Local Walmart Rolls Back Buprenorphine Decision

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Great news! After my blog on Sunday, the pharmacy in the North Wilkesboro, NC Walmart decided to stock buprenorphine products again.

I am grateful to my faithful readers. I suspect some of you know people, or are people, with enough clout to get Walmart’s attention. I know the Alcoholism and Drug Abuse Weekly journal is planning a story about pharmacies refusing to stock buprenorphine, and talked with Walmart officials. Other readers contacted people they knew, and raised awareness about this issue.

All day yesterday I got email from people who were outraged about my local Walmart’s decision not to stock buprenorphine. By now, it’s clear that it was a regional decision and not a dictate from corporate Walmart.

The head of media relations called me yesterday afternoon, saying “the problem was fixed,” and that everything was fine. I wanted details, but she didn’t have any for me. I told her blog readers in other parts of the country said their local Walmarts were not stocking buprenorphine products. I feared she didn’t recognize the extent of the problem, but she kept saying the problem was fixed and she thanked me for bringing to Walmart’s attention.

I wanted to make sure, so I called my local Walmart again yesterday evening. I reached the pharmacist on duty, and asked him if it was true that Walmart was going to stock buprenorphine products again. He said yes, they had to, and that they had a “big long meeting today” about this issue. To make sure I understood, I asked, “So if I write a prescription for a buprenorphine product, and my patient brings it to Walmart pharmacy, will you fill it?”

“Yes,” he said. “Send him right over.”

This is the best possible outcome. I’m happy this issue is resolved, and I glad I won’t have to boycott Walmart (they have great pies).

However, I’m still curious about why the original decision was made not to stock the product, and why it was reversed.

I’m eager to see the article in Alcoholism and Drug Abuse Weekly.  http://www.alcoholismdrugabuseweekly.com/

Walmart in North Wilkesboro, NC, Refuses to Fill Buprenorphine Prescriptions

 

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When one of my patients told me he could no longer fill his prescription for Suboxone films at Wal-Mart, I was puzzled. Surely this couldn’t be true, especially not in an area of the country where people die from opioid use disorder too frequently.

My patient said, and I have no way of verifying this information, that the DEA visited  the Walmart in North Wilkesboro, NC, and told them if they continue filling prescriptions from the doctor at the pain clinic, they would be accused of some sort of collusion. In response, the Wal-Mart – allegedly – decided not to stock any form of buprenorphine.

Yes, my fingers itched to call Walmart to determine if this was true.

Completely in keeping with Walmart’s reputation for efficiency, I was cut off the first two times I asked to speak to a pharmacist. On my third try, I left my cell number and asked the pharmacist to call me. Surprisingly, he did call, after only fifteen minutes or so.

I asked him if it was true that Walmart no longer fills buprenorphine prescriptions, and he said yes, that’s true. I asked was that for all forms of buprenorphine, including the films, Zubsolv, generics, etc., and he said yes, all of them. He was obviously reticent to give any further information. I asked him if that was for one doctor, and if my patients could still fill prescriptions there. Again, he answered that Walmart had decided not to stock any buprenorphine  products for any patient or doctor. Starting to feel a little riled, I asked him if he thought that decision would interfere with appropriate treatment of a potentially fatal illness, he just repeated Walmart had decided not to stock buprenorphine at all.

So that’s that, right?

I don’t think so.

At a time when Congress passed CARA, the Comprehensive Addiction Recovery Act, which contained specific provisions to increase access to buprenorphine, Walmart’s pharmacy refuses to sell buprenorphine?

At a time when Health and Human Services passes a new law enabling physicians to have up to two-hundred and seventy-five patients instead of only one hundred patients, Walmart’s pharmacy refuses to sell buprenorphine?

During the same week that NIDA, the National Institute on Drug Abuse, announces increased access to buprenorphine will help the opioid overdose epidemic, Walmart’s pharmacy refuses to sell buprenorphine?

Can buprenorphine be misprescribed and misused? Yes, of course it can. Not as often as all other opioid pain medications, but it can be misused. But I don’t know of any pharmacy that refuses to stock all opioids just because some patients misuse them. That’s not appropriate. Walmart hasn’t stopped selling prescriptions for Opana, oxycodone, hydrocodone, Xanax, Valium, or clonazepam.

