change. I did an ECG as soon as I knew he was on Geodon, and his QT interval was significantly lengthened. I called his new psychiatrist and explained the problem and she immediately switched him to a lower-risk medication. A repeat ECG done a few days after the switch showed his QT was back to normal, and he did well on this second medication, with good resolution of his mental health symptoms.

Drug affected methadone metabolism by the Cytochrome P450 System

Other drugs and substances affect methadone blood concentrations by influencing the rate of methadone metabolism. Methadone is an active opioid, while its first metabolite, 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine (called EDDP for short), is not pharmacologically active. That metabolic process is done in the liver via the cytochrome P450 (CYP450 for short) system. Many other medications affect this system.

Some medications that affect the CYP 450 system slow methadone metabolism and are called inhibitors. They can increase methadone blood levels and the opioid effect it has. Conversely, medications called inducers speed metabolism of methadone into its inactive metabolite, and thus can reduce methadone’s blood level and effect.

Of course, rising or falling methadone blood levels affects patient stability.

To add to the complexity, there are different types of cytochrome P450 enzymes. Several are involved with methadone metabolism, named CYP 3A4, CYP 2D6, CYP2B6, and CYP 2C29. And each enzyme’s activity is further determined by what genes we’ve inherited. Other medications that are metabolized by CYP3A4 are thought to be particularly prone to affect methadone metabolism and regarded with more caution.

So…it’s complicated. But as if that complication weren’tt enough, some scientists now say that though in the past we thought methadone was mainly metabolized by CYP 3A4, that’s old data, and now, we should be looking at drugs metabolized by CYP 2B6. In fact, in a recent article I read, “It has now been unequivocally established that CYP2B6, not CYP3A4, is the principle determinant of methadone metabolism, clearance, elimination, and plasma concentrations in humans.”  [1]

Also, some medications act as inhibitors of inducers of methadone in a test tube but not in real life.

What’s a doctor to do?

Again, I’ve searched the internet for evidence-based recommendations. Should we increase the patient’s methadone dose if he’s started on a medication that induces methadone’s metabolism? Or should we wait to see if the patient has symptoms before we change the dose? Conversely, should we decrease a patient’s methadone dose if she is started on a medication that inhibits methadone’s metabolism, in case her blood levels are going to rise? Or should we just prohibit the use of any medication that can affect methadone blood levels?

That last option, though it would make my life easier, isn’t possible. For example, nearly all mental health medications interact with methadone in some way or another. There’s no way for a patient to get treatment without using medications with the potential to affect methadone metabolism.

Same as with the QT interval problem, the degree of risk must be assessed for each patient. The degree of risk varies with patient medical history, and the known risk of the inducers or inhibitors. For example, patients newly started on phenytoin nearly always have a clinically significant drop in methadone blood level. For those patients, I’ll make sure I have an order in place to increase their methadone dose with any symptoms of opioid withdrawal.

Most other cases aren’t so clear-cut. I’ll inform patients of potential risks and ask that they communicate with us regularly.

Almost all medications that treat HIV influence methadone metabolism, making it essential for the opioid treatment provider to communicate directly with the provider prescribing HIV medications.

In fact, good communication is essential with other prescribers and I try to cultivate a cooperative attitude with them, so far as it is possible with me.

Our opioid treatment program patients, particularly as they age, will be prescribed medication with possible interactions with their methadone. For their safety, each OTP must have a system in place that: 1. Gets patients to report new prescriptions as soon as possible 2. Gets that information to the program medical provider in order to make decisions about safety and monitoring 3. Informs patients of potential risks 4.  Arranges follow up meeting with medical providers when appropriate 5. Opioid treatment providers must collaborate with other prescribers when necessary

Each OTP needs a system that works for their facility, and methods can differ widely between OTPs. It doesn’t matter how we get the job done, just that it gets done.

Our patients’ safety depends upon this.

1. Kharasch, “Current Concepts in methadone metabolism and Transport,” Clinical Pharmacology in Drug Devopement, 2019

Contingency Management

Lately I’ve been thinking about contingency management.

I listened to some sessions about contingency management (CM) during several of the national Addiction Medicine conferences this year. That reminded me our opioid treatment program had been talking about using contingency management to improve attendance at our intensive outpatient group just before COVID hit. But after COVID…*POOF* …no more groups.

