Updates: Law Enforcement Behaving Badly



Last week, a federal judge ruled the lawsuit against Macomb County, Michigan, and against county Sherriff Anthony Wickersham could go forward. The lawsuit was filed by the family of David Stojcevski, who died several weeks into a jail sentence given to him for unpaid traffic tickets. The autopsy showed he died from untreated prescription medication withdrawal.

This case has received media attention after the family decided to release a multi-day video recording, taken by the jail, showing David’s gradual and painful death, as he received little if any medical attention. The video documents his fifty pound weight loss, poor appetite, onset of seizures, and his eventual death from prescription opioid and benzodiazepine withdrawal.


The FBI is also investigating this case, after the Justice Department asked them to get involved.

This story “has legs,” meaning it’s getting more media attention from news outlets like ABC News and NPR. This is probably because of the release of the disturbing video; I’ve seen bits of it and it is disturbing, to put it mildly.

The county sheriff still denies any wrongdoing on the part of the jail staff, and says Macomb County will fight the civil suit.

It’s really hard for me to understand how this sheriff feels he and his staff have no responsibility for this inmate’s slow death. The inmate died of a condition that’s not only treatable, but also preventable, yet received no medical care. The company hired to provide medical care to jail inmates has been dropped from the lawsuit, which speaks volumes. To me, this implies no one from the medical group was summoned to care for the patient. If they had been summoned, surely the responsibility would have shifted to them.

At any rate, I hope the family gets a check with lots of zeros in it, not that any amount of money will erase the family’s sorrows.


In another law enforcement fail, another of my patients reported that a county deputy confiscated his naloxone kit. The kit we gave him was funded through Project Lazarus, just like the last patient’s kit.

All over the country, there’s a push to get naloxone kits delivered to people with opioid addiction, their families, first responders, anyone who wants a kit. The FDA just approved the nasal kits for use in opioid overdoses. States and provinces in the U.S. and Canada started initiatives to distribute these life-saving kits. Even President Obama has specifically endorsed the distribution of naloxone kits.

It feels really frustrating to work so hard at distributing kits, only to have our local law enforcement confiscate them.










Recovery Means…





It’s nearly Thanksgiving, so to celebrate, I wanted to re-run a post about what recovery means to me. Hopefully my readers can add to this list:

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.

….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.


Insurance Companies Behaving Badly





Another one of my patients was denied coverage for his buprenorphine treatment because he’s still using marijuana.

I’ve written about this kind of situation before, and I have mixed feelings.

It was time for me to fill out this patient’s prior authorization form, which must be completed every year, before for the insurance company will agree to continue to pay for his Suboxone. Among other questions, the form asked if all the patient’s urine drug screens have been negative for illicit drugs. Much as I personally may be tempted to answer “No” in order to save the patient some aggravation, that would be a lie. I’m not willing to commit insurance fraud, so I answered honestly. In the insurance company’s eyes, this means my patient is noncompliant with treatment.

Last year, we had no problems. I answered all the questions the same as this year, but I suspect insurance company workers inadvertently overlooked my answer. Not this year. We got news that the prior authorization was denied, and I suspected the positive drug screens were the reason.

We called his insurer, and had a devil of a time confirming that. At first, insurance company personnel said I hadn’t provided all the information that they needed to make a decision. We persisted, and another worker said she’d already talked to my female nurse about what information was missing.

That’s a pretty good guess, since most doctors’ offices have female nurses, but I don’t. I am the only female working at my practice, and I did not talk to them.

It was a bold-faced lie. When asked what number she had called to talk to the non-existent nurse, she recited our fax number. That’s when we told her it would have been a hell of a trick to talk to an imaginary nurse on a dedicated fax line.


Eventually, of course, the insurance company said ongoing use of marijuana constituted non-compliance with treatment and they were no longer going to pay for my patient’s Suboxone.

Putting the insurance company’s incompetence and dishonesty aside for a moment, not an easy task, I have mixed feelings about this whole issue.

On the one hand, my patient is using an illegal drug (at least in this state). I have talked to my patient numerous times about the reasons I would like for him to quit using marijuana. He smokes several times per week for stress relief. I’ve been working with him, asking him to identify other non-drug ways of dealing with stress. My objections are not completely based on the physical or social harms caused by marijuana, since I agree much less harm is caused by pot than alcohol (which is legal – and toxic to the body’s organs). Still, we know marijuana can cause memory loss and loss of IQ points when used long-term, so neither is it completely harmless.

