In Praise of Opioids, Part 2

 

 

 

 

Long-time readers of my blog will recall that I broke my leg – tibia and fibula – around six years ago. The point of the post was mainly to get to talk about my medical ailments, which I love, and that opioids, when used correctly, can be a huge blessing. I described how EMS personnel, on the way to the hospital, gave me a dose of fentanyl. The relief of intense pain was so miraculous.

Well, now I get to talk about my latest medical adventure.

I had a tibial intramedullary rod placed when I broke my leg. It worked beautifully and allowed my broken leg to heal much more quickly. I was ultimately able to get back to my usual activities after what could have been a devastating accident, had good medical treatment not been available.

But starting a few years ago, I had some swelling right at the middle of the tibia, with some pain. I went back to see the orthopedic surgeon, who X-rayed it, and said there was a bone callous forming there due to irritation from the tibial rod. He said he could remove the rod, and that would take care of the problem.

I asked him how big of a deal it was to remove the rod, or “nail” as it’s sometimes called, and he said, “Oh, about as much as putting it in.” That was enough for me to decide against surgery. Well, I also made the mistake of watching YouTube videos of removal of tibial intramedullary nails. Yikes. Let me just pause to tell readers that if you have an upcoming surgery, DO NOT Google or YouTube your procedure. It’s a bell you can’t un-ring.

Over the last few years, after moving to the country, I’ve been much more active, and pain at this area of my leg has bothered me more and kept me from being as active as I’d like. So, this summer I got fed up, went back to the orthopedist, got my surgery scheduled and had it done yesterday.

I was confident I could handle any pain after the surgery, since it certainly couldn’t be as bad a breaking a leg, right? Only as soon as I woke up in the Recovery Room, I had intense pain from my knee down, and started groaning and mumbling. The nurses were attentive and asked if I needed something for pain. I said yes. I’m no martyr. I had one injection of hydromorphone (Dilaudid) and it relieved all pain. I think I had one more injection of the same about a half hour later and didn’t need any more. By that time, I was awake and eager to get out of there.

Thankfully the surgeon injected the incision areas with Marcaine, a long-acting medication similar to Novocain that we get at the dentist. My leg felt numb, but that was good.

I really haven’t had much pain since leaving the surgical center. Of course, my leg is sore at the places where the screws were removed, and my knee is sore, where they withdrew the rod.

My biggest problem has been bleeding. I didn’t notice anything on the ride home, since I was drowsing in the back seat with my leg elevated on two pillows. Then when I got home, I noticed blood soaked my sock, through the wrap they’d placed.

I went to my recliner, got the two pillows, and slept, with my leg extremely elevate. I still felt a little goofy from either anesthesia or the Dilaudid, or both. I slept for a few hours, then woke to find the pillows covered with blood. In fact, the whole lower dressing was soaked, and I had to remove it, despite directions that say to leave dressing in place for 48 hours.

There was a stream of blood coming from the lower leg incision, where screws had been removed. I got some gauze and held pressure on the area with a bag of frozen corn, and the bleeding slowed to an ooze, then eventually to drops. It took nine hours to get this bleeding to stop.

As a physician, I do understand that a little bit of blood looks like a lot of blood, when it’s your blood. I put off calling the 24-hour number, thinking I was overreacting, and that the person I talked to would tell me to hold pressure, keep it elevated, and put ice on it. Still, by 10pm, I was worried enough to call, estimating I’d lost about a unit of blood.

A very nice physicians assistant returned my call, listened to my detailed report, and said if it was still bleeding in the morning, come to the Urgent Care. He also suggested elevation, pressure, and ice.

Eventually, I was so tired and sleepy that I put loads of gauze around it, replaced the pressure bandage and hoped for the best. I went to bed.

So far today, all is well. If there’s bleeding under there, I’m blissfully ignorant of it, and at least it’s not as bad as yesterday, when it soaked through the dressing.

I was given a prescription for hydrocodone, but I don’t think I’ll need it. I just took a few Tylenol and all the soreness is gone. I will keep my leg elevated, which I believe does more than anything to assist in healing, and gradually get back to normal.

