The Future of COVID Take Home Doses

This may be a controversial blog post. I’ve been mulling over the ideas I’m presenting in this blog for many weeks and have changed my mind several times. So don’t get too upset with what you read, because I may have changed my mind again by the time you read it.

The events of this past year have given us experiences and information, and it seems prudent to learn what we can from them.

In the spring of last year, state and federal authorities moved quickly to allow patients enrolled in opioid treatment programs to receive more take homes doses than usual. They did this to reduce the risk of patients’ exposure to the COVID virus. Most opioid treatment programs were able to give many more take home doses of buprenorphine or methadone than ever before. This cut down the number of patients physically present at OTPs at any one time, thus creating more social distancing than ever before.

Now patients – and providers – are wondering what will happen after our country no longer has a high risk of COVID transmission in crowds. Will the previous regulations snap back into place? Will patients receiving extended take home doses now be asked to come more frequently and give up the convenience of extra take home doses?

In my state of North Carolina, as I understand it, once the state is no longer under a “state of emergency” declaration, the permission to give extra take homes to patients will no longer exist.

I’m not sure what state and federal authorities will advise, but I have some thoughts.

As I see it, we have two sets of questions. The first is what to do about patients presently receiving extra take homes. The second is deciding if information from events of the past year should cause us to change regulations about methadone take home doses.

At my opioid treatment program, we have about half our patients dosing of buprenorphine and half on methadone. Because of its better safety profile, buprenorphine patients already get take homes more quickly than methadone patients. So, my next paragraphs will be about patients being prescribed methadone at opioid treatment programs.

Let’s take the first question: what shall we do about patients who are getting extra take homes now? This has been an unusual time in history – I hope – and we have a cohort of patients who were suddenly given many more take homes than they were accustomed to getting.

Some patients had problems with those extra take homes. They came back to the opioid treatment program early, saying they didn’t know what had happened to the extra doses, or that the nurse hadn’t given them extra doses, or that some other person stole their medication. These problems almost always came to light within the first few months. Those patients were not ready – at that time – for extended take homes, though they may be able to do so in the future.

However, most patients with extra methadone take home doses did well. We’ve done bottle recalls (like pill counts done at pain management clinics) and most patients brought their bottles back in with the correct number of bottles untouched, with the appropriate amount of medication contained in them. This reassures us that these patients can take only one dose per day and are able to store it safely where it won’t be stolen or tampered with. Most of these patients have been reachable by their counselors for weekly in-person or telehealth meetings, showing further evidence of stability.

For patients who have proven their ability to manage their take home doses, it seems counterproductive to reduce the number of take- home doses again after the COVID emergency passes. Why would we want to do this? So long as patients have been making appropriate contact with their counselors at their programs and are doing well, I will advocate for them to stay at their advanced take homes. I might have to submit an exception to get permission for this from state and federal authorities, but that’s easy to do, and would seem a reasonable request.

Then comes the question of what to do with these patients if they have drug screens positive for illicit drugs. Should these patients move back to daily dosing? What if the only illicit drug they use is THC? Before the extra COVID take homes, our state said patients who remained positive for THC couldn’t advance past a level 1, which means they had to come every day but Sundays. In the past, I agreed with this policy. I reasoned that people using THC weren’t as stable as those not using it.

Now I have changed my mind.

Don’t misunderstand. I am no fan of marijuana. I think it can hold patients back in some insidious ways. It’s not harmless, as some people think, but neither is it a toxic substance, like alcohol is. Some day we may have beneficial medications derived from the marijuana plant, but at present, lighting the plant on fire to inhale the smoke isn’t a medically safe way to ingest those chemicals. We know marijuana use affects adolescent brains adversely, but even in adults, it can shave off IQ points, and may interfere with motivation to make life changes.

However, regular marijuana doesn’t cause the chaos that other illicit drugs cause.

 Since COVID, I’ve seen many patients, long-term smokers of marijuana, managing their additional take-home doses quite well. They appear as stable as non-smokers of THC. I don’t see that it would help anyone to revoke those take-home doses, and it may benefit some of these patients to be able to give even more take homes. At present I am more open to such ideas than I ever have been in the past.

Patients using alcohol and other sedatives are not getting extra take homes at the opioid treatment program where I work, due to the dangers of mixing methadone with sedatives. I have not changed my mind about that.

