Case Study of an Opioid-addicted Patient: New England Journal of Medicine

A doctor friend of mine sent me an article from the New England Journal of Medicine from November 13. 2014. I subscribe to the NEJM, but somehow overlooked this article, so I’m happy he brought it to my attention. My friend reads my blog and knows I have lamented how I was taught in my Internal Medicine residency to treat endocarditis (potentially life-threatening infection of a heart valve), but not the underlying cause, which was addiction (read in my blog post of December 7, 2014).

The journal article he sent me is a case study of a young woman with endocarditis from intravenous drug use. The case study begins in the usual way, describing her history and physical findings. Nothing was uncommon here: the patient told them she was a drug user, and she had track marks, fever, and a heart murmur. The history and physical findings screamed, “Endocarditis! “ A chest x-ray and then chest CT scan showed multiple septic emboli, commonly seen with endocarditis, sealing the diagnosis.

But this case wasn’t only about the diagnosis and standard treatment with antibiotics. To my delight, the first sentence describing the case management was “Methadone was administered orally.”

Huzzah!

But as it turned out, the patient was only put on a methadone taper while hospitalized. She was started on a protracted course of antibiotics and sent to an extended-care facility, where she quickly relapsed. This relapse illustrated the second point of the article: medication-assisted therapy must be continued to be effective.

As the case discussion points out, “As with other medications for chronic diseases, the benefits, at least in the short term, last only while the patient is taking the medication.” In other words, her relapse was predictable, and not due to failure on the part of the patient. The relapse happened because of failure to continue the medication by the doctor.

A little later in the case study I read these wonderful sentences: “Although making a diagnosis of endocarditis is a crucial first step (emphasis mine), understanding the root cause of the endocarditis is a key feature in the diagnosis and management of this patient’s illness. Endocarditis is only a symptom of her primary illness, which is an opioid-use disorder.”

I loved this case presentation for two reasons: it emphasized treating the entire patient, including the underlying disease of addiction, and it pointed out that short-term medication with methadone or buprenorphine doesn’t work, just like temporary treatments for other chronic diseases don’t cure anything.

This patient developed endocarditis again after her relapse, and needed a second hospitalization. This time, she left the hospital on buprenorphine maintenance. She relapsed again after two months, had a third episode of endocarditis, this time due to a fungus, and required a third hospitalization.

After that treatment was over, she was maintained on buprenorphine. At the end of the article, the authors reported that the patient had over a year of abstinence from drug addiction, was taking buprenorphine, and going to AA and NA regularly.

In the discussion of appropriate treatment of both the endocarditis and the opioid addiction, I read this delightful sentence::The opioid agonists methadone and buprenorphine are among the most effective treatments for opioid-use disorder.”

Can I get an “Amen!”?

The same paragraph goes on to describe the benefits seen with MAT, which include decreased opioid use and drug-related hospitalizations, and improved health, quality of life, and social functioning. This article also clearly states MAT will reduce the risk of opioid overdose and death. Many references are cited at the end of the article for non-believers in MAT.

This article also included recommendations about educating patients about overdose risk, and providing them with naloxone.

At the end of the article, the patient who was the subject of this case study discussed her perspectives regarding her treatment. She related how each time in the past, she was treated for whatever medical problem she had, and then sent on her way, with little effort to treat her addiction. She says she’s grateful for the second episode of endocarditis, because she met the doctor who treated the addiction and gave her hope that she had a treatable disease. Prior to that, she doubted she could stop her active addiction, because she saw herself as a bad person, not as a sick person.

This article ends with this patient’s words: “To be honest, I never thought I would be standing here, clean for over a year. I thought that I was going to die.” That effectually describes the hopelessness of patients in active addiction.

I hope such endorsement of medication-assisted treatment of opioid addiction by the prestigious New England Journal of Medicine will help convince more doctors of the legitimacy of MAT.

During my training in the 1980’s, I didn’t learn how to treat the underlying cause of the endocarditis. I am delighted and encouraged to find the New England Journal of Medicine has published an article that does just that. This article clearly and overtly states the importance of treating the real problem, not just symptoms of the problem. Today’s doctors have a valuable opportunity to change the lives of many of their future patients.

Goblins of Addiction

Time for some whimsy…

Misery and Deceit, two goblins who worked for the Emperor of Wretchedness, were talking in a dark alley. Hopeless, another goblin, had just left them and was shuffling down the street, trailing the stench of sulfur.

