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Recovery Means….

September is National Recovery Month, so it’s a great time to review what recovery means to me. I hope my readers will write in with their own definition of recovery.

Recovery means…

….taking the worst and most embarrassing thing in my life and turning it into my greatest asset.

….becoming less judgmental of other people.

….remaining teachable.

….having more free time, after the burden of looking for the “next one” has been lifted.

…looking in the mirror, and feeling content at what I see.

….being satisfied with the small pleasures in life.

….developing a thicker skin for judgmental people. They aren’t going to ruin my day.

….re-connecting with the human race.

….re-connecting with the God of my understanding.

…reconnecting with myself.

….doing what I need to do for my well-being, even if other people don’t approve.

….being happy when I make progress, no longer expecting perfection.

….understanding it’s more important what I think of me than what other people think of me.

….talking frequently with other people who share my passion for recovery.

Recovery goes beyond 12-step programs or medication-assisted treatment. Recovery can apply to issues other than drug addiction. It can apply to eating disorders, co-dependency, gambling problems, sex addiction, or any other compulsive activity that is bad for our health. We can be in good recovery in one area of our life and be in active addiction in other areas. We have good and bad days. We relapse, and we try again, and we stop listening to the voice of addiction that tells us we should give up because we will always fail. We learn from our failures and come to look at them as opportunities for growth. We turn stumbling blocks into stepping stones. We lift up our fellow travelers when they weaken and they do the same for us.

We do recover.

 

Embracing Change

My cat knows computer

 

 

 

Kicking, screaming, and whining, I entered the 21^st century today.

Thanks to my long-suffering fiancé, we started electronic prescribing in my office. It went better than I feared.

A few years ago, North Carolina passed the STOP Act, which contained measures to help make the prescribing of opioids safer. One of the Act’s provisions was that by January 1, 2020, all targeted controlled substances must be prescribed electronically. The targeted substances are all Schedule II and III opioid prescriptions.

Here’s a weird thing, though: when I went back to read the text of the actual STOP Act, buprenorphine wasn’t listed as one of the targeted substances, even though it is a Schedule III opioid. But I’m erring on the side of caution. Besides, E-prescribing is a good idea. Paper prescriptions are becoming a thing of the past anyway, to my dismay.

I struggle with technology. Readers of this blog have no idea how annoyed I feel when my posts come out weird, with extra spaces and unintended placement of pictures. I’ve sworn at my laptop many times and only self-interest keeps me from hurling it against a wall. I know it’s me, accidently making unintended changes, then struggling to change back. Sometimes I must edit four or five times before it’s satisfactory. And this is on WordPress, one of the most user-friendly blog platforms around. I’m better at it now, after nine-plus years of blogging.

My fiancé did all the research for the E-prescribing software and vetted the available vendors. We set it up last week, with some difficulty.

At one point my sweetie said something that sounded to me like, “Now we need to get the verification code to authorize the pending password credentialing security code of the product.”

I looked at him, confused as my dog when I explain why our walk must be postponed until after I get home from work. “Eh…I thought we already did that step? I’m not sure what you mean.”

Patiently, he showed me on my computer.

“Oh. Now it’s asking for a password, but the one I chose isn’t working.”

“Yes but you must have used your login password and what it’s asking for there is the second tier pending security question and related password that you set up back under step sixty-three of the verification process. Do you remember what it was?”

“No. Maybe I used the dog’s name again?”

“Please don’t use the dog’s name anymore. That’s too easy to hack. So is your date of birth.”

“Oh. I know! I could use my social security number as my password!”

For some reason, Greg did a facepalm and shook his head slowly.

“OK. I’ll invent a new one. But it’s very hard to remember all of these. You know I have passwords for Methasoft, the prescription monitoring program, the ASAM website, the ABAM website, work email, home email, the OTP exception website, login at work, Ebay, the bank, Paypal, Amazon, ETSY…. “

“I thought I showed you how to store them in your Identity Safe.”

“Yes but I forgot the password to it, so…”

Another facepalm from Greg.

Eventually we had the software set up, though I was a little suspicious if we had done it correctly.

The next day, yesterday, was a relatively light day in my office. We used the system for six or seven of the patients, and it went relatively well. I got hung up only at the end, when I have to access a randomly generated code to type in within sixty seconds to match the system’s code that I request at the time I want to submit.

