Taking a Break

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Hurricane Harvey and Other Emergency Situations

 

Hurricane Harvey

 

 

 

 

 

We all felt heartbroken as we watched the plight of citizens of Houston and other locations deal with the latest weather emergency. I worry most about debilitated senior citizens, children, and animals, all of whom won’t understand what’s happening. I’ve prayed for all people affected by the storm, but that didn’t feel like enough, so I donated to an emergency relief fund.

I said special prayers for patients on medicated assisted treatment. By that I mean any patient who can’t get much needed medications during the flood for serious illnesses. That includes patients with diabetes, heart disease, depression, asthma, opioid use disorder, and many other illnesses.

After Katrina, my state pushed for all opioid treatment programs (OTPs) to formulate emergency planning for their patients for these situations. In New Orleans, patients on methadone (there weren’t many patients on buprenorphine in 2005) had no way to get their medication, and no way to contact their home clinic for confirmation of their dose if they were re-located to a new area with a new OTP. It was only one aspect of the giant disaster that was Katrina.

I thought about what our OTP would do if struck by weather so bad that the facility shut down.

We have a disaster plan, and we just updated it a few weeks ago, coincidently. It’s easier now, since we have a sister OTP located about an hour away. Since both are owned by the same company, sharing data should be simple. We use a server that stores data off-site and can be accessed off-site. Obviously, electronic data retrieval has grown much more sophisticated since Katrina in 2005.

Since my OTP has about nine times the number of patients as our newer sister program, we would need to transport medication to meet the needs of the extra patients routed there for their dose. I feel like that could be easily accomplished, though we’d have to get the approval of the DEA and follow protocols already arranged for these situations.

There are several other OTPs, all about forty-five to ninety minutes’ drive away, surrounding my work site. Patients living closer to those programs could be easily dosed at those facilities as well, if needed. I have a good relationship with the medical directors of those programs, and I feel sure they would go out of their way to help in an emergency. I know I would do the same if they suffered an emergency.

Office-based buprenorphine patients are a little easier. There’s a number of ways to accommodate these patients, since prescriptions could be called in to pharmacies in a pinch. I have records of my office-based patients’ phone numbers both on paper an stored electronically, so if my office can’t open I can still communicate with them for alternative arrangements, assuming phone systems are operable.

Several weeks ago, my fiancé (who also provides counseling for my office-based patients) and I drove to my office practice but forgot the keys to the front door. No problem, we thought, our health services manager, Daniel, will have his keys. Nope. He forgot too. OK, we thought, we can get the landlord, who has an office at the front of our building, will have a master key. Nope. She was out of the country.

It was a pleasant day, not too hot and still shady on the bench in front of my office door where I was sitting. While the other two went in search of another person who may have a master key, my first patient arrived. I explained the situation and asked him if he minded if we conducted the session outside. He thought that was a splendid idea, so we had a very nice fifteen-minute chat. He was doing well, as he has been for about ten years. I couldn’t do a drug screen, but I didn’t make that into an obstacle. At the end of our visit, he gave me his pharmacy’s phone number and I called in his prescription. By the time my second patient arrived, the others had found a key and we proceeded as usual.

In other words, creative solutions to problems can be easy. However, we do need to plan for how to handle situations such as floods, power outages, and other emergencies.

I spent some time on the internet trying to find something about how OTPs in Houston were handling the storm, and how their patients were faring, but so far, I can’t find anything. I hope someone in that area can tell the rest of the nation what happened, so we can better learn how to handle medical issues during emergencies. 

Avoiding Overdoses

August 31: Overdose Awareness Day

 

 

 

“I’m not gonna overdose. I know my limits.”

I really hate hearing these words. Usually patients say this in response to my concerns about their pattern of drug use while I’m prescribing methadone or buprenorphine. But many patients feel like they are the experts. They can’t imagine making a deadly mistake with their drug use. But I’ve heard this phrase, or something close to it, from at least five people who are now dead from overdoses.

I was reminded of this situation after reading an article in the latest issue of Journal of Addiction Medicine. Najman et al. wrote an article titled “When Knowledge and Experience Do Not Help: A Study of Nonfatal Drug Overdoses.”

The author of the study looked at nonfatal overdoses in Australia in 2013, where overdose deaths have risen steadily since 2007. In that country, unlike the U.S., heroin use is declining while pharmaceutical opioid misuse is rising.

This study looked at nonfatal overdoses in people who inject drugs. These people, identified by the needle and syringe exchange programs in Australia, were interviewed about the circumstances surrounding these overdoses, in order to get a better understanding of the risks. A total of 50 people were interviewed for this study.