So can’t we – and by we, I mean the brain trust that is Walmart –  think of a better option than refusing to sell buprenorphine to any patient, rather than pinpointing the real problem?

I wanted to hear the reasoning behind this decision, so I called Walmart’s corporate office, the division of Media Relations. I told the nice lady answering the phone that I was a doctor who treated addiction, and that I also had a blog. I told her about the local Walmart pharmacy’s unusual decision, and I wanted to hear Walmart’s side. I wanted to know the reason Walmart decided not to stock buprenorphine in the middle of an opioid use disorder crisis.

I waited on hold for a long while, and then the lady, Delores, said she didn’t have any information on this but that she would look into this and call me back. I gave her my cell phone and I’m still waiting.  Since this was all done on a Friday afternoon, I’m not surprised I didn’t get a return call yet.

I’m going to make some noise about this one. I’ll keep you posted.

In the meantime, I’m not going to spend any money at Walmart. I know Walmart won’t miss the couple of hundred dollars my family spends each month on household items and some groceries. But if you see me at Food Lion, Lowe’s Foods, or even better, the IGA, you’ll see a smile on my face as I check out. My decision won’t break them, but it will make me feel better.

Access to Buprenorphine Will Expand; News About CARA

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Last week, the Department of Health and Human Services (HHS) announced it was raising the limit on the number of patients each doctor can treat for opioid use disorder with buprenorphine, from the present cap of 100 patients to 275 patients. However, each doctor must first meet criteria and complete an application procedure to be approved for this higher limit.

Initially, HHS wanted to increase the limit to 200 but for some reason ended up with 275. It’s still an arbitrary number, and opioid use disorder remains the only disease to have patient enrollment limits legislated for physicians.

HHS still wants physicians to meet extra requirements before they are approved to accept 275 patients, as I blogged about in my May 8, 2016 post:

  • Have professional coverage for after-hours emergencies.
  • Provide case management services
  • Use electronic medical records
  • Must use that practitioner’s state prescription monitoring program
  • Accept third-party insurance
  • Have a plan to address possible diversion of prescribed buprenorphine medication
  • Re-apply for permission to treat up to 275 patients every three years
  • Supply yearly reports about their practice and their buprenorphine patients

For some of the reasons I names in my May 8th blog, at this time I’m not planning to request permission to treat more than 100 patients.

This measure by HHS is a good and positive thing, and will help more desperate people get treatment. Just because I have a few objections to several HSS’s requirements doesn’t mean other doctors will feel the same way. I expect many physicians treating opioid use disorder will undergo the procedure to expand their patient limit.

 

Meanwhile, both the House of Representatives and the Senate passed the Comprehensive Addiction and Recovery Act (CARA) as of last week, and the bill is going before the President for his signature.

This bill, considered weak by some members of the House, contained only a fraction of the requested money to treat addiction. However, other advocates for addiction treatment say even a weak bill is better than none.

CARA’s content addresses the following:

Expand availability of naloxone to law enforcement and first responders, in order to quickly reverse opioid overdoses and prevent deaths. I think our own Project Lazarus helped get this ball rolling many years ago, and I’m so grateful my OTP has had support from them to give our patients naloxone kits!

Expand education and prevention efforts toward teens, parents, and aging people to prevent drug abuse and promote treatment and recovery.

Encourage states to improve their prescription monitoring systems. I hope some of that money will be directed to interoperability, meaning it will be easier to access a neighboring state’s prescription monitoring program. I also hope the Veteran’s administration will start reporting their data about prescribed controlled substances, too.

Prohibit the Department of Education from rejecting financial aid for people who have had past drug offences. I didn’t know people with drug offences on their record were denied governmental financial aid. If we want people to improve themselves and their life situations, why would we deny help for them? So this measure in CARA is great.

Expand resources to identify and treat incarcerated people with substance use disorders using evidence-based treatments.

Great idea, about forty years late.

Expand drug disposal sites to keep leftover meds out of the hands of children.

Just a question I’ve always had…Of all the tons of medication which have been collected at these disposal sites, has anyone ever studied how much controlled substances are collected?