(If you don’t understand what I just wrote, don’t feel badly – I don’t either.)

I asked Greg to call the pharmacy after the first one we did, just to confirm all went well and the prescription was submitted. He called, and it was.

I felt euphoric. I did it, with some help. OK a lot of help.

Who knows what electronic field I may conquer next…maybe I’ll be able to stop losing emails.

 

 

Stigma Abounds in Rural North Carolina

 

 

 

 

What Stigma Feels Like

The opioid epidemic has rolled on for more than twenty years now, but misunderstandings and ignorance about best practices regarding treatment of patients still flourishes in medical and dental professionals. Part of my job as an Addiction Medicine treatment professional is the gentle education of other medical providers. Over the past years, I’m more patient than I used to be, knowing that most providers just need information in order to do the best thing for our shared patients. If I’m polite and friendly, our interaction is more likely to go well.

And sometimes, it makes no difference.

This week’s drama unfolded around a patient who was recently diagnosed with cancer. This patient, being treated for opioid use disorder with methadone at 110mg per day, had to see an oral surgeon to have all of her teeth removed before she can undergo cancer chemotherapy. This is because she had extensive decay in all of her teeth which can be sources of infection during chemotherapy.

She saw me a few days after her initial consultation with the oral surgeon to whom her oncologist referred her. She was upset and distressed at what the oral surgeon had said.

She had just found out that all of her teeth, about twenty-one in all, must be removed. And her oral surgeon had told her he wouldn’t be prescribing any pain medication after surgery because she was on methadone.

I listened closely to her and got her permission to call this oral surgeon to talk to him about appropriate pain management for patients with opioid use disorder.

When I called, the surgeon wasn’t there. I was put on hold for four or five minutes, waiting on the surgeon’s assistant. While I was on hold, I listened to their recorded announcements about their practice. The recording told about the educational backgrounds of their two surgeons, then had a pitch about the doctor I wanted to talk with, about how he did missionary work for a certain religion.

Excuse me while I go off on a tangent.

When I heard the bit about missionary work, I felt foreboding. I’ve had past negative experiences with medical professionals who advertise their devotion to a religion as a selling point for themselves or their practices. I notice that sometimes people who profess devotion to a religion seem to be least likely to exhibit the qualities espoused by the leader of their religion: tolerance, patience, love, etc. And I recognize that’s a type of stigma that I hold, which may be unfair to the oral surgeon in question.

I was ruminating on these dark thoughts when the assistant came to the phone. I explained that I was the medical director at the local opioid treatment program, and that the patient being discussed had a diagnosis of opioid use disorder and was being treated with methadone, and that I wanted to discuss the plan for post-operative care with the oral surgeon. The assistant assured me that his doctor’s policy was not to prescribe opioids post-operatively for someone on methadone, because it is a red flag.

“Red flag for what?” I asked.

“That the person is a drug addict & shouldn’t be given any pain medications.”

I took a deep breath and made as effort to keep my tone friendly and cheerful. “Yes, you’re partly correct. As I said, the patient is being treated for opioid use disorder by me. The older term for this medical problem was addiction. She’s being prescribed methadone as treatment for her opioid addiction. It keeps her out of withdrawal and prevents cravings. However, it won’t adequately treat post-surgical pain.”

“In fact, she just had cancer surgery three weeks ago. She was prescribed post-operative oxycodone, 15mg every six hours by the surgeon. We had her mother hold the bottle of opioid pills and dispense as prescribed. This patient did very well and made it through without relapse. We could do something similar after her dental surgery.”

“No,” he said, “We leave it up to the pain clinic to prescribe the pain medication.”

I slapped my forehead and tried to keep an edge out of my voice. “We are not a pain clinic. I don’t prescribe medications for pain. I treat opioid use disorder with methadone and buprenorphine products. I do not prescribe opioids for dental procedures since I’m not an oral surgeon. I don’t know what to expect as far as intensity and duration of pain after extraction of a mouthful of teeth. However, since the surgeon doing the procedure knows how much pain such patients have, he would be the ideal person to prescribe for the post-op pain associated with the procedure that he is doing.”

“Well he’s not going to prescribe anything if the patient is on methadone,” he answered.