Again, I think how grateful I am to have health insurance, and to have access to a great orthopedic surgeon. I feel blessed to have had good anesthesia throughout the procedure and in the recovery room, when my moderate pain was immediately addressed. I’m grateful I was given the option of taking post-operative opioids, even though I don’t plan to fill the prescription.

Yesterday I started to wonder if one of my patients, having the same procedure I had, would have been treated any differently. I hope not. Quite often, I must advocate for my patients on medication for opioid use disorder and tell their surgeons or providers that even though patients are taking a maintenance opioid, they still need short-acting opioids for acute pain situations. I hear – all too often – that patients prescribed buprenorphine or methadone are treated with judgmental attitudes, and this sort of bias has no place in modern medicine. I hope all my patients will be treated as well as I was treated yesterday, when they have medical events.

Opioids are a godsend, when we use them in the right way. The key is to use good judgment, and not to prescribe too long of a course (something that the NC STOP Act addressed) and get dependable family or friends to help a patient with opioid use disorder manage an opioid prescription for acute pain.

I’ll keep you updated with my progress. You know I will, since I love talking about my medical ailments, which are thankfully very few at this time.

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“Bosch” Full of Tired Clichés

Season 5: Bosch and the Opioid Crisis

 

(Spoiler Alert – If you haven’t seen “Bosch” Season 5, this blog post will describe events of the last episode.)

I am disappointed in Harry Bosch. Or more specifically, I’m disappointed by the writers of the “Bosch” series.

“Bosch” is now in its fifth season on Amazon Prime. I’ve always enjoyed the series, based on the books written by Michael Connelly about the adventures of a Los Angeles homicide detective names Hieronymus (“Harry”) Bosch, played on the series by Titus Welliver. I thought the writing was smart and well-paced, with interesting plots that were better than average.

This season, the writers must have thought hey, let’s do something relevant, like a case related to the opioid use disorder epidemic. I would have liked that. The trouble is, this season portrays the opioid use disorder epidemic as it was about ten years ago.

There’s plenty more going on during the season which still makes the show worth watching, but I was constantly eye-rolling at the tired clichés about people who become addicted to prescription opioids, pill mills, and approaches to treatment.

In this season, Bosch investigates the murder of a pharmacist, who had dealing with thugs who run a sophisticated pill-mill operation. Oddly, these criminal masterminds have gathered a group of people who are addicted to pain pills and shuttle them from one pill mill to another, then to multiple pharmacies to fill these prescriptions, to obtain vast amounts of oxycodone pills.

Then the crooks dole them out to the poor addicts who are physically and mentally broken down, and meek as mice. For some reason, they do whatever the bad guys tell them to do, though clearly, they could score more oxycodone on their own.

Then for some reason, the crooks put them on a small private plane and fly them to a camp in the dessert where they are housed in shoddy trailers or old buses until they are flown back for another pill mill-pharmacy outing.

California has had a prescription monitoring program for years. That system would detect people trying to see multiple providers for multiple prescriptions. This scheme could have worked before the prescription monitoring program, but not now. But the writers appear to have ignored this awkward detail.

And flying these people to and fro doesn’t seem practical to me. Private planes are expensive, no? Why fly them to and from the pill mills and pharmacies, then back to the desert camp? Why not house them in a cheap motel at the edge of town? I get that the bad guys want to keep them quiet, but all that flying about seems inordinately expensive.

It’s not even that weirdness that makes me angry. It’s how the characters of the people with addiction are portrayed. They are downtrodden, doing what they are told by the thugs. They are submissive and controllable. After getting a bottle of prescription OxyContin, they turn over the entire bottle, only to be given one or two pills doled out over time by the bad men.

Naw, this doesn’t play. A group of six or eight people with opioid use disorder would certainly be more formidable than this. In fact, given the survival skills of the average person in active addiction, I’d expect them to be running the desert camp after a day. Guns or no guns, these people are in withdrawal and very motivated to get out of withdrawal. These bad guys would be no match for them.