What about stimulant use? We’ve seen an uptick in methamphetamine use over the past several years, and some of those patients are getting extra take homes now. Some are not, depending on an assessment of each patient’s overall stability. I have not been consistent with decisions about take home doses for such patients, because stimulant-using patients can differ widely.

For example, one patient has tested positive for methamphetamines for about a year, but she has a job, a stable relationship, and no apparent clinical decline, at least thus far. But another patient tested positive for methamphetamines for two months. Since then, his family committed him once to a mental institution for a few days, for auditory hallucinations related to drug use. He’s lost twenty pounds in two months and is twitchy and easily distracted when I try to talk to him.

I was generous with take homes for the first patient and denied take homes to the second one. Of course, the second patient feels like this is unfair towards him. After the COVID take-home exceptions end, should both patients be moved back to daily dosing?

Let’s move on to the idea of changing existing take home regulations. There are eight criteria that patients ordinarily need to meet to get take home doses of medication. In an abbreviated form, these are:

  1. No ongoing drug or alcohol use
  2. Regular attendance
  3. No serious behavioral problems at the OTP
  4. No recent criminal activity
  5. Stable home environment
  6. Ability to store medication safely
  7. Benefits of take homes outweigh risks of diversion
  8. Time in treatment

I agree with all these requirements, except perhaps the last one, which I feel is the most restrictive. Federal and state authorities have firm regulations about how soon a patient, doing very well otherwise, can be granted take home doses, based only on how long that patient has been in treatment. New patients can receive up to one take home dose per week for the first three month, then if all is going well, can get three take home doses per week for the next three months, then four doses per week for three months, etc. At the one-year mark, even an extremely stable patient will need to come once per week for a year.

That’s a long time, and perhaps unduly restrictive for many patients.

Before readers criticize me for risking lives due to putting methadone at risk for diversion, let me explain that I do know how much harm methadone take homes can cause in the wrong hands. I can tell you horror stories about diverted methadone, but I won’t do that now.

But on the other side, more patients thrive with extra take- home doses, able to feel less stress about getting to their OTP in time to get dosed and get to work on time. They can spend more time with their families in the morning hours. That’s worth quite a lot.

If we decide to revisit our present methadone take home schedule regulations and ultimately relax them a bit, it will fall to treatment center staff and ultimately the medical director to decide if a given patient is stable enough for take homes. That means the medical director will need to know her patients well. This requires time at the opioid treatment program and involvement with the patients. That should already be happening, but I know that’s not always the case.

Here are a few of the warning signs we’ve seen that can indicate problems forming: coming in a day or two early to dose, even when the patient should already have take-home doses; being unable or unwilling to give urine drug screens; giving falsified urine drug screens; counselors being unable to reach the patient for telehealth counseling sessions; poor attendance or repeatedly coming at the last minute to dose; new mental health issues or new physical health issues, and unexplained change in appearance or affect.

Since the medical director is ultimately responsible for the consequences of methadone take-home doses, the medical director needs to be made aware of any warning signs seen in patients, aside from positive urine drug screens. The medical director needs to know the patients well, and have input from counselors, nursing, and even front office staff when making these important decisions. Therefore, time for case staffing, sometimes also called treatment team meetings, is so important.

At the OTP where I work, we usually have case staffing twice per week, and it includes medical and counseling staff. We make decisions about take home doses at these meetings. Sometimes we disagree, and that’s good. It means differing opinions are being voiced. Sometimes emotions run high, a reflection of the importance of our decisions to patients. It’s often a difficult process.

But because of the importance to patients, perhaps take-home regulations should be re-evaluated at national and state levels, in the light shed by our recent experiences with the extra COVID 19 take home doses.

Never mind….

You know that blog I posted a few weeks ago, about DHHS’s decision to allow any physician with a DEA license to prescribe buprenorphine products for their patients with opioid use disorder? That idea has been nixed. SAMHSA said HHS’s decision to announce the change of regulations to have been “premature.”

I have no idea what political machinations were behind all of this, but Medscape’s webpage said loosening the restrictions was an idea put forward by Trump’s administration, and Biden’s administration cancelled that plan.