Most of these people were male, middle-aged, single, and unemployed. Nearly all were smokers. Half had a diagnosis of liver disease and almost all reported a mental health diagnosis. Most injected pharmaceutical opioids, though some also injected heroin and methamphetamine. These were very experienced drug users, with an average of 21 years of intravenous drug use.

Surprisingly, more than half of the study subjects were in some form of treatment for substance use disorder. This finding is contrary to other studies, which have found being in treatment lowered the risk for overdose. Around 46% were in medication-assisted treatment with either methadone or buprenorphine. However, some of the overdoses happened on days that the person missed dosing for some reason, and substituted another opioid such as heroin or fentanyl. Thirty-two percent of study subjects dosed with either methadone or buprenorphine in the twenty-four hours prior to experiencing their overdose.

Most of these overdoses happened in private homes, and around half received some sort of folk remedy for overdose such as being slapped, put into cold water, or being shaken. Naloxone kits weren’t routinely being distributed at the time of this study.

When asked about the cause of their overdose, many the subjects said they were impaired by alcohol or benzodiazepines. Over half said they used benzodiazepines within twenty-four hours of their overdose. Of the 50 subjects, 64% said they had been prescribed anti-anxiety medications sometime in the year prior to overdose, and 38% said they’d been prescribed sleeping pills. Another 36% said they’d been prescribed some sort of tranquilizer in the year prior to overdose. I’m assuming many of the subjects were prescribed more than one of these groups of medications.

Alcohol was not as prominent as sedative medications as contributory cause of overdose; only 34% of subjects said they had some amount of alcohol in the twenty-four hours prior to their overdose.

Over a third of subjects had used fentanyl, a very powerful opioid, leading up to the overdose.

The authors of the study concluded that these experienced drug users were aware of common risks for overdose, yet drug intoxication from sedatives such as alcohol or benzodiazepines may have clouded the user’s thinking when injecting opioids. They also found that unexpected availability of drugs contributed to overdoses.

It’s an interesting study, and a little disturbing to me, particularly the data about overdoses in people who were enrolled in medication-assisted treatments. It does underline the importance of daily dosing of MAT, and the importance of avoiding alcohol and benzodiazepines in patients on MAT.

And if you didn’t know…August 31 is International Overdose Awareness Day.

Stop Sharing Medication!

 

 

 

 

 

I read a tragic article in my local paper today. A young man pled guilty to involuntary manslaughter and received a sentence of four to seven years. The article said he gave another woman a prescription opioid pill, and she died after drinking alcohol after taking the pill. He was prosecuted for her death.

The article went on to say that if a person gives or sells another person an opioid pill (or any other controlled substance) and that person dies as a result of ingesting that medication, involuntary manslaughter or second-degree murder can be charged.

People don’t realize it’s illegal to share their prescribed controlled substance medication with other people. The law says it doesn’t matter if you sell it or just give it to someone else…it’s illegal.

I can’t tell you how many times I have a patient test positive on a drug test, and they tell me they were offered a Xanax at a funeral, or a Vicodin for muscular pain from a relative.

This is not OK.

I’ve had people tell me that once they pay for and fill their medication, it should be theirs to do with what they want. That’s not true. It is a felony to give or sell that medication to anyone besides for whom it was prescribed.

So that old Lortab pill you have in your medicine chest…don’t be tempted to give it to your brother when he has a migraine. You don’t know what other medication he’s on, and you can’t know if it is safe for him. And if he dies, you could be charged with a felony, on top of the guilt you would feel for contributing to his death.

Numerous studies have also shown young people who develop opiod use disorder often get their first opioids from friends or relatives. Parents spend energy worrying about their children being approached by drug dealers, but it’s far more likely that the first opioids used by their children will be obtained from someone’s medicine cabinet.

This means it’s important to change cultural attitudes about sharing medication and saving medication.

 

 

News You Can Use

 

 

 

 

 

 

 

 

New ACOG Recommendations:

The American College of Obstetrics and Gynecology (ACOG) just released an updated recommendation about the treatment of opioid use disorder in pregnant women: https://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Opioid-Use-and-Opioid-Use-Disorder-in-Pregnancy

Their last statement was issued in 2012, in cooperation with the American Society of Addiction Medicine (ASAM). This newer statement was released earlier this month, also in cooperation with ASAM.

By my reading, this update is more direct about recommending medication-assisted treatment for pregnant women with opioid use disorder, and specifically discouraged medically supervised withdrawal from opioids during pregnancy.