“Idiot,” said Misery, speaking about Hopeless. “He couldn’t stop his human from getting help for addiction. What an incompetent. Doesn’t he realize that addiction must continue so we can make these humans miserable? Addiction is a key method to keep people in our Kingdom of Wretchedness”

The other goblin, Deceit, fancied himself a guru to the younger and less experienced dark spirits like Misery, Despair, and Hopeless. He smiled as he thought about how much wiser he was than the others. After all, he had been the original dark spirit to help lead most humans to addiction. He promised these humans that drugs would allow them feel good all of the time. He promised freedom from the usual ups and downs of a normal human life. Many times, they believed him.

“Well, now, Misery, when you’ve been around as long as I have…” Deceit started.

“Yeah yeah. Whatever. But what advice can we give the poor fellow?” Misery really didn’t feel like listening to the bombastic Deceit blather on again, and cut him off with a question.

“There are things to be done. After all, his human, Joe, entered treatment at a methadone clinic. As you know, in his part of the country, many people have bad opinions about that kind of treatment. Especially if they know nothing about it.” Deceit began laughing, but the laugh ended with a phlegm-producing cough. Ironically, Deceit was strongly addicted to cigarettes, though he kept saying he could quit when he wanted.

“I’ll call on poor Hopeless, and give him some advice. That would be gracious of me.” Deceit said. In his mind, Deceit finished the sentence with, “And he would owe me a big favor.” The dark spirits kept careful tallies of who owed a favor to whom, and often fought bitterly about this.

“All right, great. I’ve gotta go.” Misery was sick of this conversation, and wanted to get away. Misery was never happy with where he was, and always wanted to be somewhere else, which made it difficult to have a conversation with him.

Later that week, Deceit knocked on Hopeless’s door. It was smudged with some dirty substance. Hopeless believed cleaning house was hopeless, as it only got dirty again. Deceit’s knuckles were black with the stuff. As he was wiping the filth off his hand, Hopeless answered the door. It looked as if he’d been crying, as his eyes were red and there was mucus sliding from his nose. “Hello Deceit. Come on it. I’ve been feeling down this week after my failure with my human, Joe. Sometimes I feel like I’ll never get anything right. And of course I’ll be blamed for it all.” Hopeless sighed dramatically as he said this last part, feeling very sorry for himself.

“I’ve come to help you. I have much sound advice to give you, so let’s sit and talk for a while.”

“OK. But I doubt it will work.”

Deceit ground his teeth at Hopeless’s predictable self-pity. Of all the dark spirits, Deceit thought Hopeless was the least pleasant to be around.

“It will work,” Deceit said more emphatically than he felt. “The key is to use the people around your human to discourage him in his recovery.”

“For example, Joe’s wife is happy that Joe is no longer spending $100 a day for pain pills off the street, and she’s happy he’s no longer snorting them. But she won’t be happy if you can convince her that methadone is a dangerous drug. Suggest she look on the internet. She’s sure to find negative and untrue information. But keep her off legitimate websites. You don’t want her to learn any of the benefits of methadone. Keep her on the more emotional sites, where people write about their beliefs, and not actual facts. And be careful she doesn’t understand the distinction between methadone bought on the street and methadone dosed each day as prescribed by a doctor. Try to get her to hysterically demand of Joe that he “get off that stuff.”

“Or you can use his friends. Have them call him a weakling for wanting to quit drugs, and
how foolish he is to go to the clinic. Tell him that the clinic only wants his money. Be careful not to remind Joe that all medical treatments cost money. Convince him his addiction treatment should be free. After all, he is giving up drugs. Maybe you can even get him to thinking people should pay him to give up his drugs.”

Hopeless began to mewl about the impossibility of such things, but Deceit cut him off again.

“You can get an addict to believe all kinds of outrageous nonsense. Oh, and keep him from remembering that some of these same so-called friends have sold him pain pills. We don’t want Joe to perceive that these people want to keep a good customer.”

“Get him to go to a family doctor who’s uneducated about methadone treatment. Even if he’s seen for an unrelated medical problem, these docs sometimes will give deadly advice to such patients. Some of these doctors tell their patients to get off methadone as soon as possible.”

“What, his doctor wants him dead? Surely not.”

“Oh no, but many of them aren’t well-educated about the treatment of addiction. So if you can get Joe in with one of these doctors, we have the delight of watching a medical professional, who should know better, give bad advice to one of our humans. If Joe follows that advice, it will be easier for us to steer him back into addiction again. And then if Joe relapses, and tells his doctor about it, the doc is likely to shame him for relapsing. You see how funny it gets to be? He wouldn’t have relapsed but for the doctor’s bad advice….” Deceit trailed off, smiling at fond memories of previously amusing times.