Many addiction medicine specialists were wary about the idea of loosening restrictions, fearful of the consequences if any physician could prescribe buprenorphine without the mandatory training course. That eight-hour course teaches providers about opioid use disorder in general and specifically about how to prescribe buprenorphine products from an office-based practice to treat that disorder. They say prescribers need this education, since for decades it was illegal to treat opioid use disorder from an office setting. Consequently, most physicians don’t know much about treating addiction, and may mistakenly think it’s the same thing as treating pain.

On the other hand, eliminating the need to take this course could encourage more doctors to prescribe buprenorphine products to treat opioid use disorders, thus expanding access to treatment.

I’m not sure what I think.

 On the one hand, I’ve seen providers with no training or “X” number prescribing all sorts of buprenorphine products for years, and not always with the diligence I would hope for.

For example, several months ago I reviewed a new patient’s data from the North Carolina prescription monitoring program. I saw the local pain clinic had been prescribing an extended- release full opioid agonist, along with a short-acting full agonist for breakthrough pain for many months. Then I saw the Butrans patch (contains buprenorphine) was added to this regime of medication.

I asked the patient what happened when they started the Butrans patch.

“Oh I found out I was allergic to it. It made me very sick. I felt like I was back in withdrawal. I can’t take that medication.”

Of course, that was no allergic reaction. That was precipitated withdrawal, predictable to providers familiar to the pharmacology of buprenorphine. But now this patient is convinced that buprenorphine in any form will make her sick under any circumstance. She was started on methadone and has done very well, but it is a shame she had to be put through that nightmare.

However, another prescriber, this one who took the eight-hour course and who has a DEA “X” number, starts all patients at a dose of buprenorphine/naloxone 32/8mg per day (four of the 8/2mg tablets) and tapers down over a period of several months until the patient is off the medication completely. Apparently this prescriber wasn’t paying attention to instructions given at the 8-hour training course about how to do induction. Or how to do maintenance. Or that most patients need much longer than several months on the medication to remain in recovery, and few need any higher dose than 16 to 24mg per day.

Then there’s another prescriber in town, also with her DEA “X” number, who accepts methadone patients from our opioid treatment program and starts them on buprenorphine without asking for any data from us. We only find out about the patient’s medical misadventures when their counselor calls them, to find out why they’ve missed days of treatment with us. The patient says he told the prescriber what dose of methadone he was currently on, and but prescriber asked the patient to miss one or two days of methadone before she started a sublingual buprenorphine product.

If they patient was on a dose of 40mg or less for at least a week, everything will go well. But if the patient’s been dosing at 110mg per day, per example, and missed a few days…things usually don’t go well. The patient ends up in precipitated withdrawal, which is completely predictable. If we are lucky, we can get them back into treatment right away.

At our opioid treatment program, we switch patients all of the time, though much more slowly. My usual “recipe” for switching involves tapering by 5mg per week, down to 40mg, where they dose for at least a week. Then the patient misses two days and sees me on the third day. If they are in sufficient withdrawal, with a COWS greater than 12, I feel safe starting them on buprenorphine. I usually end up dosing them with between 4 to 8mg on that first day.

Anyway, my point is that most of these prescribers, who took the eight- hour course, don’t necessarily do things as I would hope they learned in the course. But perhaps it would be worse if buprenorphine prescribers took no course.

My opinion about this issue rockets from one side to the other faster than a tennis ball at Wimbledon.

I can’t decide what I think. I read opinions from leaders in the field that say untrained prescribers could lead to disasters, and I know they are correct. Then I read from other leaders in the field that increasing access will save lives and I know that’s right, too.

I have no conclusion for this blog post. I’m just acknowledging uncertainty.

My Quest to Get the COVID 19 Vaccine

In North Carolina, hospital systems are immunizing their staffs for COVID. These systems also own many doctors’ offices and immunize their personnel at those offices too. But local county health departments have been assigned the chore of providing vaccines to the public.

Most opioid treatment programs (OTPs) are not part of health systems. During our weekly state-wide opioid treatment provider teleconferences, we’ve discussed how and when OTP staff can get COVID 19 vaccines.

The medical staff, including nurses, physicians, and physician extenders, are categorized as 1a priority for vaccine, and for counselors and OTP office staff, consensus seemed to be they were also 1a, or 1b according to some county health departments.