This statement was in the update’s conclusions: “For pregnant women with an opioid use disorder, opioid agonist pharmacotherapy is the recommended therapy and is preferable to medically supervised withdrawal because withdrawal is associated with high relapse rates, which lead to worse outcomes. More research is needed to assess the safety (particularly regarding maternal relapse), efficacy, and long-term outcomes of medically supervised withdrawal.”

I suspect this released update may have been prompted by the actions of obstetricians in certain locations (Tennessee, for example), where medically supervised withdrawal is routinely recommended by obstetricians. As you recall in a blog earlier this summer, I showed you a letter written by OBs from TN, recommending “medically supervised withdrawal” for patients on medication-assisted treatment of opioid use disorders.

As the ACOG update emphasizes, there’s scant evidence to show medically supervised withdrawal provides any better outcomes for the baby, but certainly places the mother at risk for relapse.

I am pleased to see this update, and plan to mail it to a few obstetrics practices in my own area. Some OBs may be giving patients recommendations not supported by their own professional organization out of ignorance, in which case more information can help. Other OBs do it for ideological reasons, in which case I doubt any amount of information can help, but at least I’ll know I’ve tried to do something.

Screening for substance use disorders was also strongly emphasized in the new document, with specific recommendations about how this should be done. In other words, asking a pregnant patient, “You don’t take any drugs, do you?” is not considered to be adequate or recommended screening.

Increased Risk for Death in Patients with Opioid Use Disorder who Leave Buprenorphine Treatment

We have multiple studies, dating back decades, showing patients with opioid use disorder who leave treatment with methadone have higher risks of overdose deaths. We believe the same thing is true with buprenorphine treatment, but now we have more data to support that assumption.

A French study of 713 buprenorphine patients showed that being out of buprenorphine treatment was associated with a 30-fold increase in death, compared with patients who stay on buprenorphine treatment.

Now that’s impressive.

This was a study done in France, where most patients with opioid use disorder are treated by general practitioners in private practice. This would be roughly equivalent to what physicians do now in the U.S. in their office-based buprenorphine practices, often called OBOT treatment.

The study was published in the July/August 2017 issue of the Annals of Family Medicine, by Dupouy et al. It looked at new patients admitted onto buprenorphine treatment from early 2007 until the end of 2011, and covered over 3,000 person -years of treatment.

The authors say that the data showed, “…being out of treatment was associated with sharply elevated mortality risk.”

We already knew that people with opioid use disorder have an increased risk of death. Early in this article, the authors state that the accepted mortality rate of untreated heroin use disorder is around 2 people per 100 patient years. This means that if you follow 100 heroin users for a year, it is likely that 2 will be dead at the end of the year. An older study, by Hser et al., followed people with opioid use disorder over time, and found that around 50% were dead at 30 years.

We’ve had other studies that show being in treatment with buprenorphine or methadone decreases risk of death, but this may be the first study showing that getting help in a primary care setting reduces the risk of death so remarkably.

This was a very large study, so the data is more impressive to me All this data supports the conclusion that opioid use disorder is a serious and potentially fatal disease, and that being in medication-assisted treatment markedly reduces the risk of death.

 

Medicaid’s Limits for Non-compliance

 

The opioid treatment program where I work accepts Medicaid as payment, starting a few years ago. Overall, it’s been so beneficial for hundreds of our patients. However, when Medicaid patients have repeatedly positive drug screens, Medicaid overseers threaten to cut off their funding for treatment.

Our state’s Medicaid system is divided into counties, and these counties contract with agencies to provide oversight for the mental health and substance abuse treatment dollars. I’ve had several conversations with the doctors who do peer review for payment to our program.

We discuss patients’ progress, and whether more Medicaid money will be approved for their treatment. This agency says they have the right to cut off payment for treatment of Medicaid patients who don’t become drug-free within a reasonable period of time. So far, they haven’t cut off payment for any patients, but we have many patients at risk for this. If patients lose Medicaid coverage, they can remain in treatment with us, but have to pay out of their own pocket.

I feel torn about this issue.

On the one hand, I know my patients will do better if they are able to stay in treatment on MAT. If Medicaid quits paying for their treatment, many will leave treatment and go back to illicit drug use. I know from various studies that patients who leave MAT have high relapse rates. Relapses back to illicit opioid use can cost more to the Medicaid system than staying in treatment. Plus, patients who leave treatment are at greater risk of overdose death.

On the other hand, as a taxpayer, I understand why people object to using tax dollars, in the form of Medicaid, to pay for addiction treatment if the patient is still using illicit drugs. Some people may feel this is a government subsidy to continue drug use.