“I don’t know. Joe doesn’t seem to be listening to me, or his old friends. He used to be easy to lead with a suggestion or two. Now he wants to stand up for himself. He says he feels good and isn’t using drugs for the first time in years. It feels hopeless to try to convince him he’s doing a bad thing.” Hopeless shook his head and squinted at the floor.

Again, Deceit felt a great surge of annoyance at Hopeless’s attitude. “Then you must undermine his confidence. Have you had no training in that sort of interference? Tell lies, and plenty of them, before he gains even more confidence. His mind must be turned against him. I’ll get one of my friends to come and help you. His name is Denial, and he’s an expert at convincing such humans that their lives in addiction really weren’t that bad. How about I send him over here later today so you two can make a plan?”

“You can send your friend Denial, but I doubt there’s much that can be done…”

Shortly after this somewhat unsatisfying end of their conversation, Deceit waddled home. (He was very fat, having fed on the misery of humans for millennia). He knew this was not a hopeless situation, because he’d seen many recovering addicts, patients of methadone clinics, who had been shamed into stopping their treatment. It was entertaining to watch a person, leading a normal life but for dosing each day with methadone, slide back down into the darkness of active addiction once he left treatment. Quite often, goblins of the underworld used the twisted fears and inaccurate beliefs of the people who said they loved the addict to aid in the addict’s downfall.

Entertainment in the underworld didn’t get any better than this!

(…inspired by The Screwtape Letters by C.S. Lewis)

“We will not regret, nor wish to shut the door on it.”

This was a tough blog to write. I want to thread the needle; I want to relate some solid help from 12-step recovery sources without angering some of my faithful readers who become angry with any mention of 12 step recovery, and don’t feel they help people with opioid addiction.

So you’ve been warned.

I know 12-step recovery isn’t for everyone. Some people tell of bad experiences with 12-step groups. And I know millions of people have been helped by these groups, too. So take what you like from this blog entry, leave the rest, and if you read something helpful, I’ll be happy. If not, try again next week because my topics fluctuate.

I talk to many recovering addicts who voice regrets about their past. The stories vary; the patients’ main theme is regret for behavior during active addiction. I understand those feelings, and feel tempted to tell patients how to deal with these feelings… but I don’t say anything, for fear that I’ll sound too “preachy.” Who am I to tell someone that they can examine past regrets, learn from previous mistakes, make amends when needed, and face the future with a clean slate? Isn’t that a conversation for a priest, imam, rabbi, or pastor?

Yes, it is. And yet, this person is in my office. Many times my patients tell me they feel unworthy to join or rejoin a religious community, and feel judged by such groups. Some of my patients’ perceptions could be colored by their own shame, but I fear many of them are accurate in their perceptions. Addiction is still regarded as a sin by some religious groups. Other groups do know addiction isn’t a sin but a disease, which can cause us to do and say things we regret, which are contrary to our values

Twelve step groups like Alcoholics Anonymous and Narcotics Anonymous have mechanisms for dealing with past regrets and ruptured relationships. These groups didn’t invent anything new. They use the same approach as other spiritual and religious groups, which are also sound psychological advice. However, the twelve steps provide a handy framework for handling regrets.

First, in Step 4, the recovering person assesses past behavior, called a “moral inventory” in recovery parlance. That inventory is shared with themselves (ending denial), another trusted person, and the god of their understanding. Patterns of behavior emerge, giving information to be used in steps 6 and 7, where the person becomes willing to give up old behavior and ask the god of their understanding for help with this.

In step 8, the recovering person lists the people he has harmed while in active addiction. With the aid of a sponsor or trusted spiritual advisor, in Step 9 the recovering person makes plans for how best to make up for past behavior.

Amends can be as simple as saying, “I’m sorry,” to someone for past bad behavior, or amends can be more extended, like resolving to be fully emotionally present for loved ones.

Sometimes direct amends aren’t possible, if the person has moved away, died, or unable to be located. A more general amends can be made instead. For example, if a person shoplifted to support their addiction, it may be impossible to remember where and what was stolen. Part of the amends process is not to repeat the old behavior, but a more general amends may involve volunteering in the same community to help society in some way, like donating to a food bank or giving time to help a child in need.

If the recovering person feels guilty about stealing money, amends may include apologizing for the past behavior, and making a plan of re-payment. For example, I know a person in recovery now for over 16 years who sends a check for $25 each month to a governmental agency to whom he owned money after a criminal conviction. He may never get the full amount paid off, but he’s taking action to fix what he broke.