“Yes, that’s why I called. I’m trying to educate you about best practices for post-operative care for patients with opioid use disorder who are being prescribed methadone.” I was getting louder and could feel a muscle jumping over my right eye. “What I’m trying to tell you is that this patient’s methadone will not treat post-operative pain. It does keep her out of withdrawal and prevents cravings and helps her function normally, but it won’t treat acute severe pain.”

“Yes but I’m pretty sure the surgeon won’t prescribe anything for pain.”

I thanked him for his time and left my phone number for the surgeon to call me back. This was five days ago and I don’t expect a return call.

This patient is in a bind. She has cancer and can’t start chemotherapy until she heals from getting all her teeth extracted. Time is of the essence. Ordinarily, I’d tell her about the situation and recommend she find another oral surgeon, but she may decide to proceed with this surgeon only to get the whole process moving along.

It’s a real shame that this patient will be forced to suffer pain after her dental extractions. She will get by with Tylenol and ibuprofen, because she will do what she must. I just hate that she’s being treated this way.

Then today. Southern Scripts, an insurance company that one of my long-time patients just switched to, sent my office a prior authorization to fill out before it would OK coverage of buprenorphine/naloxone 8/2mg tabs, 8 mg per day. Among a host of other requirements, they need the patient’s height and weight before they’re willing to authorize payment.

Now that’s a new one. It’s hard for me to imagine what possible height/weight would disqualify a patient for this medication, but what do I know. I’m only the doctor.

Also today, I heard about an exchange one of my patients had with a Walgreens pharmacist. She wanted to fill her Suboxone 8mg film prescription two days early. I had already called ahead and left a message with the pharmacist that it was OK with me, since she had recently tapered from 16mg down to 12mg. She had more problems with that drop than we expected, and so she ran out 2 days early. Since the decrease in dose had been requested by the patient in the first place, and since I didn’t want her to be without medication for two days, I gave permission to fill it early. I did not think this was a big deal.

The patient said that she was third in line at the pharmacy, with six or eight people standing in the area waiting for service, when the pharmacist called out to her, asking why she ran out early. My patient didn’t want to compromise her privacy, so she shook her head, declining to answer. She says the pharmacist began to harangue her in front of all the other people, saying since she wouldn’t tell her why she needed to fill the medication early, she wasn’t going to get it from “her” pharmacy.

The patient left, tearful and humiliated, but not before she demanded the written prescription back from this hateful pharmacist. She took it to another Walgreens in her area and filled it with no problem.

I’m no longer shocked or surprised at the hassles my patients endure. But we are now several decades into this opioid epidemic. I think it’s time we insist on better education and treatment from medical, dental, and paramedical professionals. I’ve been patient and tried hard to approach outdated attitudes as an educational challenge.

Now I occasionally wonder if things will ever change. I find myself having the same conversations with other medical providers that I had fifteen years ago. Are we making any progress against the stigma our patients face? Only time will tell.

Novel Idea for Buprenorphine Access

 

 

 

 

I still occasionally read medical journals with articles relating to general adult medicine; I consider it a task, not as enjoyable as reading medical journals about Addiction Medicine.

So, imagine my surprise and delight to read a thoughtful opinion piece in the most recent issue of the Journal of the American Medical Association (August 13, 2019, Vol. 322, No. 6, pp 501-502.)

This article, written by Payel Roy M.D. and Michael Stein M.D., both from Boston University School of Medicine, puts forth the idea of increasing access to life-saving buprenorphine by making it available behind the counter at pharmacies with no prescription required.

The article describes the scope of our problem in the U.S: we have around two million people with opioid use disorder, most of whom aren’t getting any treatment. We have around 130 people die from opioid overdose deaths each day. Though we have medication for opioid use disorder available, it’s often hard to access. The authors acknowledge the cumbersome process of prescribing buprenorphine, both for the patient and the provider. The provider must take a special course and get a special DEA license. Patients have difficulty locating and getting appointments with these rare providers, and then must wait for their appointment and be able to pay the provider.

The authors of this viewpoint piece say that having emergency buprenorphine available behind the counter at pharmacies would eliminate some of the problems with access to this life-saving medication.