Like my co-workers, I got notification that the opioid treatment program where I work, owned by Acadia Healthcare, will not be offering vaccinations to patients or their healthcare workers at the programs. However, they do encourage providers to obtain the vaccine.

So, I was left to find the vaccine on my own.

Our local hospital immunized most of their workers near the end of December. Beginning in late December, our local health department started giving the vaccine to other community members, as they received doses from the government.

I went to our county’s health department website and was pleased to find a form to fill out with my name and data. I was under the mistaken impression that submitting the form meant I was requesting the vaccine. That was not the case. The form was a survey regarding potential interest in getting the vaccine. I got a polite email from the health department telling me to be sure and call if I needed the vaccine.

So I did. Our OTP works with our health department, so we had some contacts there. I called them but could not get through to our contact person or any other human, so I left a message. I was called back by a pleasant woman who told me to call the next week, since they were already out of vaccine, and perhaps some would be available the next week.

Many of my colleagues at other OTPs in other counties already got their vaccines, usually by appointment at their health departments.  I was feeling a bit left out of things.

Last week, I called their number again and got a general message: more vaccine had been received and “appointments were not necessary.” The vaccine would be available on a first come, first serve basis, starting at 10am at a drive-through site, only for people in the 1a and 1b categories. On previous vaccine drive-through days, they have run out of vaccine rather quickly.

I’m usually at work on weekdays, so I had to ask to leave work at 9:30 that morning, to get in line at our health department.

My fiancée, whose schedule is less structured than mine, reconnoitered for me that morning. He went to the old airport where the vaccines were being given at around 8:30am, only to be turned away by a policeman who told him that the vaccines were already all gone, and that people had been camping out there at 2 am to be first in line for the vaccine. Disappointed, he let me know there was no reason for me to leave work that day.

So, I stayed and worked as usual, thinking I wasn’t going to be able to get a vaccine that week. But then at around 11:30 one of the employees told me two of her elderly relatives had just received the vaccine after waiting in line for two hours. They got to the site at 9:30.

This made no sense, since my fiancé had seen many cars being sent back home at 8:30am. I put it out of my mind until after we finished up case staff at around 1pm.

Later, we discovered local police, helping manage crowds, mistakenly sent people back home because they thought the vaccine was already gone when it was not.

As I was leaving work around 1pm, I thought I’d drive the extra ten minutes out of my way home, just to see for myself what was happening – or not happening.

I kept thinking how silly I was to think there would be any vaccine left this late in the day, but I pushed on. I passed a flashing sign giving directions to the vaccine site. That was promising. Surely the sign would be off if everyone was gone. I turned the corner and saw a squadron of flashing police lights and lines of cars.

I pulled up behind one line and after several minutes a helper came to my window and asked if I had the correct forms. I told her I had the forms I downloaded off the Health Department’s website. She took them from me and peevishly told me they weren’t the correct forms. She took my temperature and asked about recent illness including cough and fevers. I answered no to all, and she gave me a card with a number on it.

I was in line to get my vaccine!

Hurriedly, I called my fiancé to let him know to return for the vaccine, since he’s also in the 1a risk group. I also texted other co-workers also wanted to get the vaccine. Thankfully, two other co-workers made it in time to get vaccinated.

The health department nurses couldn’t have been nicer, and the shot was a breeze. I remained in my car the whole time and got a card with the vaccine name and other information with a reminder of when my second dose was due. This whole process took maybe twenty minutes.

Then after the injection, people waited in a line of cars, because we had to wait 20 minutes to see if we were going to have a reaction.

And if you think anyone was leaving that parking area one minute early, you are mistaken. At the eighteen- minute mark, an EMS worker asked me how I was feeling, I said fine, and she said something I mistakenly thought meant I could drive away. Nope. A stout policeman literally jumped in front of my car to block my exit. He shook a finger at me. I obediently stayed four more minutes until I was permitted to leave.

My arm was sore at the injection site for two days, about the same feeling that I get with the yearly influenza vaccine. I did have body aches the day after the vaccine but was able to work as usual, though I took a few Tylenol to ease the aches. I’ve felt fine since.