Marijuana use keeps my patient with addiction in a drug culture. Since being around other people using drugs is a big relapse trigger for many patients, it puts him at risk for an opioid relapse. Some pot dealers have diversified product lines, and sell pain pills as well as marijuana, so that’s also a trigger for relapse. I also believe marijuana use interferes with developing the ability to deal with life without using a pill or a potion, which is the biggest chore of recovery. Use of marijuana also impairs judgment. My patient, under the influence of THC, could think using opioids was reasonable.

But on the other hand, this patient has made such large improvements in his life. His marijuana use hasn’t caused the chaos in his life that use of other drugs has caused. During the seven years he’s been in recovery, he has made tremendous improvements in his life. He works full-time, takes care of his children, and is involved in their after-school sports. He pays taxes, and is a fully functioning citizen. He would make a good neighbor and a good friend.

He pays a big insurance premium each month, but now they won’t cover the cost of the Suboxone films that I prescribe, because he’s “non-compliant” with this one aspect of his recovery. I don’t have qualms about switching him to the generic monoproduct buprenorphine, because I feel he’s at low risk for misuse of his meds, so that will be less expensive, but still not cheap.

I understand the insurance company’s reasoning. They are saying why should we pay if the patient isn’t willing to be compliant with their own treatment? They may have a point.

However, if they are going to take that position, they shouldn’t be allowed to treat the disease of addiction differently than other chronic disease.

What if my patient were an overweight diabetic? He isn’t, but I’ve treated plenty of them in the past, when I worked in Internal Medicine (or “eternal medicine,” as we called it, because no one EVER got better from their chronic diseases like diabetes, high blood pressure, heart disease…).

How about if my patient was told to lose weight and exercise, but instead he remained sedentary, and actually gained 20 pounds? Do you think it would be reasonable for his insurance company to stop paying for his diabetes medication, saying that he was noncompliant with treatment?

I see no difference between those two scenarios. With both addiction and type 2 diabetes, the patient has to make lifestyle changes for the disease to improve.

Let me give another example. Let’s say I treat a woman with asthma. I prescribe several inhalers to help keep her from having an attack of asthma. I’ve recommended she stop smoking, and she’s able to cut down from a pack a day to a half-pack per day. When it’s time to submit a prior authorization to her insurance company so that they will continue to pay for her very expensive and life-saving medications, do they have the right to refuse to pay for them since she’s still smoking?

I’ll belabor the point. Let’s say I have another patient with chronic back pain. He’s forty pounds overweight, and I’ve recommended weight loss and back exercises for him, along with an expensive anti-inflammatory medication. His insurance company asks if he’s been compliant with treatment, and I have to answer “no” because he has actually gained a few pounds, and admits he rarely remembers to do his back exercises. If the insurance company refuses to pay for the expensive anti-inflammatory that helps with his pain, is that justified, or is it wrong?

Imagine the outrage among patients if insurance coverage was denied for all patients who didn’t follow all of their doctors’ recommendations.

Insurance companies, you may have the right to limit coverage if patients aren’t doing what they need to do for treatment of their chronic ailments. But it shouldn’t be legal for you to pick and choose which diseases you use this approach for.

In fact, didn’t the Mental Health Parity and Addiction Equity Act of 2008 require insurers to have treatment limitations be no more restrictive for mental and addiction than for other illnesses?


Probuphine Update


About a month ago, the FDA accepted the re-submission of Probuphine, an implantable preparation of buprenorphine, for review. New Phase III studies apparently showed this form of buprenorphine to be “non-inferior” to existing products presently on the market.

As you may recall from my previous blog entry from May 21, 2013, Probuphine is an implantable form of buprenorphine that releases the medication over six months. The FDA rejected this form of buprenorphine in 2013 because the implanted rods impregnated with buprenorphine didn’t produce an adequate blood level of buprenorphine. The FDA also wanted more information about how physicians would be trained to implant the medication.