Recovering people can move forward by planning amends for past actions, but also should consult a sponsor or spiritual guide for help. For example, if an addict stole money from a drug dealer, it should not be paid back, especially if it puts the recovering addict at risk. In some situations, the best amends may mean having no contact with the other person.

Some recovering addicts have long lists of bad behavior to make amends for, and other recovering addicts’ lists may contain only a few people. Many addicts harmed only their immediate family, by not being completely emotionally available to their spouses or children during their addiction. Some recovering people feel just as bad about that as others feel about committing armed robbery for drug money.

Addiction taught harsh lessons at an exorbitant price, so we should learn from past mistakes.

The point of amends isn’t how bad the behavior was, but how the recovering person feels, and how he can leave behind guilt and shame and move forward.

Addiction, like some other diseases, affects behavior. Rather than living with regrets, recovery means facing regrets, learning from them, fixing what we can, and then moving on. It doesn’t matter what you call it: making amends, cleaning your side of the street, getting right with the god of your understanding, or some other term.

Opioid Use in Females of Child-bearing Age

Some obstetricians blame methadone clinics and buprenorphine providers for the high rate of opioid addiction they see in their pregnant population. OBs often seem angry that pregnant addicts are on methadone or buprenorphine.

This isn’t logical. Addiction medicine doctors are responding to the need for treatment in this population. We didn’t cause the opioid addiction problem; by the time pregnant opioid addicts see us, opioid addiction has been well-established. Addiction medicine doctors aren’t out combing the countryside, luring women of child-bearing years into our programs, trying to get them addicted to opioids. However, once opioid addiction is established, several decades of studies prove that medication-assisted treatment with methadone and buprenorphine produces the best results for both mother and child.

Now recent report from the Center for Disease Control (CDC) gives us a clue why so many pregnant women are addicted to opioids. The CDC’s January 23, 2015 issue of Morbidity and Mortality Weekly Report (better known as the MMWR) described a report on the frequency of opioid prescriptions in the U.S. for women of child-bearing years, aged 15 to 44:

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6402a1.htm?s_cid=mm6402a1_w#tab

This data was collected each calendar year from 2008 through 2012 by a private firm with access to a massive database with information on over 5 million insured females aged 15 to 44.

The data revealed the percentage of women who filled at least one outpatient opioid prescription per year, and was further examined by region of the U.S., by type of insurance, by specific age groups, ethnicity, and by type of opioid prescribed. The data was collected not on pregnant women, but on women likely to become pregnant.

Averaging the four years of data, twenty-eight percent of the women with private insurance filled at least once opioid prescription per year, and thirty-nine percent of women with Medicaid filled at least one opioid prescription. On a slight positive note, the rates of opioid prescriptions hit a high mark in 2009, when twenty-nine percent of women with private insurance filled at least one opioid and a whopping forty-one percent of women covered by Medicaid filled at least one opioid prescription.

Granted, one prescription per year won’t cause an opioid addiction. But the study also looked at the average number of prescriptions per year in the women who did have at least one opioid prescription, and found women with private insurance averaged nearly three opioid prescriptions per year, and women with Medicaid averaged four and a half prescriptions per year. That’s not unexpected; Medicaid covered people tend to be sicker, with worse physical and mental health. Still, increased exposure to opioids correlates with increased rate of addiction to opioids.

In other words…U.S. doctors are prescribing a hell of a lot of opioids to women who can become pregnant.

Of the thirteen most commonly prescribed opioids to this age group, hydrocodone was the most commonly prescribed opioid for both privately insured and Medicaid insured women. Hydrocodone was prescribed to 17% of the privately insured women of child-bearing years, compared to 25% of Medicaid insured women. Next most common were codeine, oxycodone, tramadol, propoxyphene (taken off the market in 2010), hydromorphone (Dilaudid), meperidine (Demerol), morphine, and in ninth place was buprenorphine. Then came fentanyl, tapentadol, dihydrocodeine, and in last place was methadone, prescribed to one tenth of a percent of women of child-bearing years.

Keep in mind this last data point probably didn’t include methadone prescribed through opioid treatment programs, since Medicaid isn’t accepted as payment at many OTPs, and private insurance usually won’t pay for care at OTPs either. (In fact, this data likely underestimates the number of women prescribed opioids, since women with no insurance weren’t counted in the study.)