These county health departments have been poorly funded for years. With relatively small budgets, the health departments have been trying to provide medical care for the many uninsured patients of the county. Now we’ve asked these health departments to perform the most daunting task of the century: get a COVID vaccine to any person who wants one. I admire their resolve to get the job done and I’ll happily overlook any inconveniences presented.

I was happy to see local police and EMS services on the site to help with the task. I thought that was a great idea. They held this drive-through vaccine program on an old airport runway, which was perfect for the purpose

I was thrilled to get this vaccine. I was thrilled the wait was very brief and I didn’t have to miss any work. I was especially happy that my sweet fiancé was also able to get vaccinated. I hope it can be quickly distributed to any person who wants one.

I was surprised that at the opioid treatment program where I work, out of around twenty-five employees, only five of us wanted to get the vaccine. I think that may change with time, as more people are vaccinated.

I still wear a mask to work and to the grocery, the only two places I need to go. I know I can still spread COVID, and it’s still possible to get sick with COVID between the two vaccines in the series, though I’m less likely to get severe illness.

Early on, I wasn’t sure about the vaccine, and told people that I didn’t want to be the first person in line to get it and I didn’t want to be the last one either.

One of my patients helped me adjust my thinking. She participated in the Pfizer vaccine trial, and we talked about this last fall. I told her I admired her courage. She said courage had nothing to do with it. She entered the initial clinical trial because she wanted to be able to tell her grandchildren that she did something to help mankind overcome this threat to us all. Even if the vaccine wasn’t successful, she was willing to take a risk to help other people.

I admire her generosity of spirit. Her outlook is more like, “What can I do to help others?” rather than, “What will be best for me?”

As always, my patients continue to teach me.

Health and Human Services Seeks to Expand Buprenorphine Services

Last week, the U.S. government’s Department of Health and Human Services announced new guidelines intended to expand access to treatment for patients with opioid use disorder. [1]

 My reading of this announcement is that HSS is exempting prescribers from obtaining a waiver to prescribe buprenorphine products from office-based practices. It appears to mean that physicians no long must take the eight-hour training course that is necessary to get a DEA “X” number waiver. Physicians only need a valid DEA license that covers prescribing Schedule III controlled substances. Physician extenders such as nurse practitioners and physician assistants must still go through the extra training already in place, however.

Non-waivered physicians can start prescribing buprenorphine products to up to thirty patients at any one time. The thirty-patient cap doesn’t apply to hospital-based physicians like those working in emergency departments.

This change applies only to buprenorphine products and does NOT apply to the prescribing of methadone for opioid use disorder. That medication must be prescribed from an opioid treatment program, as it has been.

HHS says that physicians can only prescribe buprenorphine products to patients residing in states where the physician is licensed and must keep separate charts for these patients. I think both things are already required. If they want to prescribe for more than thirty patients at a time, they will need to get the usual DEA “X” number. Prescribers must also put an “X” on the prescription to indicate it is being prescribed for opioid use disorder and not for pain.

HSS also says an interagency group will be formed to monitor implementation of these services.

For the past twenty-one years, we’ve tried to convince medical providers that instead of viewing opioid use disorder as a crime, we need to treat it as the chronic medical problem that science shows that it is. Trying to reverse a near-century of bad policy (the time from passage of the Harrison Act until the DATA 2000 Act) has not been easy.

Then our present epidemic of opioid use disorder with its corresponding epidemic of death started at the end of the 20th century and it grew like cancer into this century.

This has been a tough year for more than just COVID deaths. A record number of people – around 83,000 – died from opioid overdoses over the twelve months ending in June of 2020 in the U.S.

 We know prescribing buprenorphine products (or methadone, by the way) to patients with opioid use disorder is life -saving. Mortality is reduced at least three-fold by the most conservative estimates. I challenge anyone to name any other medical intervention that has such an impact and reduction of mortality. Yet medical providers haven’t been enthusiastic about providing this treatment. Old ways of thinking have been hard to challenge.

The new guidelines intend to loosen restrictions on prescribing buprenorphine products. People in the government fear that the eight-hour course to get a special DEA number is keeping physicians from prescribing buprenorphine products. Many patients with opioid use disorder have a hard time finding prescribers with the waiver to treat, and the Department of Human Services wants to make it easier for these patients.

Both the American Medical Association and the American College of Emergency Physicians praised the change in policy.