Launch a “medication assisted treatment and intervention demonstration program.”

Not sure exactly what this will look like, but good luck with all of that.

I feel like I’ve beaten my head against the brick wall of prejudice and stigma against MAT in my community for four years. All I have is a headache…and resentment towards the medical community. I’d be very happy if someone else wants to take over for a while.

Launch a program to promote evidence-based treatment of opioid use disorder.

Well, yeah. it needs to happen. Actually it needed to happen about fifteen years ago, but whatever.

Director money towards law enforcement, to get people with substance use disorders help, rather than incarceration. CARA wants law enforcement to be able to work with addiction treatment services.

I indulged a private snicker at that last one. What a change from only a few years ago.

About six years ago, I was trying to educate people about medication-assisted treatment of opioid addiction. I thought I could help educate law enforcement personnel about addiction treatment, since they encounter it so much. I used the internet to find a journal for law enforcement.

I wrote to the editor, offering to write an educational article for their publication about opioid addiction treatment. My hopes weren’t especially high, but I wanted to give it a shot.

I was surprised when the journal’s editor took the time to call me in person. I was so excited!

Then the editor started talking to me like I was a naughty child. He asked what made me think it was appropriate to waste his time with such a query letter. He said I should have known better than to think any of his readers would be interested in the kind of thing I was offering to write, and he was calling to see what kind of person would be so unwise as to think otherwise.

I was stunned. I regret my reaction to him. I was so taken aback that I started apologizing to him, and said I was so sorry for bothering him and wasting his time.

In reality, he behaved like an asshole. If he didn’t want to waste time, he could have passed on the urge to call me to tell me how stupid he thought I was.

I wish I would have stuck up for myself in that conversation. I like to think I would handle it differently today.

Anyway, now, six years later, the government earmarked money to help law enforcement learn about opioid use disorder treatment.

While writing this article, I’ve come to realize I have bitterness towards people in law enforcement, medical fields, judicial, etc…when they denigrated my efforts to educate them about medication-assisted treatment for opioid use disorder.

I don’t want this bitterness. It’s too hard on me. It’s a weight that interferes with my enjoyment of life, and I’m going to release it.

The tide has begun to turn. We have legislation addressing the terrible opioid addiction problem we have, and money earmarked to help the problem. I want to be able to work with people who may have said bad things about medication-assisted treatment of opioid use disorders in the past. I want to work with those people without feeling resentment and without indulging in sarcasm.

Art Therapy as Treatment for Substance Use Disorders

 

Mural at our opioid treatment program

Mural at our opioid treatment program

 

 

 

We have a bunch of really creative people enrolled in our opioid addiction treatment program, skilled in arts of all kinds. We have an art therapy group, and I love looking at their creations.

As a special project, a group of patients made a beautiful mural on one wall of our facility, seen above. On the far left, scenery is dark and foreboding, with tombstones and other images of bleakness. Gradually there’s a transition as you look to the right. At the far right, the imagery is more cheerful, with pretty flowering trees and green grass. In the middle, signposts direct the viewer to the left, labeled “addiction,” and to the right, labelled “recovery.”

I started to wonder about whether art therapy was evidence-based, probably because I wanted it to be, because I like the idea of art therapy.

I found studies showing art therapy can decrease denial, reduce opposition to treatment, and give people with substance use disorders a means of communication. (Cox & Price, 1990, Allen et al, 1985, Moore, 1983) Some studies show that art can help lessen shame, and be an aid to group discussions for people with substance use disorders. (Johnson, 1990). Art can also help patients feel more motivated about making changes. (Holt & Kaiser, 2009, Matto et al, 2003)

So it appears there’s some evidence to show that art therapy can be of help to recovering people.

I have two posters framed in my office. They aren’t the usual inspiration posters of “teamwork” and “dream big,” etc. They don’t have any writing at all, and I picked them because they both inspired me personally. It’s interesting how patients interpret them

One is a print of a representational image of a colorful mountain, topped with praying hands, with a river appearing to flow from the mountain.

I’ve had numerous intriguing comments from patients about this print. Most just say “I like it.” Others say it reminds them that prayer can help them, or that prayer can create beautiful things.