Now that COVID is on the decline, it’s time to consider re-establishing our intensive outpatient group.

For those who don’t know what contingency management is, or who are a little foggy about what it means, I can tell you I had to look it up again too. I know what it is…but putting it into words is difficult.

In short, CM is a type of behavioral therapy which rewards progress towards a set goal. Patients are rewarded in some way for positive behaviors.

CM can take all kinds of shapes. For example, during one of the sessions at the American Society of Addiction Medicine conference, presenters described how they rewarded patients with small gifts as they met treatment goals. All patients got a pen and a blank journal upon admission. As patients produced negative urine drug screens, they were rewarded with draws from a fishbowl for vouchers for various prizes. The prizes ranged from positive affirmations (“You did a good job”) to polished stones with affirmations on them to gift cards for up to $25.

This program saw impressive results with these small rewards. Their patients had better attendance and more negative drug screens.

Scientific literature shows that contingency management is effective, if it is used in ways that adhere to several basic concepts. The targeted behavior should be an observable and treatment-adherent behavior. In other words, CM should target a patient behavior that is in harmony with substance use treatment goals. Then CM program should give an immediate and tangible reinforcer to the patient when the desired behavior is exhibited. If the desired behavior is not exhibited, the reinforcer is withheld.

CM is not new; at least two-hundred studies of CM techniques have shown that it works to produce desired behaviors in substance use disorder treatments. CM usually shows at least a medium effect size. This means isn’t the next great thing to fix everyone with substance use disorders, but it does provide reliable improvements for patients.

CM has been used in diverse patient populations and appears to be effective for all different socioeconomic groups.

Strangely, despite producing reliably positive results, CM hasn’t been used as much as one would think.

Some people object to the idea of contingency management. For example, an obstacle to implementing CM in substance abuse treatment cropped up last summer. The Trump administration set a cap of $75 per year per patient on CM programs. That is, whether prizes or rewards are donated by local businesses or bought by the treatment program, these programs can’t reward patients with any more than $75 per year, for fear that money would entice patients to come to one treatment program over another. The U.S. Office of the Inspector General (OIG) said such methods of paying patients to participate in treatment might violate the Anti-Kickback Statute. In other words, it’s illegal to pay patients to come to your treatment program. This could be a type of fraud, particularly if the treatment program bills Medicaid/Medicare for treatment.

Last year, the American Society of Addiction Medicine (ASAM) sent a letter to Alex Azar, the then-Secretary of Health and Human Services, asking that contingency management treatment techniques to be exempt from the Anti-Kickback Statute. The ASAM president, Dr.William Haning, pointed out in the letter that safeguards could be applied to prevent fraud, waste, or abuse when using CM techniques in counseling people with substance use disorders.

Some people feel it’s unethical to pay patients for doing what they “ought” to be doing anyway. Other people say it’s manipulative to induce patients to behave in ways decided upon by authority figures. This may be true, but patients still have the choice of participating or not participating in reward programs.

For example, let’s say a patient comes for treatment of her opioid use disorder at an opioid treatment program. That program gives CM rewards for negative urine drugs screens. Perhaps the patient wants to quit using opioids, but she doesn’t see any need to quit using cocaine. She can continue to use cocaine, and have positive drug screens, meaning she won’t get the small rewards of the CM program. She’s not out anything by her decision, and still gets treatment for opioid use disorder.

Salespeople have been using CM for decades. Many advertisers use CM to shape consumer behavior. For example, look at the BOGO sales. The sales staff want to sell more product, so they advertise “BOGO” in large letters. This means if the consumer buys one, the second one – of whatever it is – is free. The consumer is being tempted to a certain behavior – buying something – by an offer from the seller.

By the way, there’s nothing more irritating than seeing a “BOGO” sale advertised, only to read the fine print that the deal is buy one and get some percentage off the second one. That’s not a real BOGO. That’s what I call a faux BOGO. Don’t even bother me with a faux BOGO.

But I digress.

Other contingency management sales techniques might be the reward of a free sub sandwich after you buy five regularly priced subs.

The point is, we participate in CM deals all the time, but usually the behavior desired of us is buying products or services. For treatment of substance use disorders, the desired behaviors might be attending counseling sessions or ceasing drug use to produce negative drug screens. Progress towards those goals are rewarded in some way with CM.