Prescribing rates were compared by the region of the U.S. The South has the highest rate of prescriptions for opioids in women of child-bearing years. Averaging all four years studied, the South prescribed opioids to 32% of women in this age group. The Northeast had the lowest rate, at 22%. The Northcentral and the West came in between, at 25% and 27% respectively.

This data mirrors what we’ve seen from other studies of regional prescribing rates for controlled substances (see my blog entry from August 25, 2014). I have my own opinions about why the rates are so different but for once I’m going to keep them to myself, lest I (again) anger my colleagues.

When separated by race, a much higher percentage of white women filled at least one opioid prescription per year, at 46%. This compares to 35% of black women and 34% of Hispanic women.

That’s dismaying, but is in line with previous studies that show black patients get prescribed opioid pain medications at a much lower rate than white patients with the same pain complaint when seen in emergency departments. One would assume this is due to racial bias, but there could be other reasons. For example, maybe whites demand opioid pain medication at a much higher rate than blacks. Obviously, we need more data to find out why we have such racial differences. In this case, being black could be a protective factor against developing iatrogenic (physician-caused) addiction, but is it at the cost of inadequate pain control? I don’t know.

When the data was examined by more narrowly defined age ranges, for women with private insurance, the highest percentage of prescribing was seen in the 30 to 34 age range, at 31%. For Medicaid-insured women, it was highest in the 40-44 age group, showing more than half of these women got at least one prescription for opioids per year.

This makes sense. The longer one is alive, the more medical issues one accumulates, perhaps needing pain control.

Here’s the bottom line: My interpretation of this study is that U.S. doctors, especially in the South, are prescribing too many pain pills to everyone, including to women who could become pregnant.

Around fifty percent of pregnancies in the U.S. are unplanned. With this many women getting pregnant without planning to do so, every doctor prescribing opioids needs to explain the risks of opioids during pregnancy. This includes opioid treatment program doctors like me.

Don’t blame the women. They don’t want to be addicted. In fact, no person with opioid addiction wanted or expected they would become addicted, even if they took their first opioid solely for the good feeling it produced. No one thinks they will become a hostage to opioids, especially if they are being prescribed these medications. How could patients know, when even doctors are poorly informed about the risk of developing opioid addiction?

Pregnant women with opioid addiction are not bad women, recklessly taking drugs and endangering their children. Most did not expect or plan to end up in this situation. These moms want to stop using, but the nature of opioid addiction shows that is a very difficult thing to do, and actually dangerous to try during pregnancy. Outcomes for both mom and baby have been proven to be best when the pregnant mom gets into treatment, on maintenance medications of methadone or buprenorphine.

Addiction Fiction: “All Fall Down” by Jennifer Weiner

Sometimes the greatest facts can be transmitted by fictional stories.

My bookshelves at home are groaning under the weight of all sorts of written material about addiction. I have textbooks, journals, and SAMHSA publications about addiction and treatment. I also have numerous autobiographical memoirs written by people with addiction issues, which seems to be a whole new exploding genre, with more books coming out each month. I’ve read The End of My Addiction; More, Now, Again: A Memoir of Addiction; Pill Head; Rolling Away; Drinking: A Love Story; Dry: A Memoir; Beautiful Boy: A Father’s Journey Through His Son’s Addiction; Tweak; Leaving Jersey Dirty; Broken: My Story of Addiction and Redemption; Lit: A Memoir; Parched: A Memoir; Hit Hard; The Adderall Diaries; Junky; and probably many others that don’t come to mind at present.

But I can’t think of any fiction I’ve read about addiction, probably because I tend towards non-fiction in my reading life. So this new book I recently read was unusual for me, and I enjoyed it. I also found many truths contained within the fictional story.

In this novel, All Fall Down,” the protagonist, Allison, narrates the arc of addiction from occasional pain pill use to compulsive and uncontrolled use, and then through the bad consequences that follow. The book gives a fresh and accurate account of the protagonist’s stay in an inpatient rehab, and ends by describing her life in early recovery.

I am particularly impressed by the way the author describes the thoughts of Allison, the protagonist. The author has great insight into the mind of someone in active addiction. Allison lies to herself about how many she takes, about the reasons she takes the pills, and that she functions better with the pills than without. I found the author’s description of Allison’s thought process and self-deception to be accurate and believable. I hear the same self-deceptions in my work. Allison tells herself she deserves a few extra pain pills because she’s under emotional stress dealing with a difficult family situation. She tells herself everyone uses something to get through the day. She resolves again and again to cut back on her pill use, and then has moments of clarity when she realizes she’s using more than ever.