I had one patient look at it for a long while, then back at me, and he said, “You’re a lesbian, aren’t you?” I had to laugh. I have no idea how he got that from my picture. When I told him no, I’m not a lesbian, he seemed disappointed. This illustrates how art can be interpreted differently by different people.

My other poster is a print of a painting that is so realistic that it looks like a photo. It shows a mountain goat in mid-leap between two narrow, snow covered peaks. A deep crevasse separates the two mountains. I’m intrigued by how differently patients react to that one. Many say that they like that one too, and I ask them, “Do you think he makes it?” meaning does the goat land safely? Most patients say something like, “I don’t know…” and others say, “No way. That goat falls.” And still others say, “Of course he does. He’s a mountain goat; that’s what he’s made for.”

Again, interesting perspectives from different people.

Do patients’ reactions to my art prints tell me anything useful for patient treatment? I don’t think it’s that easy. I’m tempted to assume the patient who says the mountain goat will fall is a pessimist, and the patient who says the goat will make it is an optimist, but I don’t know about that. For now, it’s just interesting.

Art is like that. It can help us understand the world in subtle, unique ways.

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Harm Reduction: Use Precautions

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I’m worried about the people in my community who have opioid use disorders. The rate of opioid overdoses appears to have risen, according to my local newspaper, along with the number of overdose deaths. I think it’s at least partly due to the arrival of heroin in our county. I think it’s time I re-posted some harm reduction suggestions for people who are using opioids.

The ultimate harm reduction measure is to get treatment and get into recovery, but if you aren’t ready for that, please be careful when you use drugs.

You can access all the following information, and more, at: http://harmreduction.org/drugs-and-drug-users/drug-tools/getting-off-right/

This is a link to a booklet about how to inject drugs more safely, downloadable for free, or available in hard copy for a small fee. It contains excellent information which could be life-saving.

  1. Don’t use alone. Use a buddy system, to have someone who can call 911 in case you stop breathing. Do the same for another addict. Obviously you shouldn’t inject at the same time. Stagger your injection times.

Many states now have Good Samaritan laws that protect the overdose victim and the person calling 911 for help, so that police don’t give criminal charges to people who do the right thing by calling for help for an overdose.
Take a class on how to give CPR so that you can revive a friend or acquaintance with an overdose while you wait on EMS to arrive.

  1. Get a naloxone kit. I’ve blogged these kits before, and they are becoming more available. So far, about seven or eight of my opioid treatment program patients have used their kits to save other people. The kits are easy to use and very effective. You can read more about these kits at the Project Lazarus website: http://projectlazarus.org/

Evzio is a commercially available kit, very easy to use, that gives verbal instructions about how to use the kit.

Some states, like North Carolina, now have third party prescribing, meaning if you have a loved one with opioid use disorder, you can request a naloxone kit prescription from your own doctor, to have on hand for your loved one with addiction.

  1. Use new equipment. Many pharmacies sell needles and syringes without asking questions. Other people with opioid use disorder probably can tell you which pharmacies are the most understanding.

    Don’t use a needle and syringe more than once. Repeated use dulls the needle’s point and causes more damage to the vein and surrounding tissue. Don’t try to re-sharpen on a matchbook – frequently this can cause burrs on the needle point which can cause even more tissue damage.