They say that making buprenorphine available on an emergency basis makes sense, because we’ve done the same thing with other medications that are relatively safe and effective for the conditions they treat. They compared the use of emergency buprenorphine to that of emergency contraception medication, and to pseudoephedrine. The authors feel that a three-day supply of buprenorphine could encourage people with opioid use disorders an opportunity to try buprenorphine legally, and to follow up with a physician provider for long-term treatment.

They also say that uninsured patients could access this emergency treatment more easily than they can at present, since there wouldn’t be provider-based costs. They feel pharmacists could observe the dosing to watch for precipitated withdrawal symptoms.

The authors suggest we define in advance the conditions where emergency buprenorphine could be obtained, perhaps limited to situations where a patient has an upcoming appointment but has severe withdrawal symptoms prior to the appointment. Another indication for emergency use would be if a patient, previously on buprenorphine but tapered off, has a relapse or feels as if she may relapse and wants to get back on buprenorphine to prevent a serious event.

The authors realize this idea is bound to be controversial. They acknowledge that use of buprenorphine with other sedating agents could be harmful but say warning labels are already on buprenorphine medication fills. They also considered accidental pediatric exposure but say that limiting the medication to behind-the-counter would provide monitoring by pharmacists.

They also acknowledge the concerns for buprenorphine becoming a gateway drug. People without physical opioid dependence can experience euphoria with buprenorphine, but the authors say that since it tends to me only a modest euphoria, it’s unlikely to become a drug of choice. They point to literature suggesting that illicit use of buprenorphine is usually seen in people who already have an opioid use disorder, not people just starting to misuse opioids.

They argue that having buprenorphine available behind-the-counter without a prescription might reduce diversion. Rather than having people with opioid use disorder buy buprenorphine from people who already have prescriptions, they can buy their own legally, with the behind-the-counter arrangement.

They point out that having pharmacists monitor use of this emergency buprenorphine would switch some of the burden of safe initiation of treatment from physicians and onto the pharmacists. They say this would require pharmacists to become better education about buprenorphine and improve the counseling that patients receive from pharmacists

They conclude that their idea of emergency buprenorphine could benefit individual and the population overall, by treating withdrawal symptoms and preventing further illicit opioid use. They feel this could reduce health care costs and criminal activity related to obtaining illicit opioids. They also say it would reduce transmission of infectious diseases. They say the risks would be low, given buprenorphine’s safety relative to other illicit opioids, and people could access this medication at night and on weekends, when doctor’s offices are closed.

What do I think of this idea?

I like it.

I think we could define conditions under which buprenorphine could be provided. However, I think the biggest problem could be getting pharmacists to go along.

My patients see plenty of kind, helpful, and well-informed pharmacists, eager to help them with their recovery from opioid use disorder by using buprenorphine products. And other patients have pharmacists that…well…aren’t like that.

Last week, I had a pharmacist call me about a patient of mine who had tapered from 16mg to 8mg over a month. I didn’t recommend she do this; I thought it was a little too fast. But she was optimistic, and asked I write for only #30 films. That’s what I did, but I got a phone call from my patient on day 25 of her month, saying she’d taken more than 8mg per day and she was out of medication, and could I call in a few days of medication until she could see me at her scheduled appointment on day 28?

I didn’t see a problem with this. Yes, she had been overly optimistic about her ability to taper, but I saw no reason to let her go into withdrawal from day 25 to day 28. I called the pharmacist but couldn’t reach a live human. I left a message, saying it was fine with me for them to dispense enough medication for three days, since we had tried to taper, and it hadn’t gone as well as we’d hoped.

The patient called later in the day, crying, saying the pharmacist refused to fill any buprenorphine/naloxone films early, and that she intended to report me, the physician, presumably for careless prescribing.

Sheesh.

I tried again to call the pharmacist, to explain the situation and try to work it out. I was put on hold for eleven minutes, when it occurred to me that this pharmacist had no intention of coming to the phone. I hung up and called my patient back, telling her to go to a different pharmacy and I’d call in three days, which is what I did.

This emergency buprenorphine could be a wonderful thing, but some pharmacists in my area are extremely cautious about buprenorphine products. I think it’s weird that after practically throwing OxyContin and Xanax and Opana medications at patients for fifteen years, now pharmacists are worried about an established buprenorphine patient filling a prescription three days early.