When Allison has these moments of clarity, the author accurately describes her confusion and self- blame. Allison realizes she’s doing things that are against her personal beliefs, resolves to stop, and yet can’t. The author truthfully describes the self-reproach and shame an addict feels when she can’t control her drug use.

Eventually, she admits she needs help, but still has to be forced into treatment by her family.

Buprenorphine makes a brief appearance, and I’m not too happy about how it was portrayed. In desperation because her pill stash was gone, Allison goes to an urgent care to get a prescription for pain pills, so a made-up reason. She surprises herself by being honest to the doctor about how much oxycodone she’s using. Even more surprising, the doctor is knowledgeable about opioid addiction and prescribes Suboxone. But in the book, the doctor doesn’t set her up in an addiction treatment program. Then Allison goes into precipitated opioid withdrawal after she takes the Suboxone, and has to go to the hospital. The hospital talks to her family and Allison is eventually admitted to an abstinence-only treatment center called Meadowcrest.

Meadowcrest gets harsh treatment from the author, but the details are amusingly accurate. Allison is dismayed that most of the treatment center staff have few counseling credentials, other than being past graduates of the treatment center themselves. She also illustrates the petty meanness some people are capable of when given power over other people. She describes Michelle, an overweight recovering addict who delights in thwarting Allison’s plans to use the phone or go to her daughter’s birthday party. She describes how some of the treatment center staff talk down to patients they are supposed to be helping, by calling them selfish and lazy.

This author does such a great job of describing all of the facets of early addiction and treatment that I can’t help but think she must either have personal experience or has a close friend or family member who went through opioid addiction and recovery.

I appreciate the honesty of the Allison character. She thinks the slogans of 12-step recovery are dumb and trite, and that she’s different from all the other patients because she never injected opioids or was homeless. She feels out of place around patients who have obviously gone much farther down in their addiction. She resents the twelve step program and finds some of the steps to be shaming. She has a difficult time with the idea of a higher power.

Then gradually, as Allison slowly starts bonding with other patients, she acknowledges she has the same feelings as they do, underneath the addiction circumstances. She comes to see that when she was stopped from driving by a teacher at her daughter’s school when she was impaired, that was her bottom. For other people, stealing or prostitution constituted the low of their addiction, but the feelings of shame and self-reproach were the same.

Allison starts to focus on her similarities to other addicts, rather than her differences. She starts to feel empathy for other addicts and wants to help them recover. Her own healing begins.

By the end of the book, Allison is going to 12-step meetings and she feels connected to the other people there. She sees that the slogans do have value, even though she finds them trite. She still struggles with any concept of a Higher Power, and is honest about that. She often doesn’t want to go to meetings but still goes, if only to see how the other addicts are doing. She develops a focus outside of herself, and begins to do things that are helpful for her and her recovery. Her marriage may be over, but she’s able to tolerate not knowing what will happen, allowing things to play out on their own.

This book will resonate with all people who have addiction, but especially with the relatively well-to-do opioid addicts who didn’t experience the low-bottom consequences of jails and institutions. I think the author accurately described the inner experience of the opioid addict. She certainly illustrated the failings of the Meadowcrests of the world while still showing how they can help people.

After I read the book and wrote this blog entry, I went to Amazon and read the book’s reviews. The people who liked it and gave the book five stars seemed to be either life-long fans of the author, Jennifer Weiner, or to have had some previous encounter with addiction. The readers who didn’t like it, and gave it one star, said the book was boring and depressing, or that it wasn’t like the author’s other books and they were disappointed. A few of the one-star readers said they were in recovery themselves, or worked in a treatment center, and they didn’t feel the book gave a realistic portrayal of addiction.

It’s always fascinating to me how two people can read the same book and come away with such opposite views.

I recommend this book for people with opioid addiction, in recovery or out, and for those who love them. It’s a great book for anyone who has been puzzled by the weird behavior of the addicts in the world.

I’d like to see more addiction fiction like this…

The Broken System

I’m feeling discouraged this week, due to a recent vivid display of my state’s broken mental health/substance abuse treatment system.

Details of this encounter have been changed to protect identities.

One of our former opioid treatment program patients returned to us, asking to be admitted again to methadone maintenance. In previous admissions, this patient struggled with repeated bouts of benzodiazepine addiction and had several near overdoses. He also had months at a time when he did relatively well, with little benzo use. I felt we were helping him – to some degree – until late last summer, when his condition worsened after his son died from an overdose. He was distraught and using all types of drugs in order to push away the pain of his loss. I became worried he would die of an overdose if we didn’t do something different. We really wanted him to go to inpatient care, because he’d become too sick for outpatient, medication-assisted treatment. He rejected this option and left treatment.