Part of my prediction is based on how the bad guys are shown to be bumbling fools by the end of the season. At one point, one of them, armed, is supposed to throw Bosch out of the plane. Of course, Bosch, unarmed, turns the tables throws the thug out of the plane instead. Then at the end of the season, three of these hardened thugs come to Bosch’s lovely little home in the Hollywood hills for a sneak attack. They are armed with automatic rifles. Bosch, with a handgun, and takes them all down. These guys must be the worst shots in the world, because they spewed bullets galore, but missed Bosch completely.

Then the writers have Bosch trying to help one woman, using outdated methods. Elizabeth is a lovely yet troubled woman grieving the murder of a child. She has a heart of gold but prostitutes herself for one OxyContin 80mg with one of the bad men just to feel better. Of course, Bosch must help her. This lady is a veteran, like him, and he obviously has a soft spot for her in his hard-bitten heart.

He takes her for help to small seedy agency that helps veterans. He doesn’t take her to the Veterans Administration medical system, which now has excellent treatment programs for opioid use disorder using medication-assisted treatment. No, he takes her to a cold-turkey, you-must-suffer, just-for-veterans, hole-in-the-wall kind of facility. When Bosch remarks that he wants to say goodbye before he leaves, the proprietor of the “facility” says he’d better go now, before she chews her fingernails off.

This show perpetuates that tired idea that a person with opioid use disorder must suffer in order to be redeemed, gain recovery, and be worthy of respect again. This is not only an outdated concept, but dangerous. We’ve known since the 1950’s that a detox alone doesn’t do much good unless it’s followed by other treatment, but Bosch offers none of that information. The expectation is that if Elizabeth is tough and brave, she will beat her addiction.

Addiction isn’t like that.

In another scene, J Edgar, Bosch’s partner, is talking with this same woman, and she asks for relief from withdrawal. J. Edgar says a doctor will see her soon. She scoffs, “What and give me, Suboxone? I might as well snort Splenda.”

So, the show also downplays the effectiveness of medication-assisted treatment.

*SIGH*

I hereby announce that I am available for consultation on television and movie scripts. I can keep shows relevant and current with information about opioid use disorder and its treatment. Hollywood, I can help you.

Call me. We’ll do lunch.

 

 

Don’t Sweat It

 

 

 

 

It’s that time of the year: it’s getting warmer, and patients are asking about ways to relieve the sweating that is sometimes a side effect of taking methadone or buprenorphine. I thought this would be a good time to re-run a past entry about this topic.

All opioids can cause sweating and flushing, but methadone is perhaps worse to cause sweating than other opioids. Buprenorphine also can cause sweating, but it is usually less of a problem than for patients on methadone.

We don’t know exactly why opioids make people sweat, but it is related to opioids’ effects on the thermoregulatory centers of the brain.

Excess sweating can also be caused by opioid withdrawal. If other withdrawal symptoms are present, like runny nose, muscle aches, or nausea, an increase of the methadone dose may help reduce the sweating.

At least half of all patients on methadone report unpleasant sweating, but some patients have sweats that are more than just inconvenient. These patients report dramatic, soaking sweats, bad enough to interfere with life.

What can we do about this sweating?

First, non-medication methods can be attempted. These methods include common sense things like wearing loose clothing, keeping the house cool, and losing weight. Regular exercise helps some people. Talcum powder, sprinkled on the areas that sweat, can help absorb some of the moisture. Antiperspirants can be used in the underarm area, but also in any area that routinely becomes sweaty. The antiperspirant can be applied at bed time so sweating won’t interrupt sleep. There are prescription antiperspirants, like Drysol or Xerac, but these sometimes can be irritating to the skin. Avoid spicy foods, which can also cause sweating.

Make sure the sweating isn’t coming from any other source, like an overactive thyroid, and check your body temperature a few times, to make sure you don’t have a fever, indicating the sweating could be from a smoldering infection. A trip to the primary care doctor should include some basic blood tests to rule out medical causes of sweating, other than the dose of methadone.

Some prescription medications can help, to varying degrees, with sweating.