Not surprisingly, I have some thoughts about this change in HSS policy.

Weirdly, my first thought was, “Wow, someone is going to have to tell all the CVS pharmacists because they are going to lose their minds about this.” Readers of my blog may recall the comical insistence of CVS pharmacies that providers to include a “NADEAN” number in a specific format before they will fill any buprenorphine product.

Overall, I agree that dropping training requirements may make providers more willing to prescribe buprenorphine products. Providers may not be as educated about buprenorphine before starting to use it, but other than causing precipitated withdrawal, it’s hard to kill anyone with it.

We experts may not like to admit it, but just providing the medication saves lives. Even with no psychosocial counseling and very little provider interaction, lives are saved if patients just take the medication. Ideally, the medication should be provided in concert with counseling, but some patients aren’t interested in counseling, for whatever reasons.

There may be diversion if physicians with little experience miss evidence the patient is selling medication. I hate to see diversion, even as I recognize the benefits of buprenorphine when used off the black market. I also know that every day a person with opioid use disorder takes buprenorphine instead of fentanyl, the risk of overdose is decreased. And that’s worth a lot.

Will dropping the eight-hour training requirement prompt more physicians to prescribe buprenorphine? Perhaps, but as I said above, it’s hard to convince doctors that this is a disease that can and should be treated, and not criminalized.

Here’s the biggest value I see with these new guidelines: hospital-based physicians can prescribe buprenorphine without needed the “X” DEA number.

For years, I’ve wished our local emergency department physicians would start buprenorphine when they see patients with opioid use disorder. They have not, partly because they say they don’t have the required “X” number, and partly because they say they don’t have anywhere to refer patients newly started on buprenorphine products.

This new guideline will eliminate the first problem, and the second problem has already been solved. Our opioid treatment program does intakes five days per week, Monday through Friday. Even if the patient is seen on a Friday night, the emergency department physician could write two days of medications to last until we can evaluate and admit the patient on Monday.

And there are three or four office-based providers of buprenorphine in the community now, as well as another good opioid treatment program. Surely we can all get together to make a plan to admit a patient to treatment very quickly.

I plan to keep pushing for this, because the studies show the reduction in the risk of overdose and death. At some point, it will be malpractice NOT to provide life-saving treatment to people with opioid use disorder.

Hopefully we will continue to make progress. That’s why I started this blog in 2010. I wanted a platform to tell people about the mountain of evidence to support the treatment of opioid use disorder with medications and get patients and providers interested.

Change takes time.

And change also takes patience and perseverance.

  1. https://www.hhs.gov/about/news/2021/01/14/hhs-expands-access-to-treatment-for-opioid-use-disorder.html?mc_cid=d21a328f2d&mc_eid=9c7edff92d

Compassion

Maybe with all the suffering around us, it’s easier to feel compassion. I don’t think I’ve had a year when I felt more concerned about other people, to the point I pray more for them, have donated more to charitable organizations, and even started donating blood on a regular basis. I’m not bragging; I’m just happy I’ve felt more like doing these things. I’m at my best when I have that feeling of wanting to be helpful, and I tend to be happier with myself.

I am not, by nature, a very compassionate person. Left on my own, I can be judgmental, the opposite of compassionate. But I don’t want to be that kind of person. Thankfully, over the past twenty-plus years that I’ve been in recovery from substance use disorder, I’ve learned a few things. I’m better at recognizing my own negative attitudes and challenging them.

 It helps me to be around other compassionate people. I’m grateful I have such people in my life; my sister has natural compassion, as do many of my friends and my best friend of all, my fiancé. Spending time with these people helps change my outlook.

 Prayer helps change me. I ask for compassion each day on my way to work. I pray to be able to see people as my Higher Power sees people and to treat them accordingly. I also read books that help me cultivate compassion. Alternatively, focusing on negative content in my conversations and reading can dampen my mood and tip me into more pessimistic attitudes.

Compassion doesn’t always look warm and fuzzy. Sometimes true compassion leads to difficult conversations, odd as that sounds. It can even lead to conflict, if I don’t remember to be respectful. If I didn’t feel compassion for patients, I wouldn’t take pains to talk to them about their lives and their desires for change.