Swallow a camel, strain at a gnat, as the biblical saying goes.

So yes, I’d like to see some pilot programs try this novel idea, but you’d better make sure the pharmacists are all on board first. Perhaps in Massachusetts, it would be easier than in rural North Carolina.

Book Review: Out of the Wreck I Rise: A Literary Companion to Recovery

 

 

This book, written and edited by Neil Steinberg and Sara Bader and published by the University of Chicago Press in 2016, will appeal to intellectual and thoughtful people in recovery.

The book is a compilation of writings from famous and non-famous people throughout history regarding aspects of substance use disorder and recovery from this disorder. It’s an impressive effort. The book is composed of essays, statements, prose or poetry relating to the topic of each chapter.

The book is organized by sections. It’s easy to miss the topic of each chapter unless you read the lead-in writings by the authors at the beginning of each chapter. For example, I started one chapter in the middle, and was unsure of the topic until I started at the beginning of the chapter and found it was about going to Alcoholics Anonymous.

The nine chapters cover the topics of drug use and the negative experiences that lead people to recovery. Chapters cover the experience of early recovery, maintenance of recovery, and 12-step meetings. The last chapters cover the experience of the family and friends of people with substance use disorders, the possibility of relapse, and the blessings of a rich life in recovery.

Some of the cited excerpts are tangentially related to drinking, drug use, and recovery. For around ten percent of the book, I have a hard time seeing how it’s relevant to the topic. But then, over the years my scientific brain has become stronger than my poetic brain, so it could be me and my limited, linear thinking. And that’s a benefit of the book – it got me thinking just a little more outside the box about substance use disorders and things related.

For example, there are three excerpts from Khaled Hosseini’s The Kite Runner, a book that is not about substance use disorders at all, unless I very much misread that whole book too. The excerpts are lyrical, and I appreciate them…but they are not about addiction or recovery. This compares to the same number of entries, three, from William Burroughs, who wrote exclusively about substance use disorders.

Surprises lurk in this book; would you have expected to read something from Dickens’ A Christmas Carol in such a book? Would you have expected only three excerpts from Keith Richards? No to both.

Yet as extensive as it is, there are obvious quotes that the authors neglected. What about Lenny Bruce’s famous quote about using intravenous opioids: “I’ll die young, but it’s like kissing God.” What about Drew Gates: “Heroin gave me wings but took away the sky.”? There’s nothing from Augusten Burroughs, one of my favorite authors, (“I myself am made entirely of flaws, stitched together with good intentions.”) and only one entry from the Big Book of Alcoholics Anonymous.

So, while I enjoyed this book, I did find it to be uneven in its selections for inclusions.

This isn’t a book you’ll sit down and read through. It’s a book to be picked through, read in sections and pondered. It’s great for the ADD readers like me, who tend to read several books at once because I need different books like different foods. Sometimes I want meat, sometimes a good carbohydrate, and often a light and fluffy dessert.

This book is a sophisticated French dish that’s tasty but rich.

Here are a few of my favorites that I had not read before: “How many people thought you’d never change? But here you have. It’s beautiful. It’s strange.” From Kate Light in “There Comes the Strangest Moment,” a poem from her book Open Slowly. I think I will have to read this book of hers.

Most of the quotes I’d never heard before, and I consider myself very well-read on this topic. Many quotes are from very old writing, from Seneca or Ovid, for example, but the quotes still hold up over time. The age of the quotes gives more perspective about how this illness isn’t new, and substance use disorders have been with use since man has been alive.

This book is well-annotated, with extensive source notes, a list of permissions, and an index, making it easy to find a reading.

Maybe I lack appreciation for the poetry of this body of work. I would give the book a solid 4 stars – interesting and appealing to most people interested in substance use disorders and recovery from substance use disorders.

I suspect this book will be most appetizing to people in recovery who are avid readers, no only because readers like books, but because this anthology points towards other authors and other books that might interest us. With the tidbits in this book we are pointed toward potential feasts with other authors who understand the peculiarities of addiction and recovery from addictions of all sorts.

I know I now have a list of other books I’d like to read. Some are old and some new; some may be out of print and others will be at my local library. I’m thankful to the authors of “Out of the Wreck I Rise” for pointing me towards these resources for the soul.