A double-blind, double-dummy phase 3 trial was completed in May of 2015 which apparently showed Probuphine did as well as the present sublingual buprenorphine products now available. I’ve searched the internet for this information but haven’t found the actual data. I’ve seen some information saying the Probuphine implant was compared to sublingual buprenorphine patients dosing at 8mg per day or less. If so, this would mean the company set the bar lower than the last study, when it was compared to patients on 16mg or less.

The process of Probuphine implantation may be cumbersome; doctors who wish to do this procedure must have a DATA 2000 waiver, and most of these doctors are not surgeons. Will general medicine doctor and psychiatrists presently prescribing buprenorphine want to learn this surgical procedure? I don’t know.

Unless the regulations are changed, if DATA 2000-waived physicians prefer to let surgeons implant the rods, we still must be physically present with the surgeon during both implantation, and explanation six months later. Will the patient’s insurance pay for the time and expertise of two doctors? I don’t see that happening.

What do I think about Probuphine? I think it’s an excellent method to reduce diversion. I think it would probably reduce opioid overdose deaths. However, I think it will make it more difficult to get patients to engage in the psychosocial counseling that’s so necessary for long-term change and recovery.

At present, the need to get new buprenorphine prescriptions keeps patients coming back to healthcare providers. We can, in a way, hold the prescription hostage until our patient engages in counseling. With an implantable form, we have no such leverage.

Probuphine could be an ideal treatment for incarcerated patients. If opioid-addicted patients are sent to jail, they could agree to have Probuphine implanted in order to reduce opioid craving and withdrawal symptoms. These patients would still need the psychosocial counseling for the treatment of addiction, but the Probuphine would be a humane comfort measure for these pateints.

If any of my readers have more information about Probuphine, please chime in.

And buprenorphine patients, what do you think about getting buprenorphine implanted every six months? Would this be something you’d be interested in, if it were covered by insurance?

Injecting Buprenorphine (Suboxone, Subutex)


I know why addicts inject buprenorphine (Subutex): they think it saves them money. Over the long run, however, I doubt that’s true, given the hidden costs of addiction.

Buprenorphine has a relatively low bioavailability, at around 30%, when taken sublingually (under the tongue). This means only 30% of the total dose reaches the blood stream. If the pH of the mouth is lowered, bioavailability is reduced even further. This is why we recommend patients on buprenorphine avoid eating or drinking anything acidic for about twenty minutes prior to taking their dose.

By definition, when a drug in injected, it has 100% bioavailability. Therefore, some people inject their prescribed buprenorphine in order to get the desired blood level with a lower dose of buprenorphine. If they are prescribed 8mg per day, perhaps they use 4mg intravenously and sell the rest of their dose, or stockpile it.

People who misuse buprenorphine in this way may be blinded by their addiction to the multiple dangers of injecting drugs.

Anytime humans inject drugs into their bodies that weren’t meant to be injected, problems will occur. All sorts of medical complications can arise, which can cause exorbitant medical bills for drug users…and tax payers.

Skin: These pills weren’t meant to be injected, so they are not sterile. Buprenorphine does come in a sterile ampule to be used intravenously in healthcare settings, but I doubt that form would be found on the street for sale. The sublingual pills and film have bacteria in them, and we all have bacteria on our skin. Inevitably, some bacteria “go along for the ride” when pill matter is injected. This can cause skin and soft tissue infection of varying severity. Patients who inject can get anything from a mild cellulitis, which is an infection of the skin and soft tissues underneath, to life-threatening sepsis, which is a blood infection from bacteria. Many patients get abscesses, which are localized pockets of pus which must be drained in order to resolve.

The worst skin infection is called necrotizing fasciitis, which is a rapidly progressive infection that kills tissue. It’s also known as “flesh eating” bacteria. Often, surgeons have to remove whole infected areas of this dead tissue in order to save the patient’s life.

Scars and track marks are probably the most common skin manifestation of intravenous drug use. These can be minimized by also using a new needle, and not re-using needles.

As an aside, please don’t try to treat your own skin infections by yourself. I’ve seen horrible complications when patients try to drain abscesses on their own. And that leftover antibiotic you have on the shelf at home may not be a good choice to treat skin infections, particularly not the newer resistant bacteria.