Most people feel we do have an obligation to the disabled and the poor to provide medical care. But should we apply different criteria for payment of substance use disorder compared to other chronic medical illnesses, which also have behavioral components?

The doctors who decide when to stop paying for MAT could use similar criteria to decide when to stop paying for other medical care of chronic illnesses.

Imagine this conversation:

“Hello, this is Dr. X. I am calling regarding approval of payment for the treatment of Mrs. Sweet, the diabetic you are seeing. I’ve authorized ninety days more of payment for her, but if her blood glucose readings and her hemoglobin A1C don’t improve, I will be recommending we stop paying for her treatment. She will have to pay for her diabetic medication and her medical care from her own pocket.”

“I don’t understand. I’ve been treating Mrs. Sweet for years…her diabetes is about as well-controlled now as it has been for years.”

“Our point exactly. She isn’t showing any improvement. You told her to follow a diabetic diet, lose weight, and exercise, and she hasn’t done any of these things. If she’s not willing to follow physician recommendations, Medicaid won’t approve payment for the medical care she needs for diabetes.”

Can you imagine the outrage at such a decision?

Let’s use an example of another chronic illness: heart disease. Let’s say I have a patient who has coronary artery disease. He had one heart attack and had to have a coronary stent placed. He has very high cholesterol, but despite dietary instructions, he continues to eat fatty foods and plenty of red meat. He also isn’t compliant taking his cholesterol medication.

He has another episode of chest pain, goes to the hospital, gets admitted with another heart attack, but the Medicaid overseers say his medical care will not be paid for, since he hasn’t made the changes recommended by his physician.

Are these scenarios starting to hit a little close to home?

Let’s be careful when we start deciding who deserves or doesn’t deserve to have their medical treatment paid for, if we use behavioral change as the yardstick for such decisions. Few of us with chronic illnesses do everything perfectly.

It’s part of human nature.

Book Review: “American Pain,” by John Temple

 

This nonfiction book, published in 2016, describes in amazing detail the rise and fall of one of the biggest of South Florida’s pill mills, named American Pain. The book reads as easily as a novel. It describes the casual criminality and greed that fueled one of our nation’s biggest drug overdose epidemics.

The book starts by describing how a felon, his twin brother, and a body-building buddy decide to open a pain clinic. They hire doctors to work there, but still manage clinic, in appallingly unprofessional ways. These owners and managers show a shocking lack of concern for human life and the suffering they saw daily. For example, they talk derisively of their customers as “druggies” and “zombies,” yet the owners were also drug users. Bribes were taken for all sorts of unethical activities, from advancing a patient through the line more quickly, falsifying drug screen results, or getting the patient seen by a doctor with a reputation for being a generous prescriber.

This pill mill saw mostly people from Appalachia – as the book points out, 43% of the clinic patients lived in Kentucky, 20% in Florida, 18% from Tennessee, and 11% from Ohio.

The methods developed by the addicted patients and their handlers were astounding. Appalachian families who in the past may have distribute moonshine, marijuana, or methamphetamine used the same organizations to distribute these pain pills transported out of Florida. People called “sponsors” would arrange for a group of people to come to American Pain, located in Broward County, Florida, sometimes traveling hundreds in buses or vans or just carloads of people. Each of these people would be given money by the sponsor to be seen by the physician and to buy the pain pills and benzodiazepines dispensed on site. They gave a portion of these pills to their sponsor to be sold through the networks of drug dealers already established, or they could give all the pills to the sponsor in return for a tidy profit.

Some airlines offered cheap flights from the Appalachians to Florida. So many pain patients flew on one flight that it was called the “Oxy Express.”

MRI owners and operators profited because the pain clinic made every patient get an MRI, to maintain a veneer of medical respectability. Patients could bribe their way to the head of this long line, too. Pharmacies profited, as long as they didn’t ask too many questions. Many times, the pain clinics had their own pharmacies and dispensed on site, to make yet more money and to keep legitimate pharmacies from asking uncomfortable questions.

Flea markets in Kentucky sold urine in Mason jars to pain clinic patients who were required to pass a drug test. Dive motels in Florida rented rooms to “oxy-tourists,” and some overdosed and died in these places.

Between 2007 and 2009, Broward County went from having four pain clinics to having one hundred and fifteen. In one area, there were eighteen pain clinics within a two mile radius.

Everyone was happy; the people with addiction got more pain pills to inject or snort, the sponsors made money, the doctors made money, and the clinic owners made staggering amounts of money.