I’d like to start our groups again, and for every three-hour session attended, each person gets a draw from a fishbowl. The fishbowl might contain any number of rewards: gas card for $10, coupon for a sandwich at a local restaurant, a card with positive affirmations, or something similar. The possibilities are endless. Perhaps local businesses could donate goods or services in exchange for some free advertising, or just to do something nice for people who are trying to achieve recovery from substance use disorders.

Twelve-step meetings have been using a type of CM for decades: group members get chips or key tags for achieving days in recovery: they have these for one day, thirty days, sixty days, ninety days, six months, nine months, and one year and multiple of years. The chips or tags themselves are worth very little, but the value of being recognized for achievement in recovery can be important, especially when the recognition is given by people who understand how difficult recovery is.

Some of our patients don’t get the recognition they should for their achievements in recovery from friends or family. Maybe CM is a great way to acknowledge that achieving little goals is a big deal.

Mobile Opioid Treatment Programs

Opioid overdoses killed 47,600 people in the United States in 2017.

Last spring, just before COVID demanded all our attention, a friend at our state opioid treatment authority emailed me a link to document titled, “Registration Requirements for Narcotic Treatment Programs with Mobile Components,” and asked what I thought of it. This was a new document – at that time – posted on the DEA’s website, under the Diversion Control Unit. The document described new rules for mobile opioid treatment programs (they call them NTPs, for Narcotic Treatment Programs).

The intention of the new proposal was to make it easier for treatment providers to meet demand in rural areas.

Sometimes I have an opinion about an issue before I get all the information, and the idea of a mobile OTP seemed dangerous and ill-advised. But after reading the DEA document, I’m convinced mobile opioid treatment programs could be great options, if done with proper care.

The DEA stated that it recognized the extent of the financial burden needed to open a brick-and-mortar opioid treatment program. Because of all the regulations, a new facility owner must pay rent on a building for a very long time before all the permissions and inspections are done by all regulatory bodies. That often ends up being more than a year. That’s a considerable outlay of time and money for new programs, and rural areas with few prospective patients are financially unattractive sites for new OTPs.

Mobile units are a way to fill the void.

This new proposal means mobile units can be operated as a “coincident activity” based out of a brick-and-mortar treatment program. The new rule proposes doing away with the present requirement that mobile unit need their own licensing and registration. This change makes it much cheaper to operate a mobile unit.

There are several caveats involved in creating a mobile OTP unit. For example, trailers won’t qualify. The unit must be a “conveyance,” that is, able to move on its own power. This conveyance would be subject to inspection just as brick-and-mortar opioid treatment programs are.

Medication must be stored securely, of course. Medications must be stored in a safe that is bolted to the floor or side of the vehicle and must be accessible only from inside the vehicle. Medication can’t be accessed from outside of this van or vehicle. Patients should not be able to step into the portion of the vehicle containing the safe with medications in it, so there must be some sort of door dividing the portions of the conveyance.

There must be an alarm system on the unit.

Records may be kept in paper or electronic forms while the mobile OTP is in service but must be stored inside the brick-and-mortar structure overnight.

Analysis of the proposed system indicated that opioid treatment programs will save money because of the reduction in start-up costs for mobile units that are under the auspices of existing brick-and-mortar programs. Mobile vans could reduce healthcare costs and reduce time lost from work for patients.

 At first, I thought the idea was a little goofy, but then I thought of all the ways such mobile units could be creatively used.

Incarcerated patients: Patients already on methadone or buprenorphine products could have their medications delivered and dispensed by the mobile OTP. Jail and prison staff wouldn’t have the headaches of storing and administering these medications, and inmates would be evaluated each day as usual. Or, depending on the stability of the patient and the willingness of jail staff, the patient could be dosed by staff on the mobile OTP, and enough daily doses left until the mobile OTP needs to return. With that method, jail staff would still have to store, track, and administer some doses.

The biggest benefit would be reduction of illness from enforced withdrawal from life-saving medication, and reduced risk of death after the patient is dismissed from jail, assuming the patient remains in treatment.