Cardiovascular system: The tablets aren’t pure buprenorphine. The manufacturer’s website lists corn starch as another main ingredient. I don’t know for sure what that does to veins, but I know I use it in the kitchen to thicken a concoction if it’s too liquid. I imagine it does the same thing to blood in the veins. Even if the addict uses something to filter what he is injecting, some particles can still get through to the veins. Risks can be minimized by using a micron filter.

Again, bacteria can cause problems in the cardiovascular system. Sepsis, an overwhelming blood infection, can lead to endocarditis. This is a serious and life-threatening infection of heart valves. If the infection destroys a heart valve, heart surgery with valve replacement may be necessary.

Thrombophlebitis is a condition where the veins become clotting and possibly infected, usually at the injection site but sometimes further “downstream” in the vein. If this occurs in the deep veins pieces can break off and go to the lungs, causing pulmonary emboli.

If a drug is accidently injected into an artery instead of a vein, catastrophic complications can occur, including loss of limb below the level of injection. The artery becomes damaged which causes inflammation and clotting. The patient usually feels intense pain and burning immediately after injecting. Some sources suggest this can be treated with elevation of the limb and blood thinners, so go to your local emergency room if this happens to you.

Pulmonary: Corn starch and other particles like talc can cause clots and inflammation, creating structures called granulomata. As more granulomata are created, oxygen exchange in the lungs becomes more difficult, causing low oxygen levels in the patient.

Pulmonary emboli are clots from the venous blood system that break off and travel to the pulmonary arteries. When these clots are large enough, they can kill rapidly. The patient may have sharp chest pain, feel short of breath, and have a fast heart rate with low blood pressure. Blood can’t travel through the lungs to get oxygen, and the patient dies from lack of oxygenated blood. Even small clots can cause serious problems, particularly if they are also infected with bacteria.

This list isn’t complete – many other medical problems occur with intravenous drug use. Of course the most common may be transmission of the Hepatitis C or B viruses if needle/syringes/injection works are shared, as well as HIV. There are weird things like endophthalmitis, and infection of the internal eye, and other medical problems too numerous to list.

Opioid addicts using intravenously can get addicted to the process of injection. The brain repeatedly associates the ritual of injection with a rush of pleasure, and so the whole act of injecting can be difficult to stop. I’ve had patients on methadone and buprenorphine who continue to inject saline with no drugs just to feel the rush from using a needle. This can be overcome with time and counseling, but some patients have enormous difficulty with this.

So if you are reading this and considering injecting your buprenorphine in order to save money, please don’t do it. You will likely end up paying much more in the long run, and I don’t necessarily mean in a financial sense.

Insomnia Medications for Patients in Medication-Assisted Treatment


In one of my recent blog entries, I talked about some simple measures that can help patients with insomnia, called sleep hygiene. Many times these methods can fix the problem, but other times, patients still can’t sleep well, which interferes with life. In these cases, medications may be of some help.

The “Z” medications
The “Z” group of medications includes zolpidem (Ambien), zaleplon (Sonata), and eszopiclone (Lunesta). These medications, which are not benzodiazepines, have been touted as being safer and less addictive than older benzodiazepines, like temazepam (Restoril), triazolam (Halcion) or clonazepam (Klonopin). However, the “Z” medications stimulate the same brain receptors as benzodiazepines, and are all Schedule IV controlled substances, just like benzodiazepines. This means they all have roughly the same potential to cause addiction, despite enthusiastic marketing by some drug companies.

I don’t prescribe the “Z” medications for patients on medication-assisted treatment with methadone or buprenorphine because they can cause overdose deaths in these patients. Also, these medications can give many patients with the disease of addiction the same impulse to misuse their medication. I’ve had patients develop problems with misuse and overuse of these medicines.

Many doctors, including me, have prescribed trazadone to help patients get and stay asleep. It’s an antidepressant, but daytime use has been limited due to drowsiness. In an effort to use this side effect for benefit, it’s often prescribed at bedtime to treat insomnia. But a recent study called this practice into question. In this study, trazadone was not found to be effective for methadone maintenance patients with insomnia. Test subjects were monitored with sleep study apparatus, and these subjects had no subjective or objective benefit from trazadone, either in initiating or staying asleep. [1]

Because trazadone can affect the QT interval, just like methadone, it’s possible these two drugs used together will dangerously prolong the QT interval. Also, both can cause sedation, also a concern. In view of this data, I have stopped recommending or prescribing it as an insomnia medication.