Of course, in the long run, irreparable harm was done. Patients of the clinics died, people who bought pills from American Pain patients died, and families suffered from the deaths of their loved ones. Many people were incarcerated, children were put into foster care, and medical costs of complications from addictions soared. The cost to taxpayers and U.S. social fabric can never be calculated.

Police routinely pulled over cars traveling north on the interstates if they had Kentucky, Tennessee, or West Virginia license plates and were filled with people. Usually, some crime could be detected. If one person had pill bottles from multiple doctors, this was the crime known as doctor shopping. If a pill bottle had too few pills remaining, the owner could be arrested for drug dealing. Many times, there would be drug paraphernalia in the vehicles. The driver could be impaired.

The book is painfully funny in places; the manager of the pain clinic describes what he calls “addict stunts,” like when an RV filled with three generations of a family from Appalachia rolled into their parking lot, spread an outdoor carpet on the asphalt, and set up folding chairs and a grill, planning to make a day of it at the pain clinic. It was a family outing, going to a Florida pain clinic to get pills to fuel one’s addiction.

Pain clinic patients would pee in the hedges, fornicate near other businesses, and shoot up in the parking lot, all of which appalled the owners, who were trying not to attract attention.

The owners even asked themselves, “How could this be legal?” But it was.

Apparently Florida didn’t have any corporate practice of medicine laws, which prevents non-physicians from owning any medical facility. I’ve derided these types of laws in the past, but here’s one situation which cried out for this kind of law.

Florida also had no prescription monitoring program, as I pointed out in my blog of March 8, 2011. Long after Florida’s pain clinic problem exploded, their governor inexplicably blocked development of a PMP. They have one now, but only after Purdue Pharma (manufacturer of OxyContin) offered money to the state to start one.

Florida also allowed physicians to sell pain pills and other medication directly, without involving a pharmacy. This allowed much of the mis-prescribing to go unnoticed.

Of course, things finally ended badly. The FBI got involved, and did investigations, undercover work, and eventually got wire taps to prove RICO indictments of all the main people. After they were arrested, the owners and operators, who talked big about how they would never turn on each other, all ratted on each other to get favorable plea deals.

The main owner got 14 years in prison for his part in the scheme that earned him 40 million dollars, and his twin was sentenced to 17 years in prison. Their friend, the manager of American Pain, was sentenced to 14 years.

All but two of the physicians took plea deals, and most lost their medical licenses and had various criminal penalties.

The two doctors who refused to take plea deals were both charged in the deaths of patients who had overdosed on medications these doctors prescribed. Both doctors said they had no idea they were working for a pill mill, and the juries acquitted both of them

However, they were both convicted of money laundering, under the premise that they would have to be willfully blind not to know the operations of this place weren’t legitimate medical care. Prosecutors said the doctors had to have known they were prescribing to people with addiction or people who intended to sell their pills. In one doctor’s case, she would see in excess of sixty patients per day, and was the largest prescriber in the nation for certain drugs.

She also made 1.2 million dollars in just the sixteen months she worked there. That last fact alone is so far out of line for what legitimate physicians make in that same time period that she had to have known she was committing crimes. She was sentenced to 6.5 years in prison.

The only other physician not to take a plea deal made around $160,000 for working at the pill mill, and was sentenced to 18 months in prison.

This is a fascinating book, about an incredible time in Florida’s history. Of course, as the book illustrates, Florida’s problem bled into other states, and poured gasoline of the raging fire of opioid use disorder that already existed in Appalachia.

The book illustrated the mindset of people who operate such pill mills, their derision towards the people who are making them all this money, and their disregard to the human misery caused by addiction.

One of the most poignant scenes in the book is when the mother of a young man who dies of an opioid and benzodiazepine overdose goes to talk to the doctor who prescribed him the pills. This mother left the hills of Kentucky and drove to Florida for the confrontation. But the doctor said nothing, only looked downward to the floor. For what could she say? Under the best light, she was guilty of willful blindness, and under the worst, something much more sinister.

The events in this book took place not even ten years ago, and we were about ten years into the opioid epidemic when American Pain opened its first clinic. The owners and operators and doctors weren’t the only ones at fault. Why did it take Florida so long to get an operational prescription monitoring program? Why did their governor, Rick Scott, block efforts to establish this important program? Where was the state’s medical board, and why didn’t they investigate the doctors’ actions at American Pain?

I highly recommend this book to anyone interested in the opioid use disorder situation in the U.S., to get better insight into how it started and how it was perpetuated