Clonidine, a blood pressure medication that blocks activation of part of the central nervous system, blocks sweats in some patients.

Anti-cholenergic medicines, drugs block the effect of the neurotransmitter acetylcholine in the involuntary nervous system, block sweating. Anticholinergics tend to dry all secretions, causing such common side effects as dry mouth and dry eyes. These medications can cause serious side effects, so they must be prescribed by a doctor familiar with the patient’s medical history.

Some examples of anticholinergics include oxybutynin (also used for urinary leakage), bipereden (used in some Parkinson patients), scopolamine (also used for sea sickness), and dicyclomine (used for irritable bowel syndrome). All of these have been used for excessive sweating with various degrees of success, in some patients.

For unusually bad situations, Botox can be injected under the skin of the most affected areas, like armpits, palms and soles. Obviously, this is somewhat of a last-resort measure.

Patients affected with severe sweats, unresponsive to any of the above measures, need to decide if the benefit they get from methadone outweighs the annoyance of the side effects. In other words, if being on methadone has kept them from active drug addiction, which is a potentially fatal illness, it would probably be worth putting up with sweating, even if it’s severe.

Of course, discuss your symptoms with the provider prescribing buprenorphine or methadone. She can help you decide if your dose needs adjustment, if you need further medical workup, or some of the medications listed above are worth a try.

Please Stop Smoking

 

 

 

 

 

 

Although my blog is dedicated to opioid use disorder and its treatment with medications, this blog is about the importance of stopping smoking.

I was listening to the American Society of Addiction Medicine’s annual review course from 2018, and while I listened to the lecture of nicotine use, became convinced I must do more to promote smoking cessation among my patients and readers of this blog.

In the ASAM lecture I listened to by Dr. Abigail Herron, she remined me of some bleak facts about smoking: it is the leading cause of preventable deaths worldwide, and it accounts for 20% of deaths in the United States. Half of all smokers will die from tobacco-related illness.

Smokers die, on the average, of ten years earlier than they would if they never smoked.

That last bit of data stopped me. If you are a smoker who is reading this, what would you do to be given the gift of ten more years of life? For me, it would also depend on the quality of those years, but then, stopping smoking is likely to increase the quality too.

Rates of cigarette smoking are going down in the U.S., but as smoking is being promoted in the developing world, we will see more problems in these areas. By 2030, it’s expected that 80% of all smoking deaths will be in developing countries.

Deaths from smoking are usually from cardiovascular disease (heart attack or stroke), lung cancer, and chronic obstructive pulmonary disease (COPD) like asthma and emphysema.

Nicotine causes blood vessels to constrict, and smoking also causes blood to clot more easily, causing vascular disease of all types. We usually think of smoking causing lung cancer, but smoking increases the risk of cancers of the esophagus, kidney, pancreas, stomach, liver, urinary bladder, and uterine cervix. Smokers also are more likely to develop Type II diabetes, osteoporosis, erectile dysfunction, cataracts and macular degeneration, and early menopause.

And wrinkles. Lots of wrinkles, because nicotine cause blood vessels to constrict, limiting blood flow and depriving skin of oxygen and nutrients. I dabbled with smoking when I was younger but stopped after a few months when I thought I saw wrinkles developing. Vanity saved me from nicotine use disorder, and I’m happy about this.

It’s not only the nicotine that does the damage with cigarettes; they also contain harmful ingredients like hydrogen cyanide, ammonia, benzene, formaldehyde, and particulate matter like lead, cadmium, and nitrosamines. Cigarettes contain around forty-eight hundred compounds, and eleven are known carcinogens.

The active product, nicotine, is quite physically addicting. It stimulates the release of dopamine in the brain, producing feelings of pleasure, but nicotine also stimulates other neuro transmitters.

In the past, patients entering substance use disorder treatment programs weren’t asked to quit smoking, because we worried quitting both cigarettes and drugs (including alcohol) would be too hard and people needed something to fall back on. We worried patients would do worse in substance use treatment if they were asked to quit smoking too. Now, we have good evidence that shows the opposite may be true.