Rural patients: In areas too small to support a traditional opioid treatment program, mobile units would be able to treat patients more efficiently. I could imagine that arrangements could be made for the mobile unit to be at “X” location in a small community at a set time daily, for treatment of patients living in that area. Then the unit could be scheduled for another location in that rural area for later in the day. Patients would have to make sure they arrived at set times, but they would have far less distance to travel to a more traditional program. This would save them time and money, particularly in areas too rural for public transportation.

Outreach: Some communities are less likely to participate in treatment; for example, a minority community might hold negative opinions about medications for treatment of opioid use disorder. But if a mobile unit repeatedly traveled to that community, both treating patients and educating citizens, hopefully their concerns could be addressed. Healthcare workers could dispel misinformation and reluctance. Or perhaps immigrant communities with suspicions about treatment could be addressed in similar ways.

 A report released last fall described Massachusetts General Hospital’s success using mobile opioid use disorder treatment to reach vulnerable homeless populations in Boston, where overdose death rates were high. This program was called Community Care in Reach. This mobile unit reached homeless populations in the city who have special difficulties accessing healthcare.

Studies showed the homeless die of opioid overdose at a rate approximately twenty times the general population, proving the need for outreach to that population.

The mobile unit wasn’t an opioid treatment program, but it was staffed with primary care providers who diagnosed and treated patients with sublingual buprenorphine products. At the same time, the program dispensed naloxone kits to reverse opioid overdoses, and provided clean needles to people who were injecting drugs. This program, which started in 2018, logged nearly ten thousand patient contacts by late 2019. [1]

As I scoured the internet for information about established mobile OTPs, I found much more information about mobile units that provide buprenorphine treatment. I found less information about true opioid treatment programs on wheels, which provided both methadone and buprenorphine.

I found an article describing how mobile services for methadone maintenance tend to retain patients in treatment longer than typical fixed-site programs.  In this article from 1996 by Greenfield et al., mobile program patients were retained in treatment an average of 15 months, compared to around 4 months for traditional patients. [2]

This study was done in Baltimore, in the inner city. I wonder how much better retention would be for rural areas that have very little public transportation compared to cities.

I want owners of our opioid treatment program to invest in a mobile unit. We have rural counties to our north that have no opioid treatment programs within their borders. They have several office-based programs which prescribe buprenorphine products, but not every patient responds to this medication. Patients who need methadone for stabilization drive an hour or more to our program or drive over the border into Virginia for help. I think a mobile OTP could reach many patients in that area.

However, our nation’s system of healthcare as a business means the mobile OTP would have to make a profit, or at least break even. I have no idea if it would be financially attractive, but I know that with the revision of the DEA rules, it is less costly than in the past.

The whole aim of encouraging development of mobile dosing units is to increase access to treatment in this time of opioid epidemic, while still using appropriate controls to reduce diversion.

1. https://www.frontiersin.org/articles/10.3389/fpubh.2020.00501/full?&utm_source=Email_to_authors_&utm_medium=Email&utm_content=T1_11.5e1_author&utm_campaign=Email_publication&field=&journalName=Frontiers_in_Public_Health&id=573744
2. https://pubmed.ncbi.nlm.nih.gov/8889411/

Grand Jury Indicts Buprenorphine Physician

I am not an apologist for any physician who breaks the law. The government should prosecute true criminal offenses. I just would prefer those offenses be actual crimes and not part of generally accepted medical practice.

I’m not going to name names. I don’t want to bring any additional grief to the parties involved. My purpose in writing this blog is to point out some disturbing portions of the grand jury indictments against this provider, and to ask my audience how they feel about specific details of the indictments, like “…buprenorphine doses were often not appropriately tapered.”

I am writing this from the point of view of a physician, of course. I am not a lawyer, despite having watched all “Law and Order” episodes so often that I can quote large chunks of dialog. Sometimes my husband will ask me if recognize the episode from the opening scene. Often, without looking up, I’ll say something like “Bad uncle up in Yonkers,” or “People ain’t just one thing,” or – my favorite – “You heard my husband. He’s not a perfect man. He’s made some mistakes.” That last one is said with grim satisfaction by a wife who successfully set up her husband to take the fall for the murder of his mistress.

I digress. My point is I don’t know law. I’m giving you my reactions and opinions and asking for yours.