He was back last week, asking for help. He admitted to using a wide variety of drugs, including benzos, illicit methadone, cocaine, alcohol, and marijuana. He knew he was still grieving for his son, and he too had come to fear that he would die from his addiction. He was now ready to go to an inpatient residential treatment center. Even though we don’t offer that service, he came to us when he couldn’t find help anywhere else.

He’d already gone to our local hospital emergency department two days prior, asking for help, but he said he was turned away with no evaluation and no medication. Our patient told us the emergency department personnel told him he could be put on a waiting list for an inpatient program, and that it could take weeks for a bed to open up for him. Our patient left the emergency department feeling like personnel there didn’t care about what happened to him. He suspected they judged him as a bad person, not a sick person. He got no further referrals for treatment and wasn’t even offered clonidine, a blood pressure medication that can help with some of the opioid withdrawals.

Granted, our patient may be leaving out part of the story, or too sick to remember accurately. I know better than to take every patient report as completely accurate, but what this patient said had the ring of truth to it, and I tend to believe he gave an accurate account of his emergency department experience.

After this disappointment, he came to our program, saying he knew we did care about what happened to him. For the next five or more hours, our OTP counselor tried to get help for this patient.

First, she called our local management entity, or LME. This is a weird, non-descriptive term for local governmental agencies in North Carolina that contract with other mental organizations to provide care for any patient with substance abuse and/or mental health issues. LMEs are the safety net…but the net is broken.

The counselor called the LME and they offered to send a mobile crisis team. This is a grand term implying quick, on-site help for resolution of crises facing the service recipient. Service recipient is the new term for patient, by the way.

The mobile crisis management team consisted of a young woman with a bad attitude and little idea how to talk to patients who were sick and suffering. After an assessment of about forty-five minutes, which necessarily consisted of questions that we had already asked her, this mobile crisis management worker told our patient that he was in opioid withdrawal, and it was likely to get worse instead of better.

At this epiphany of the obvious, our patient thrust his face towards the worker and said sarcastically, “Ya think??” It was obvious our patient did not regard this revelation as particularly helpful. It was also obvious he had offended the worker, who angrily started to pack up her belongings. She said the only thing she had to recommend was going to the emergency room. When our patient informed her he had already gone there two days ago and no help had been forthcoming, the mobile crisis worker said that if he didn’t want to take her advice, she couldn’t make him. She said she could put on the list for a bed at an inpatient program, but it could take weeks for a bed to open. Then she left.

So…I was not at all impressed with the mobile crisis management team.

Our tenacious OTP counselor flew into action again, and called our favorite inpatient treatment program directly. This is a state-run program that’s also an opioid treatment program, named Walter B Jones ADATC (alcohol, drug addiction treatment center). It’s affectionately called “Walter B” by us. It’s the only inpatient program in the state that I know of that will admit patients with opioid addiction and keep them on their maintenance meds or start them on maintenance meds.

I felt that starting the patient on methadone as an inpatient, while benzodiazepine withdrawal was being managed, would be much safer. His mental health status could also be addressed, or at least begin to be addressed. A few weeks as an inpatient won’t fix everything, but it is a start, and the best option we could think of.

Walter B said they wouldn’t have a bed for at least a week, and that they needed an EKG and various labs prior to admission. This is because they don’t want to admit a medically unstable patient. Our patient would still have to go back to the hospital emergency department for the EKG and labs, since our OTP doesn’t have the capacity to do those. But our local emergency department sometimes refuses to do lab tests for inpatient admissions. I don’t know why, but I’m guessing it’s because most of these patients have no insurance, and the hospital assumes they’ll get stuck with the bill.

Next, our OTP counselor called a local detox facility. This facility does not “believe” in methadone maintenance and doesn’t even use buprenorphine to ease opioid withdrawal symptoms. But they do administer phenobarbital to help with benzodiazepine withdrawal, and they could perform the labs this patient needed for admission to Walter B. It wasn’t an ideal solution either, but an option.

No one answered the phone at this detox facility. The counselor left several voice mail messages, but didn’t get any calls back.

Frustrated but by no means willing to give up, our tenacious counselor called Project Lazarus. This is a program in Wilkes County that has received accolades for its work at preventing opioid addiction, overdose deaths, and promoting evidence-based treatments for opioid addicts. People who work at Project Lazarus have connections. They tend to know everybody in the treatment field, so they are often a valuable resource for us. One of their employees did know someone at the detox, and was able to call them through a back channel. That person finally called our counselor back.