Most of the studies done in this area show better outcomes in patients who quit smoking early in their recovery from substance use disorders. Smoking cessation may improve the likelihood of longer-term sobriety. (Gulliver et al., Alcohol Research and Health, 2006) Several studies showed that patients entering addiction treatment were 25% more likely to maintain abstinence from alcohol and other drugs if they also stopped smoking (Prochaska et al, 2004, Joseph et al., 2004).

Patients’ brains may recover more quickly if they quit smoking. A study of patients with alcohol use disorders (Durazzo et al., Alcohol Clinical Experience Research, 2014) showed patients recovering from alcohol use disorder who quit smoking at the same time they stopped drinking rapidly improved on measures of learning and mental processing speed during their first month. Patients who continued to smoke had slower recovery of these mental functions.

Smoking during pregnancy has well-known risks. Moms who smoke are more likely to have miscarriages, low birth weight, ectopic pregnancies (pregnancy in the Fallopian tubes instead of in the uterus), placental abruption (when the placenta tears away from the uterine wall), and increased risk of Sudden Infant Death syndrome. Given these known problems, many moms chose this time to quit smoking.

I already talk to patients about smoking cessation, but after I listened to Dr. Herron’s lecture, I vowed to redouble my efforts, and talk to everyone about quitting.

Here’s what we know about quitting smoking: though not easy, it can be done. If you have a failed attempt, don’t give up. As with other substance use disorders, learn what you can from each relapse. Learn what does work for you and what doesn’t. Pay attention your triggers.

Medications can help, and double quit rates. The three first-line medications are bupropion (brand names Wellbutrin and Zyban), varenicline (Chantix) and all the nicotine replacement therapies (NRT). NRT comes in patches, gum, lozenges, inhalers, and nasal sprays.

Each of these products have some drawbacks; the gum can stick to dentures, making it less desirable for some patients. The patches can cause a skin rash, and the inhalers can potentially cause breathing problems, so patients may want the advice of their primary care provider.

I’d like to educate readers about e-cigarettes and vaping, but that’s difficult, due to the many products on the market. One product may have significant carcinogenic particulate matter in what is being vaped, and another product may not. Overall, vaped products have fewer cancer-causing substances, but still contain things other than nicotine. At a minimum, e-cigs and vapes contain flavoring and humectants. Since people tend to puff longer with a vape or e-cig, these substances may still be harmful to the heart and lungs.

Though smoking rates in the U.S. have dropped significantly over the past decades, down to around 15% of the population, adolescents use of e-cigs and vapes has increased rapidly. Manufacturers make products targeted towards adolescents, for example, with cotton-candy flavored products.

Thus far, no electronic nicotine delivery systems are FDA approved for smoking cessation. These products might be helpful if they are used as a complete substitute for tobacco. However, people who both smoke cigarettes and use vape products, called dual users, are no more likely to quit smoking than people who aren’t trying. That’s discouraging data about using e-cigs and vapes to quit.

There’s good news for people who want to quit smoking. Circulation improves after only a few weeks of smoking cessation, and lung function can increase up to 30% within the first three months. After one year of stopping smoking, the cardiovascular risk drops to half that of someone who continues to smoke. Ten years after quitting smoking, the risk of developing lung cancer drops to half that of a smoker.

Talk to your doctor to form a plan to help you quit. Consider accessing the free North Carolina quit line for help: https://www.quitlinenc.com/

They have a 24-hour hotline, and even have coaches available to help you.

I’m writing this because I have many friends in recovery from substance use disorders, and some of them still smoke. I like these people, and don’t want them to die early. I want them to quit and be around for many more years, sharing their experience, strength, and hope with the rest of us.

Harm Reduction Dilemma

Harm Reduction Cat

 

 

 

 

What happens when harm reduction tenets clash with actual patient experience? That’s my recent dilemma.

Our opioid treatment center is blessed to have an organization that comes to our facility to do free testing for HIV and Hepatitis B and C. They also do needle exchange, or more precisely, they distribute clean needles to anyone who wants them.