This all started nearly three years ago when this physician, who owned a chain of office-based buprenorphine facilities in Eastern Tennessee, Virginia, and North Carolina had his offices raided by federal agents. They took banking records, patient records, billing records, and other things. This put the physician out of business and disrupted the treatment of patients with opioid use disorder who were being treated by physicians working in those offices.

The grand jury indictment was just made public this spring, nearly three years later.

The indictment contains multiple charges, and is a little hard to read, but primarily accuses this doctor, and other providers working in his programs, of prescribing buprenorphine without legitimate medical purpose.

Thus far there is only one FDA-approved reason to prescribe sublingual buprenorphine products: opioid use disorder. Did this doctor prescribe for another reason? Since his practices were described as opioid use disorder treatment programs, this charge puzzles me.

I suppose he could have prescribed sublingual buprenorphine for pain, both because it works and because it’s less likely to be misused. I know the DEA frowns upon this and prefers patients with only pain and no opioid use disorder be prescribed the transdermal products, but I doubt this would be an offense that federal prosecutors would pursue. Besides, separating patients into “pain only” and “opioid use only” groups isn’t practical because of the large overlap.

Among the many complaints, the indictment said the medical records of patients were “superficial” and used cut- and -paste from prior notes.

I’ve blogged about this before. Many of the office-based notes I get from other providers contain obvious cut-and-paste documentation. It’s very common. It’s irritating to get pages and pages of notes on a patient, only to realize there’s very little information there, only repetition. It’s poor documentation and unethical. I am reminded of the notes I got from a local buprenorphine provider that described the patient as having “abdomen consistent with 8-month pregnancy,” for over a year.

Physicians do this because it saves them time and allows “upbilling.” Insurance companies and Medicaid pay on the intensity of the office visit, and if the doctor includes extensive history and physical exam components at each visit, they get paid more. Rather than take the time of doing an extensive review of systems and exam each visit, unethical providers will cut and paste from prior visits. Of course, if the doctors don’t perform what they’ve documented, it’s insurance fraud.

But these practices didn’t accept insurance or Medicaid, which brings me to the next part of the indictment: that the doctor had a “cash only” practice. That is, patients paid for their visits with cash, check, debit/credit cards even if they had insurance or Medicaid. So, these practices couldn’t commit insurance fraud, if they didn’t even participate in insurance programs.

The government can’t force physicians to accept Medicaid or Medicare payment for medical services. Physicians have the right not to participate in these programs. However, as I understand it, providers need to submit something to Medicaid saying they opt out of that program for three years. If you do that, it is perfectly legal to ask patients who have Medicaid insurance to pay whatever cash price you decide to charge. Patients with Medicaid are free, of course, to select a provider who does accept Medicaid.

That’s difficult to do since Medicaid doesn’t reimburse physicians very well for their time. Medicaid pays much better for procedures and surgeries. It’s hard to find buprenorphine prescribers who are willing to accept what Medicaid pays for their time, and in rural areas may be impossible to find.

So, as I understand it at least, it isn’t illegal to refuse to accept Medicaid. You just can’t accept Medicaid from some patients and refuse to accept for other Medicaid patients.

The indictment says Medicaid patients took their prescriptions to their pharmacies, where Medicaid paid for them. I don’t know how that violates the law unless the physician owns the pharmacy.

Then we come to the part of the indictment that describes laboratory shenanigans. Sadly, these also are all too common in our field and give good providers a bad name. (You can also read about this in a past blog of mine, January 23, 2019) As I understand it, this is how it usually works:

A laboratory organization makes an office-based physician a seemingly fantastic offer. They will provide urine drug screens testing for a hundred or so drugs, with the most accurate system that there is. This is usually something involving gas chromatography or mass spectrophotometry. This type of test is more specific and provides fewer false positives than the cheaper immunoassays usually used. And that’s not all – the laboratory company might provide an employee to the doctor’s office to collect and package all those drug screens. This frees the physicians’ employees to do other chores and saves money. The lab company promises to do free testing for patients without insurance, which sounds altruistic, but they will bill patients with insurance, including Medicaid.

And they really bill private insurers and Medicaid. Labs charge hundreds and even thousands for a single urine drug screen testing for a hundred or so substances. The physician feels like he’s able to do better lab tests, the patients without insurance don’t pay at all, so it seems superficially like a good thing. But private insurers and Medicaid get soaked and the laboratory company makes a juicy profit.