And I’d like to offer my readers my very favorite quote, not found in any books but uttered by a stranger at a 12-step meeting: “If I could drink like normal people, I’d do it all the time.”

That’s the dilemma, perfectly.

Where Did All the Pills Go?

On the left, number of pills per capita by county
On the right, opioid overdose death rates by county

 

The Washington Post has written some amazing stories this month about our present opioid epidemic. One of their articles described how they accessed data about the distribution of all the prescription opioid pills manufactured and consumed in the U.S. https://www.washingtonpost.com/graphics/2019/investigations/dea-pain-pill-database/?utm_term=.f9fb5fdb26b7

This data is amazing. There’s a box where you can enter your state or county and learn how many pain pills were sold, how many that averages per person, and which pharmacy sold the most.

For my state of North Carolina, around 2.5 billion pills were sold from 2006 until 2012. Most of these pills were distributed by Cardinal Health. Omnicare Pharmacy of Hickory, NC sold the most pills of any pharmacy, at over 9 million pills.

In my county, 26 million pills were prescribed from 2006 until 2012, enough for 55 pills per person. SpecGx pharmaceutical company manufactured the most pills sold in our county. (They make Roxicodone, called “roxies” by the patients I admit to treatment.)

The data, while interesting, needs to be interpreted with caution. For example, we could jump to the conclusion that Omnicare Pharmacy of Hickory, NC, which sold more pain pills than any other pharmacy in NC, is doing something wrong or inappropriate. But this pharmacy doesn’t sell directly to the public. It supplies opioid pain medications to assisted and skilled nursing facilities. This means the pharmacy may supply pain pill to facilities where patients stay to recuperate after orthopedic surgeries, for example. For such patients, opioid pain pills may be not only appropriate but necessary. The data is also seven years old, but that’s the way data is obtained; it takes time to collect and process information.

But the data gives overall trends and shows the staggering numbers of opioid pain pills consumed by residents of certain areas.

The Washington Post website also published two maps: one shows the number of opioid pills sold, and the other shows opioid deaths by county. The overlap, though not absolute, is striking.

The Washington Post’s recent articles contain valuable information for us, if we chose to learn from them and act on them. To me, they have given us maps of where to concentrate opioid use disorder treatment programs. Unfortunately, some of the most severely affected counties are rural, with few providers who know how to treat opioid use disorder. We’ve got to continue to focus resources on these areas.

The Washington Post also published an article about which pharmaceutical companies made the most opioid pills, which corporations distributed the most prescription opioid pills, and which pharmacy chains sold the most pills. Right now, lawsuits are proceeding against all these participants in the opioid epidemic.

The biggest manufacturers include Janssen Pharmaceutical, Purdue Pharma, Endo Health Solutions, Teva Pharmaceuticals, Allergan, and Mallinckrodt. Some of the biggest distributors were AmerisourceBergen, Cardinal Health, and McKesson Corp. The biggest pharmacy chains are CVS, Rite Aid Corp., Walgreen’s, and Walmart Inc.

The lawsuits against these companies allege that they should have notified the DEA of suspicious orders for large amounts of opioids, and that they violated the Controlled Substances Act by failing to report. Some lawsuits against pharmacies allege the pharmacies had to know that medications were being diverted to the street.

Other than that, I’m not sure I understand the basis of these lawsuits.

For sure, if a company mislead physicians in its marketing, as many people feel that Purdue Pharma did, I understand that as a crime.

But I don’t know enough about what manufacturers and distributors and pharmacies are supposed to do when supplying opioids. This must be driven by physicians’ prescriptions, I would think. I doubt drug companies would manufacture opioids unless there was a demand, or that distributors would distribute and pharmacies would sell, unless there are legitimate physicians’ prescriptions.

I don’t understand how we can expect manufacturers, distributors and pharmacies to know more about good prescribing than physicians should. And physicians surely did underestimate the dangers of these medications, thanks in part to the so-called experts, who downplayed the risks of long-term opioid prescribing for chronic pain. Also, the “under-treatment of pain” movement accused doctors of being callous to suffering and encouraged them to view pain as the “fifth vital sign.”

At any rate, Washington Posts’ series of articles bring some facets of the opioid epidemic to light.