Our patients have benefitted tremendously from the free HIV and hepatitis testing. Many of our patients have been diagnosed with active Hepatitis C. Since we now have a Federally Qualified Health Center in a neighboring town, about an hour away, our patients can get treatment for Hep C, even if they have no insurance or Medicaid. I’d estimate that two or three dozen patients have been diagnosed with Hep C, been referred for treatment, and are now cured of their Hep C.

The value of this can’t be overstated. Besides reducing the burden of Hep C in the community, these patients are free from worry that their Hep C will cause future problems. They don’t have to worry about it anymore, if they remain in recovery.

Our dilemma isn’t about this part of what they do, but about the needle exchange.

At our facility, we endorsed harm reduction as a healthy goal. If patients inject drugs, we want them to be as safe as possible, while still hoping they will be able to quit injecting once they get some traction in treatment.

However, some established patients, doing well now and free from illicit drugs, have told us the available free clean needles are a trigger for them to use drugs intravenously again.

This isn’t supposed to happen. Studies about needle exchange have not showed that clean needles influence people to inject drugs who weren’t already planning to inject drugs, which is why we’ve been supportive of the needle exchange.

But now we have some specific patients who link a relapse to intravenous drug use (usually intravenous methamphetamine or cocaine) to the available clean needles. These patient experiences contradict what the studies show us.

What should we do?

We need the services of Hepatitis and HIV testing, but we don’t patients to relapse, obviously. Do we ask the organization to keep do the free testing, but put the clean needles away and not mention them?

We had a spirited debate about the issue last week at our case staffing/treatment team meeting. This topic raised some passionate feelings both pro and con clean needle exchange, which surprised me a little. Some personnel thought patients shouldn’t be offered clean needles because, after all, these were patients in treatment who should be trying to be drug-free. Other people pointed out that continued intravenous drug use is inevitable, to some degree, in patients trying to get help, and we should want these patients to be as safe as possible while they inject, citing evidence about reduction of transmission of HIV and Hep C with needle exchange.

Some people felt the patients reporting that their drug use was triggered by being offered clean needles was an excuse, an effort to displace blame from themselves onto someone else. Those people felt these patients were going to use anyway and used needles exchange as a scapegoat.

I listened to everyone and decided there was possible truth to everything that was being said, but there was no way to know for sure.

In the end, we decided to ask our patients who were most vocal about the needle exchange program being a relapse trigger if they would talk to the personnel who work for the harm reduction agency that supplies the testing and clean needles. I thought offering information in both directions would be a good start.

Patients are often the harshest critics of other patients who aren’t doing well. Many times, I’ve had a patient tell me I ought to kick another patient out of treatment because they were still using drugs. Of course, I have to tell them I can’t talk about any other patient, but in general, we try to keep patients in treatment rather than turn them away for drug use, although sometimes we do refer them to more intense treatment.

Sometimes patients say that other patients using drugs makes them feel triggered to use drugs too. I can’t deny anyone’s experiences. If someone says they are triggered, then they are. And we do want to provide a safe treatment facility. How much drug use should we tolerate if it negatively impacts other patients’ treatment experiences?

What do my readers think? Is offering clean needles at a treatment program going too far, as some of our OTP employees think? Is it not going far enough, and should we offer safe injecting sites if it were legally allowed, as it is in Canada and elsewhere?

Insomnia

 

 

 

 

 

I planned to regale my readers with news from the big annual American Society of Addiction Medicine conference, held earlier this month. But it was not to be. The day before I was to depart, I woke up with pink eye.

I woke up with the kind of pink eye that caused fluid to sprout from my eye like an overfull bathtub. Of course, this material in highly infectious, and very messy. I dabbed my eye and face with a tissue, discarded it and washed my hands, only to have to repeat the whole process a minute later. In good conscience I couldn’t get on a plane and go to a meeting of hundreds of people and risk infecting them, so I stayed home, feeling grumpy.

I’ll still go to the sessions, online. ASAM has a wonderful online program, where you can hear sessions at conferences you’ve registered for. So as soon as they are posted, I’ll listen to them at home, and then pass new information on to my readers.