  2. Don’t share any equipment. Many people who wouldn’t think of sharing a needle still share cottons, cookers, or spoons, but hepatitis C and HIV can be transmitted by sharing any of this other equipment. If you have to share or re-use equipment, wash needle and syringe with cold water several times, then do the same again with bleach. Finally, wash out the bleach with cold water. This reduces the risk of transmitting HIV and Hepatitis C, but isn’t foolproof.
  3. Use a tester shot. Since heroin varies widely in its potency, use small amount of the drug to assess its potency. You can always use more, but once it’s been injected you can’t use less. The overdoses on heroin are thought to be due to fentanyl added to the heroin, making it more powerful and more dangerous.
  4. Use clean cotton to filter the drug. Use cotton from a Q-tip or cotton ball; cigarette filters are not as safe because they contain glass particles.
  5. Wash your hands thoroughly before preparing your shot, and clean the injection site with an alcohol wipe if possible. Don’t use lemon juice to help dissolve heroin, as it carries a contaminant that can cause a serous fungal infection.
  6. Opioid overdoses are much more likely to occur in a person who hasn’t used recently or has used less than usual for a few days, weeks, or longer. Overdose risks are much higher in people just getting out of jail and just getting out of a detox. Patients who have recently stopped using Suboxone or Subutex may be more likely to overdose if they resume their usual amount of IV opioids.
  7. Don’t mix drugs. Many opioid overdoses occur with combinations of opioids and alcohol or benzodiazepines, though overdose can certainly occur with opioids alone.
  8. Don’t inject an overdosed person with salt water, ice water, or a stimulant such as cocaine or crystal methamphetamine – these don’t work and may cause harm. Don’t put the person in an ice bath and don’t leave them alone. Call for help, and give mouth-to-mouth resuscitation if you can. And use naloxone if you have it.

To people who believe I’m giving addicts permission to use, I’d like to remind them that people using opioids don’t care if someone gives them permission or not. If they want to use, what other people think matters little. But giving people information about how to inject more safely may help keep them alive.

The Harm Reduction Coalition has excellent information on its website: http://harmreduction.org

In North Carolina, we are fortunate to have a robust Harm Reduction Coalition chapter. You can read more about their remarkable work at:   http://www.nchrc.org/

If you are a person who uses drugs and never plan to quit, your life has purpose and meaning. Use these safety tips to stay around for it.

I Get So Mad….

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A friend emailed me a video clip of former President Bill Clinton on a stage, talking with Senator Joe Manchin of West Virginia. This clip was from a talk given as part of the Clinton Global Initiative, and discussed the state’s present plague of opioid overdose deaths. West Virginia now surpasses all other states in per-capita deaths from opioids. (Yeah, they beat out Tennessee!)

Clinton talked first, about our nation’s situation with opioid addiction and overdose deaths. He emphasized that economically distressed small towns and rural areas were hardest hit. He also said the U.S. Senate recently voted to treat this like a public health problem instead of a criminal problem.

Then Senator Manchin starts to talk. At first, he admits that he used to be guilty, twenty years ago, of believing addiction as a crime and needed to be treated as such. He says that now, he knows it is an illness which needs treatment, and he doesn’t have enough treatment centers in his state for the large number of people who need treatment to get it.

So far, I’m with him.

He goes on to talk about a bill he’s introduced, called “Life Boat.” This is a proposed tax on every milligram of opioid produced and sold in the U.S., to create permanent funding for treatment centers around America.

Not a bad idea…

Then he talks about “Jessie’s Law,” named for the daughter of a friend who became addicted, got into recovery, had a sports injury, and was prescribed an opioid despite being in recovery. She had an antibiotic port for a bone infection, and she injected the OxyContin that was prescribed for her, and she died. Jessie’s Law says charts of addicts will be stamped with some sort of indication that the patient has a substance use disorder.

Uh, no. That’s a terrible idea, given the ignorance and stigma that medical professionals still have regarding addiction. Terrible idea.

At this point I see that Mr. Manchin probably doesn’t grasp the intricacies of addiction and its treatment.

Next, he says he’s pushing for legislation to help people convicted of non-violent crimes related to addiction to have their criminal records expunged. The expungement would be contingent on finishing one year of addiction treatment, and then another year spent working as a mentor to other addicts.

Then Senator Manchin said of addiction: “It’s an illness and it can be cured.”

He followed this statement by going down a verbal rabbit hole, describing the drug court of Judge Will Thompson. He described how wonderful this drug court was, and as an aside, said that this judge won’t accept the methadone clinics, despite the fact that, “The feds are pushing him hard.” Manchin said, “Suboxone, etc, he’s not for any of that. He says all you’re doing is extending this illness. It sustains the dependency.”

*SIGH*

Well, if it’s an illness, who better to cure it than a judge? I’m being sarcastic, of course.

Why do non-medical people agree addiction is an illness, and then think they know what works to treat it?

I now have a clue as to why West Virginia is number one in the nation in per-capita opioid overdose deaths…..