Finally, a plan emerged. Our patient would go to this private detox that day or the next, where he could get the labs Walter B wanted. In a perfect world, our patient would leave the detox on the day a bed opens at Walter B. However, if that can’t be worked out, I will admit our patient to methadone as a stop-gap until the inpatient bed opens up. After treatment at Walter B., our OTP will accept him back into treatment and continue efforts to stabilize him.

This isn’t the best plan and it isn’t the safest plan. It’s piecemeal at best, and the plan could still fall through.

Ideally, our LME would contract with an agency that could do all of this for the patient. Ideally, detox beds could be offered on the same day the patient asks for help, with a seamless transition to inpatient treatment to continue patient stabilization. Inpatient treatment programs would offer patients medication-assisted treatment of opioid addiction or abstinence-based treatment and the patient could participate in the choice. Instead, most inpatient facilities don’t even mention the possibility of medication-assisted treatment, so there is no informed consent about which type of treatment is given.

If it took a dedicated and savvy counselor five hours and multiple phone calls to work out a plan for this patient, how would he have been able to access care on his own? Indeed, he did try to access care on his own, and failed to get timely help.

I wish all of the people who recommend inpatient abstinence-based treatment of patients with opioid addiction should be made to try to navigate our present labyrinth of care. This wasn’t even a non-insured person; he had Medicaid, and we still couldn’t find a bed for him.

I know our state has little money with which to treat mentally ill and addicted patients. Budgets for mental health and substance abuse treatments have been cut to the bone and then deeper. The public expects a safety net to appear without having to pay for it. The state-funded facilities do miraculous things with the little money that they have. But no one should have the misperception that our system of care is anything but broken.

Insurance Company Woes

In my solo practice, which is mostly made up of buprenorphine patients, I don’t take insurance as payment. The patient pays me at the time of the visit, and I give them a receipt with the necessary codes so that they can submit a claim to their insurance company. Ideally their insurer pays them back directly for the amount they paid me. I stay out of the middle, and charge less than other doctors for office visits, since I save on overhead. If I took insurance, I’d have to hire another person to file and to deal with denials.

Some people criticize me for doing this, and imply I’m doing something shady because I chose not to participate in our current insurance mess. I see it as my right. When I consider that over 30% of each health care dollar in our country goes to administrative costs – people and activities that do nothing to deliver actual care to actual people – I prefer not to participate. So far, it seems to be working.

Alas, there are still some insurance-created woes I can’t escape, like prior authorizations. Prior authorizations are requests for insurance companies to pay for certain medication s or procedures. Almost all insurers ask that prior authorizations be done before they pay for the patient’s buprenorphine prescription. Most of these forms are simple, and ask if I’m licensed to prescribe buprenorphine, if I have an “X” DEA number, and if the patient has opioid addiction. Most of the time, these go smoothly, but other times, there’s a snafu.

For example, the last new patient I admitted had insurance, and his prior authorization form asked if he was free from illicit drugs. Of course I had to check “no,” since his reason for seeing me was opioid addiction. Even though I also checked the box that said this was a new prescription, the insurer wouldn’t pay. It took a forty-five minute phone call to explain that my new patient is expected to test positive for illicit opioids, since he was just starting treatment. Otherwise, duh, he may not need treatment.

Yesterday I got a warning letter from a long-time patient’s insurer. They said in their letter that the patient was filling too many prescriptions for her medication. She’s on buprenorphine/naloxone film, and we have discovered over the past few years that she does better if she fills only one week at a time. If she fills one month at a time, she often runs a few days short. It’s not convenient for her, and more expensive, since she has to pay her pharmacy co-pay once per week instead of once per month, but it works. It gives her more accountability with her medication.

She has thrived in her recovery. She’s been able to make positive change in all areas of her life, and she is high-functioning in a stressful job. But all her insurance company sees is that she fills a prescription every week instead of every month.

Apparently someone is unable to do math at her insurance company. She fills only one week at a time, and the total is the same as if she filled it all at once. I’m not sure why the insurer sees this as a problem, but I will have to spend time explaining this issue to them. Maybe they would spend less money on this patient if she filled once per month, but clinically that’s not best for the patient.

I know my complaints are cheap shots. Insurance companies are easy to ridicule since they have silly rules. But is a smidgen of common sense too much to ask?