Quetiapine (Seroquel)
Quetiapine is in the group of medications known as atypical antipsychotics, and is indicated for the treatment of schizophrenia, the mania of bipolar disorder, and treatment-resistant depression. Because it is a sedating medication, many doctors prescribe it for treatment of insomnia, usually at low doses, around 25 to 100mg at bedtime.

Does it work? Two small studies, designed to see if the drug can help insomnia, showed conflicting results. One study showed significant improvement and the other showed no significant improvement.

Furthermore, this medication is not without side effects. At higher doses, used to treat bipolar disorder and schizophrenia, patients can develop diabetes and hyperlipidemia. But even at low doses, we see weight gain, restless legs, dizziness which can lead to night time falls, and dry mouth. There’s a risk, though likely small, of tardive dyskinesia with this drug. This is a serious movement disorder more commonly seen with the older antipsychotics like thorazine; patients on the atypical antipsychotics can also develop this potentially devastating disorder.

With little evidence to support its use, and potential serious side effects, I no longer initiate a prescription for quetiapine in a patient with insomnia. I do have some patients who’ve been started on this medication before they started seeing me. If they still feel it’s effective and I see no side effects, I’ll continue the medication. I make sure they get yearly lipid profiles done and recommend yearly screens for diabetes, and monitor for weight gain.

At addiction medicine conferences, I’ve heard doctors say that some of their patients misuse quetiapine. Personally, I think that must be unusual, and maybe these are patients in an experimental phase of addiction. I don’t see seasoned addicts using this medication to get high.

Ramelteon (Rozerem)
This medication, approved by the FDA for treatment of insomnia in 2005, isn’t addictive. It works by stimulating melatonin receptors and it helps patients get to sleep somewhat more effectively than placebo, but doesn’t help keep them asleep. Ramelteon doesn’t cause the rebound insomnia commonly seen after use of the “Z” medications, and has few clinically significant drug interactions. Last time I checked, it’s more expensive than many sleep medications, and many insurance companies demand a prior authorization before they’ll pay for it. I’ve had a few patients do well with this medication, so I like to prescribe it.

Once hoped to be the miracle treatment for insomnia, studies show that at best, melatonin is mildly more effective than placebo for the treatment of insomnia. Melatonin isn’t a prescription medication, and is sold by many manufacturers with little quality control. Since it is categorized as a dietary supplement, the FDA does not examine or approve these products. Since 2010, the FDA only requires that dietary supplements be made according to “good manufacturing practices,” and that companies make a consistent product, free of contamination, with accurate labeling. As I see it, that’s not much oversight and people take their chances with dietary supplements of any kind.

More commonly known as Benadryl, many over-the-counter sleep medications contain this sedating anti-histamine. It can cause sedation in patients taking methadone, and should be avoided or used with caution. I’ve seen one methadone overdose death I believed was due to the interaction with methadone and diphenhydramine, though the patient had taken more than one 50mg diphenhydramine pill.

Otherwise, the medication is mildly to moderately effect at helping people get to sleep. Don’t take more than 50mg, because higher doses can have a reverse effect, and interfere with sleep.

Hydroxyzine (Vistaril) is another potentially sedating anti-histamine that is felt by some doctors to be safer than diphenhydramine, but I can’t find any data to support that view.

Other medications
I occasionally prescribe clonidine if I think my patient is having a degree of opioid withdrawal as the cause of insomnia. I’m talking about patients who wish to taper, not patients on maintenance. If a patient on maintenance has insomnia from withdrawal, it’s best to increase the dose of the maintenance medication.

Clonidine can help insomnia from withdrawal. Because this is a blood pressure medication, it can drop night-time blood pressure when taken for sleep. This can cause a patient to fall if they get up during the night. I caution patients that if they must get up at night, stand beside their bed for a few minutes to make sure they don’t feel dizzy. I usually prescribe a .1mg pill and have them take only one pill.

Gabapentin (Neurontin)
This anti-seizure medication is used for a little bit of everything, so why not insomnia? Officially, gabapentin is approved by the FDA for treating seizures and for the pain of post-herpetic neuralgia (that’s the pain that stays after a shingles outbreak). But doctors use gabapentin for fibromyalgia, insomnia, migraine headaches, bipolar disorder, and probably other conditions. According to Medscape’s drug interaction checker, gabapentin has no interaction with methadone or buprenorphine, but Epocrates’ drug interaction checker says use with caution with these medications due to possible daytime sedation.