When Pigs Fly

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Last week, along with our opioid treatment program director and several others, I was invited to meet with the owner of the local detoxification facility. He wanted to see if we would be interested in referring patients to an intensive outpatient program designed specifically for people on medication-assisted treatment. One of the goals of this program would be to link patients with 12-step recovery.

At first I was skeptical. Yeah, right, I thought. When pigs fly…  Why the change of attitude? I’ve heard – from patients – that the facility he owns has discouraged our patients from getting the medication-assisted treatments that we provide. I had always assumed that this ingrained attitude of the staff came from the top.

He says that’s not so. He agreed that in the past, their emphasis has been on abstinence-based, twelve-step oriented recovery, but he’s not anti-medication. In fact, he says he’s tired of watching people die from addiction, and was trying to think of ways he could add services to help.

I felt surprised, pleased… and cautious.

As we talked, it appears we have the same underlying motivation to be in this business: to help people with addiction (substance use disorders) recover and lead happy, productive lives. We do have disagreements about the approach to treatment, but he was open to hearing facts about medication-assisted treatment.

He raised the biggest issue when he cautiously broached to topic of tapering patients off medication: “Am I correct in assuming at some point your goal is for patients to get off methadone? I was curious about the timeframe.”

“No. Our goal is not necessarily to taper people off medication. Studies show that the people who do the best are the ones who stay on medication the longest.” I was intentionally blunt to gauge his reaction.

He stared at me and looked like he’d swallowed a fishbone. I was quiet too, thinking how I probably had the same expression the first time I heard patients should not necessarily be tapered off medication.

That thought made me laugh, and I said, “I know! It’s not what you want to hear. It’s not what I wanted to hear, and it’s not what my patients want to hear. Most of them, due to the time and money they spend, and the stigma they endure, want to be off medication at some point. But that’s what the science shows!”

I continued, “But that doesn’t mean we never help patients taper off medication. We do. But we are careful to explain the risks and the benefits, work with them to discuss issues that could cause a relapse, and let them decide when they are ready. And it often takes time to do the work of recovery.”

“In other words, it’s a complex issue, and each patient has to be treated as an individual. What’s right for one patient isn’t right for another.”

Of course, I didn’t say all of this as eloquently as I’m writing it, but he understood what I meant nonetheless.

We continued to discuss how our two facilities could collaborate to provide better patient care, and I was excited by the possibilities. I think he was surprised at my positive feelings towards twelve-step recovery. Perhaps he assumed that since I’m an advocate of medication-assisted treatment, I was opposed to 12-step recovery. Nothing could be farther from the truth.

I’m a believer in 12-step recovery because I’ve seen it work, just like I’m a believer in medication-assisted treatment because I’ve seen it work. There’s also data to support both forms of treatment. There’s much more data to support medication-assisted treatment, but to be fair, 12-step recovery is more difficult to research, for obvious reasons.

Leaders of our opioid treatment program had a second meeting last week with the staff of that program, and this time I got to meet and talk with their doctor. He’s had experience treating addiction, and is not opposed to medication-assisted treatment at all. His attitude seemed much like mine: whatever works. We chatted about the benefits and pitfalls of various approaches to treatment of substance use disorders, and I sensed we could work well together.

I left the meeting feeling like we could develop an alliance with this program that could be deeply beneficial to all patients being treated. No doubt we will have wrinkles to work out, and we don’t know the details of their intensive outpatient program. But if, as he said, it is supportive of medication-assisted treatment, I think it will help.

I don’t know what attitude members of local 12-step recovery meetings will have toward patients on methadone and buprenorphine. If they aren’t accepting, the efforts made to connect them to 12-step recovery may not work. If that’s the case, I hope we can get a core group of patients with strong recovery start an MA meeting. That’s Methadone Anonymous; that name may have been changed to Medication Anonymous. MA is a 12-step fellowship set up for people on buprenorphine or methadone, though you don’t have to be on either medication to attend. Anyone seeking recovery from addiction is welcome.

One form of treatment will never be right for everyone. Let’s be happy there are different treatments, stop bashing one approach in favor of another, and start doing what works.

I never could have imagined being able to work with the staff of the local detox. If this program is successful, you can call me a believer in porcine aviation!

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