For this to work, the physician must provide a statement that all these tests are medically necessary. It’s not true, of course. All the rest of us physicians get by nicely with drug panels testing for seven to twenty specific drugs. We must decide which patients need more extensive testing and which ones don’t, to keep costs reined in.

The indictment describes this sort of lab arrangement and implies it’s illegal. To me, it appears to be insurance fraud. However, the primary beneficiary to this arrangement is the laboratory. The doctor’s office does get an employee to collect drug screens that he doesn’t have to pay for, but that’s hardly a bonanza. This indictment opines that the money that patients saved on drug testing was channeled to the doctor, to pay for office visits. That’s fuzzy reasoning.

The indictment also said the test results were not available at the time the patient was seen and that no “appropriate actions” were taken regarding abnormal findings. I wonder what prosecutors think that “appropriate action” would be.

Any unexpected drug screen result should result in a conversation between patient and provider, but should not result in termination of treatment, except for extraordinary circumstances. I worry that prosecutors imagine that the physicians at these programs should have stopped treatment for patients with unexpected drug screen results, when the opposite is true. Ongoing drug use means patients need more treatment, not less. In fact, stopping or tapering buprenorphine increases the risk of overdose death by at least three-fold, so that would be the worst option.

The indictment also complained that the drug screens weren’t random, and they were done at the time of the patient’s visit.

Uh oh. That’s exactly what I do, except in unusual situations. Once in a great while, I’ll call a patient and ask them to go to a Labcorp facility for a random urine drug screen, if I’m worried about them. Random drug screens probably are the best option, but logistically it’s difficult. Most of my patients work, and it’s hard enough for them to get time off to see me each month.

The next part of the indictment made me giggle with delight. It said providers at the facilities had inappropriately co-prescribed benzodiazepines with buprenorphine products.

I’ve said in the past, jokingly, that it should be illegal to prescribe benzodiazepines to patients on buprenorphine. But it isn’t. Or at least, it isn’t in places other than this corner of the world. Elsewhere, it’s a matter of physician judgement, or it should be. I’m the most anti-benzo physician I know, and I still have a few patients on benzodiazepines while also on buprenorphine. Patient circumstances vary widely, and providers must be allowed to use our best judgment.

Then there was a confusing section where the indictment said patients were prescribed inappropriately high, but they didn’t say what dose they considered to be too high. Instead, the indictment had odd little tables of appointment dates and how many doses were filled per unidentified patients.

I could not understand what these tables were supposed to demonstrate, but I’m going to guess the prosecutors allege that doses above 16mg per day are excessive. Five or so years ago, some experts in the field said no patient should ever need more than 16mg sublingually per day. That’s been debunked, and current teaching is that doses up to 24mg per day might work better for some patients and retain them in treatment. You can read more about this in my blog of October 8, 2017, because this is not new information.

It feels to me like these prosecutors got way down in the weeds with these indictments, trying to decide what appropriate medical treatment should be. I don’t think prosecutors should try to decide what a patient’s dose of buprenorphine should be. I don’t think they should be the ones to decide how often the patient gets drug screened or when – or ever if – the buprenorphine dose should be tapered.

Maybe it’s typical of grand jury indictments to throw everything that could remotely be criminal action into their document, just to see what sticks. But to me, that weakens the overall announcement that the individual who was indicted committed crimes. The real issues get diluted by non-issues, inducing me to think that maybe there are no real issues.

More will be revealed as time goes on and I’ll keep readers updated.

New Ideas and Common Themes at Addiction Medicine Conferences

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

Overdose drug deaths:

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

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

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

Medications for opioid use disorder during incarceration:

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

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

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

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

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

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

Micro-dosing of buprenorphine:

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

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

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

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

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

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

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

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

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

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

Racial inequities in medical care including addiction medicine care:

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

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

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

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

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

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

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

Conference Season

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

This year, all of them were/are virtual.

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

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

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

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

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

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

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

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

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

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

But I digress.

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

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

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

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

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

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

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

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

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

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

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

Blog Anniversary and…. I Win an Award

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Primary Care Difficult to Find for OTP Patients

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

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

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

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

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

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

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

But my patient got no care.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

They absolutely bungled it.

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

Well OK.

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

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