Muscle relaxers
Some patients take these medications at bedtime for their sedating effect, but I don’t think there’s any evidence these medications are particularly effective.

I include placebo as a reminder that about thirty percent of people will get benefit from a pill containing no medication. Our minds are powerful. (Parenthetically, I’m highly susceptible to suggestion. As a young adult, I got “drunk” on cider that I was told contained alcohol. I felt intoxicated, to the point of losing my balance and getting dizzy. But my friend had played a trick and there was no alcohol in this cider.) It’s difficult to know if a pill or potion for sleep works because it’s effective, or if it works because of the placebo effect. If you’ve found a medication that works, keep taking it, so long as it’s not doing any harm.

A recent study showed that adults who use sleeping pills are more than three times more likely to die prematurely compared to matched controls who didn’t use sleeping pills. This relatively large study looked at the medical records of over 10,000 patients who were prescribed hypnotics for sleep, and compared their outcomes to over 23,000 matched control patients, similar except the controls weren’t taking sleeping pills. The sleeping pills, also called “hypnotics” were associated with significant increases in mortality and significant increases in cancer incidence. [2]
The patients’ average age was 54, and they were followed for an average of 2.5 years. All were members of a large U.S. healthcare system in Pennsylvania. The data from the two groups were adjusted for age, gender, smoking status, prior cancer diagnoses, body mass index, ethnicity, and alcohol use.

Patients in the group taking prescribed hypnotics most frequently, defined as more than 132 doses per year, had over five times increased risk of dying than patients not taking hypnotics. Even the group of patients taking hypnotics relatively infrequently (up to 18 doses per year) had a three times higher risk of death. These differences were statistically significant. The medications in the study included all of the “Z” medications, as well as temazepam (Restoril), barbiturates, and the sedating antihistamines, such as diphenhydramine (Benadryl).

The author of this study estimated that hypnotic medications are associated with 320,000 to 507,000 deaths in the U.S. over the year 2010.
This study raises some important questions, since hypnotic drugs are the most commonly prescribed drugs in the U.S., with an estimated 6 to 10% of the population being prescribed these medications.

Sleep medicine doctors say that correlation doesn’t mean causation, and we shouldn’t jump to conclusions. One sleep specialist pointed out that the study didn’t control for psychiatric illness, which could be a significant factor. Additionally, patients who are prescribed sleeping medications may be sicker overall, in ways the study didn’t control, and therefore a generally less healthy group. This could distort study findings.

Other scientists say that sleeping pills could make sleep apnea worse, and cause deaths in that way. Obesity increases the risk of sleep apnea, and with more adults becoming obese, perhaps sleeping pills make apnea worse and these people die in their sleep. Other scientists say sleeping pills slow reflexes, and perhaps patients taking these medications are more likely to be involved in car accidents and other accidents, increasing their death rates.

As for my patients, many of whom are prescribed methadone or buprenorphine, the risk of drug interaction and overdose with the hypnotics usually outweighs all of the benefits, and I recommend that patients do not mix these two types of medications.

As a final bit of advice, I want to remind readers that other physical and mental health conditions can cause insomnia. It’s a good idea to see a primary care doctor to screen for these conditions, which can include sleep apnea, asthma, gastroesophagel reflux, hyperthyroidism, bipolar disorder, depression, and anxiety disorders. Sometimes patients need sleep studies to assess for sleep disorders.

1. Stein et al, “Trazadone for sleep disturbance during methadone maintenance: a double-blind, placebo-controlled trial,” Drug and Alcohol Depend., 2012, Jan 1;120(1-3):65-73
2. BMJ Open 2012;2:e000850 doi:10.1136/bmjopen-2012-000850

Inmate Dies From Withdrawal, FBI will investigate


An interesting article from this week’s issue of Alcoholism & Drug Abuse Weekly caught my eye today. On page 4 is the article, “Video of jail drug-withdrawal death leads to FBI inquiry.” This seized my attention, since I view the awful treatment of U.S. prisoners as one of our nation’s biggest moral failings. I get particularly agitated when patients enrolled in medication-assisted treatment for addiction are denied access to medical care.