In the meantime, here’s a re-run on insomnia. I get so many patients with insomnia. It’s a common problem for people in recovery, who are waiting for their brain chemistries to calm down. Nearly every week, I recite the main points of good sleep hygiene to patients in need of a good night’s sleep.

For someone who has grown accustomed to taking some sort of substance to fix every problem, hearing that the solution isn’t another pill can be hard to accept, but I’m convinced most sleep issues can be cured or improved with the following principles of sleep hygiene:

Many U.S. citizens, and not only addicts, have become “chemical copers.” We have the idea that every problem can and should be fixed with medication. But with insomnia, sleep hygiene is the best first option, and medication can be used if sleep hygiene doesn’t work.

Sleep hygiene, which sounds it means washing behind your ears at bedtime, really refers to habits that help us get satisfactory sleep. Most are common sense ideas, and they can really make a big difference. Here are some of these ideas:

Go to bed at the same time and wake at the same time every day, even on weekends.

If it’s at all possible, don’t go to bed later or sleep later on weekend days. Get your body into the habit of keeping a regular sleep/wake cycle. You will fall asleep more easily with a fixed bed time.

Besides making your feel better because you’ll get more regular sleep, this practice has other benefits. For example, people with migraine and tension headaches have fewer pain episodes with regular sleep/wake times. Keeping regular sleeping hours is also highly recommended for patients with bipolar disorder, as it can help with mood swings.

Avoid caffeine late in the day. For some people, drinking caffeine in the late afternoon can affect them up to six hours later. To be sure, cut off caffeine at least eight hours before you want to sleep. Caffeine doesn’t affect everyone to this degree, but unless you know for sure, try to limit late-day caffeine. If you consume energy drinks, consider cutting back or stopping them.

Make sure your bed is comfortable and your room as free from distractions as possible. Pets and rowdy bed partners may need to sleep in other areas. Make sure the room temperature is conducive to sleep and there’s no noise or light that may interrupt sleep. Keeping the television on for background noise isn’t a good idea and can prevent you from getting to the deeper levels of sleep.

Don’t set your alarm for earlier than you need to. Many of us like to do this so we can hit snooze a few times. However, the most beneficial sleep, REM sleep, comes at the end of the night, and we are depriving ourselves of REM sleep by hitting the snooze button a few times before getting out of bed for good.

Have a bedtime ritual. Have things you do each night before going to bed that relax you and put you in a mindset to sleep. This could be a series of ablutions like brushing your teeth, flossing, or taking a warm bath. Other people may prefer doing prayer or meditation to quiet the mind, or reading.

Don’t nap during the day to catch up on sleep. More than anything else, napping will keep you from sleeping at night.

This is a tough one for me, since napping has long been one of my hobbies. Because I think of a good nap as one of life’s great joys, on some days I’m willing to risk not being able to get to sleep at night and take the nap anyway.

Don’t use alcohol to help you sleep. While alcohol does cause faster sleep onset, it also shortens the sleep cycle, causing us to wake earlier, and robs us of the important REM sleep. Over long term, alcohol can greatly interfere with your sleep cycle.

Only use your bed for sleep. OK, for sex too. But don’t live in your bed so that you become accustomed to eating, watching television, and working on the computer in bed. Your mind should associate bed with sleep, and not these waking activities.

Exercise each day. More than most other suggestions, this one can help you more than you expect. Even a small amount of exercise can have surprisingly good benefits. Don’t exercise too close to bedtime, since exercise can have a stimulating effect.

Sometimes people in early recovery find they want to sleep more than usual. This can be part of your physical recovery, and I think it’s best to listen to your body and allow yourself extra sleep time without feeling guilty. However, some mood disorders also make people want to “take to the bed” during times of stress and negative emotion. This latter situation may need medication if it continues or interferes with your life.

If you try all these sleep hygiene measures and you still can’t sleep, talk to your doctor about a safe medication for sleep. I’ll write more about medications in a later blog.