This story is heart-wrenching.

In June of 2014, David Stojcevski , 32 years old, was jailed in the Macomb County, Michigan, jail for thirty days for failure to pay a traffic ticket. He was denied access to his usual medications; news sources said he was being prescribed methadone, Klonopin, and Xanax for the treatment of addiction. No mention was made of whether he was a patient of an opioid treatment program.

David died seventeen days into his thirty day sentence. His autopsy listed the cause of death as “Acute withdrawal from chronic benzodiazepine, methadone, and opiate medication,” and also mentioned seizures and dehydration as contributing factors.

A jail nurse, noting his medical condition upon intake to the jail, recommended he be sent to a medical detox unit, but her recommendations were not heeded. Instead, when Mr. Stojcevski began behaving in unusual ways, he was sent to a mental health cell, where he was monitored with video around the clock. He was supposed to have personnel checking on him every fifteen minutes. Apparently his withdrawal symptoms were so severe he declined meals and lost 50 pounds within these eleven days. He had what appear to be seizures as he lay on the jail floor dying.

Understandably, David’s family was livid. In order to illustrate the jail’s indifference to their son’s suffering, they posted all 240 hours of the video monitoring on the internet, where it went viral. David’s family is seeking to change the way prisoners on medications are treated, to avoid senseless deaths like David’s. They have also filed a wrongful death lawsuit against the county and against Correct Care Solutions, the company which was supposed to have provided medical care to prisoners in the county jail.

I have often heard my patients describe the callous indifference jailers have toward them as they withdrawal from legally prescribed medication, but it’s quite another thing to actually watch this man die slowly. I only saw a few clips from the local news program above, and was horrified. It does not take any medical knowledge to see how this man was suffering. He became thinner, wasn’t eating, and didn’t get off the jail floor for the last two days of his life. At the very end, he has some agonal respirations, what looks to me like seizure activity, and then becomes still.

Then jail personnel crowd into his cell.

Too little, too late. He’s already dead and can’t be revived.

Some of the frames were televised on the area’s local news segment and can be seen here: http://www.clickondetroit.com/news/man-jailed-for-ticket-dies-in-custody/35452790
Be warned this segment is not for the faint of heart.

This man died from a treatable condition, opioid and benzodiazepine withdrawal.

An addiction expert interviewed by the area’s local television statement called the treatment of this man “unconscionable.”

I could quibble about the appropriateness of prescribing two benzodiazepines to a person with addiction in the first place, but since that’s not the point of this blog post, that’s all I’ll say about that.

Just yesterday, local TV news said the ACLU had filed a request for a formal Justice Department investigation of the Macomb County jail, saying prisoners are having their civil rights violated by the actions at the jail. The ACLU has also asked for an investigation into the judge’s decision to imprison David after he was unable to pay his traffic ticket, creating what was in essence a “debtor’s prison.”

A representative of the ACLU said anyone watching the video could deduce there was “Something systemically wrong at the Macomb County Jail.”

Recently, the Justice Department in Washington, D.C. contacted the FBI, asking them to investigate this case for evidence of criminal behavior on the part of Macomb County jail staff.

Macomb County officials steadfastly maintain they did nothing wrong, have nothing to hide, and welcome investigations into David Stojcevski’s death.

What I saw on this video clip appears criminal to me. The neglect, the reckless disregard for the wellbeing of another human is a far more serious crime than David’s traffic ticket. Every person who worked in that jail who turned a blind eye to the dying man belongs on the other side of the bars.

I am grateful to David’s family for their decision to post this painful video. That had to be a hard decision, but David’s graphic suffering causes more impact than written descriptions. I wonder if the ACLU, Justice Department, and FBI would have gotten involved had his family not publicized David’s gradual death, and had it not gone viral.

This behavior on the part of law enforcement is stupid, inhumane, and egregious. Do these law enforcement personnel have no shame, no basic human decency? Are we in a third world country where prisoners have no rights?

I will follow this story and give updates when possible.

I’d love to see the FBI investigate, and I hope criminal charges are filed. I hope the family sues and wins millions of dollars. I hope something can finally change in county jails across the nation, so that people who are incarcerated are no longer denied medical care.


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