 

Treating Acute Pain in Patients Prescribed Buprenorphine Products for Opioid Use Disorders

 

 

 

 

 

 

 

Many physicians still get confused about how to treat acute pain in patients who are prescribed buprenorphine products for opioid use disorder.

While buprenorphine products (whether Suboxone, Subutex, Zubsolv, Bunavail, or the generic forms of these) are partial opioids, when they are prescribed long-term for treatment of opioid use disorder, they don’t work very well for moderate or severe pain. These patients usually also need treatment with short-acting opioids.

Buprenorphine has a high affinity for the opioid receptors in the brain, which means this medication sticks to those receptors like glue. Other opioids, with lower affinities, have more difficult time exerting their effects in the central nervous system. This high affinity for receptors is one feature of buprenorphine that makes it work so well for patients with opioid use disorder, but we’ve worried that it also can complicate the treatment of acute pain in those patients.

If the pain is mild, sometimes pain relief can be improved by splitting the dose of buprenorphine. The anti-withdrawal effect of buprenorphine usually lasts longer than 24 hours. That’s why once -daily dosing works fine for this purpose. However, the analgesic (anti-pain) effect lasts from eight to twelve hours. That’s why patients with both opioid use disorder and chronic pain issues may feel better when they split their doses and take half in the morning and half at night. This approach may also help patients when experiencing mild to moderate acute pain.

Sometimes when patients on medication-assisted treatment for opioid use disorder have mild pain, non-opioid measures can help the patient. For example, many dental procedures are well-treated with anti-inflammatories like ibuprofen, rather than with opioids. Or a long-acting version of Novocain can give sustained numbness to the area.

Any of the three following methods can be used to treat acute pain in buprenorphine patients:

In the past, many experts recommended patients stop their dose of buprenorphine 24-36 hours prior to an expected painful procedure. (Of course, many things happen without warning, so this option isn’t always possible.) Patients were then treated with short-acting opioids such as oxycodone or hydrocodone until the pain situation resolved or improved. After the patient stopped taking short-acting opioids for 12-24 hours, the patient re-started buprenorphine.

Currently, a simpler process is being used. Many experts recommend buprenorphine patients stay on their usual dose and add short-acting opioids on top of the maintenance medication. Patients still get some analgesia, because buprenorphine rarely blocks the effects of other opioids completely.

A third option is to reduce the dose of buprenorphine to 2-8mg per day, then use short-acting opioids on top of this reduced dose. This way, reduction of the buprenorphine allows for some open opioid receptors, but the patient doesn’t have to come off buprenorphine completely. Plus, the buprenorphine still available appears to block some of the euphoria that short-acting opioids may cause.

Some patients do better with one of these options than the others, so I always ask about past experiences.

Years ago, one of my patients dosing on Suboxone films 24mg per day had to have emergency cardiac bypass surgery. I was worried, fearful that he would have inadequate pain relief after this big surgery. But he did very well. He had no significant pain post-operatively, and decided he only needed 8mg per day. He has done very well on this lower dose with no withdrawal.

Problems do arise. Some of my patients tell their other doctors, surgeons for example, that they are taking buprenorphine for pain. Perhaps they are embarrassed to tell these physicians that they are being treated for opioid use disorder, or maybe they are confused. But that information makes the surgeons think I’m going to manage pain postoperatively, which will not be the case. Most times a phone call can straighten out the misunderstanding.

Providers prescribing buprenorphine products need to help their patients manage the supply of short-acting opioids which may be prescribed by other physicians for acute pain. For example, I ask my patients if a dependable person in their household can hold on to the pill bottle and give medication to the patient as prescribed. We don’t want that person to be stingy or to overmedicate – merely to give out the medication as directed on the bottle’s label.

Buprenorphine prescribers can ask the patient to come back earlier than planned, perhaps a few days after a procedure, to check in about how things are going and get an extra counseling session if any cravings are triggered by either the short-acting opioids or the pain.

As I tell other physicians, just because my patients have opioid use disorder doesn’t mean they can never have opioids for acute pain. In some situations, pain medications are essential. But we can mitigate the risk with careful, short-term prescribing and good communication.