No one is compassionate all the time. I have my early warnings that I’m slipping back into old patterns of thinking. For example, when I start making sarcastic jokes at other people’s expense…not good. I can justify by saying I’m blowing off steam and I’m only joking, but as a close friend pointed out to me, sarcasm is “flesh-eating” humor. It can be damaging to the person who is the butt of the joke and corrosive to me.

When I start muttering negative things under my breath at work…not good.

So, what do I do when I start feeling negativity?

First, I don’t have to express it. Expression of negativity contaminates my workplace. It can make my home life feel heavy. I try to keep it to myself. It’s my issue and I don’t need to make it my co-workers, patients, or friends’ issues.

Next, I try to decide why I’m feeling what I’m feeling. Usually, it’s because I’ve decided other people aren’t acting like I want them to. I’ve slipped into a pattern of thinking that other people, organizations, politicians, whatever, need to conform to my ideas for them. Which brings up the real issue: such an attitude shows I haven’t accepted the basic truth that there are many things in the world that I can’t control and shouldn’t try to control.

When I can accept people as they are, while still being willing to extend myself towards them when they request help, I’m in a good place.

Compassion helps me do my job better. Patients wanting help are more likely to engage in treatment when they sense their helpers are rooting for their success, and willing to go an extra mile to help them. Patients sense these things; a helper who is just going through the motions doesn’t inspire patients effectively.

I started to write this blog thinking that compassion is a difficult subject; the blog post could end up being a self-serving treatise extolling my virtue of compassion. Or it could reveal how much I struggle with compassion because at heart, I’m not a very nice person. I hope this blog post has threaded the middle ground by presenting the message that we can feel and act with more compassion by practicing, like any other habit. We can also refuse to cultivate more negative personality traits, like negative thinking and speaking. I’m not saying we should ignore problems when we see them, but rather try to focus on solutions.

Anyway, I hope 2021 is a better year for all of us. May we all feel more compassion for ourselves and others, and struggle less with negativity.

Holiday Guide for Families

Last year, who could have predicted that in one year, people would be making life and death decisions to travel to see family on Christmas, versus staying home? Many of us decided to postpone holiday gatherings with loved ones until the COVID situation is safer.

Each year I post a blog about getting along with family. I thought I could post the same thing this year, because while some family get-togethers may be online, the advice is still appropriate. So here it is again:

What to do:

  1. Do invite your loved one in recovery to family functions, and treat her with the same respect you treat the rest of the family. If you have resentments from her past behavior, you can address this privately, not at the holiday dinner table. Perhaps given how holidays can magnify feelings, it’s best to keep things superficial and cheery. Chose another time if you have a grievance to air.
  • Allow your relative some privacy. If the person in recovery wishes to discuss her recovery with the entire family, she will. Let her be the one to bring it up, though. Asking things like, “Are you still on the wagon or have you gone back to shooting drugs?” probably will embarrass her and serve no useful function.
  • Accept her limitations graciously and without comment. Holidays can be trigger for drug use in some people, and your relative may want to go to a 12-step meeting during her visit. Other people in recovery may need some time by themselves, to pray, meditate, or call a recovering friend. Allow them to do this without making it a big deal.
  • Remember there are no black sheep. We are all gray sheep, since we all have our faults. In some families, one person, often the person with substance use disorder, gets unfairly designated as the black sheep. She gets blamed for every misfortune the family has experienced. Don’t slip into this pattern at holiday functions.

What not to do:

  1. Don’t ask the recovering person if she’s relapsed. If you can’t tell, assume all is well with her recovery. If she looks intoxicated, you can express your concern privately, without involving everyone.
  • Don’t use drugs, including alcohol, around a recovering person unless you check with them first. Ask if drug or alcohol use may be a trigger, and if it is, abstain from use yourself. If you must use alcohol or other drugs, go to a separate part of the house or to another location.

Being around drugs including alcohol can be a bigger trigger during the first few years of recovery, but any recovering person can have times when they feel vulnerable, so check with them privately before you break open a bottle of wine.

If your family’s usual way of celebrating holidays is to get “ all liquored up,” then understand why a recovering relative may not wish to come to be with family at this time, and don’t take it personally.

For some of us, remaining in recovery is a serious issue, so please accept we will do what we must to remain in recovery, even if that means making a holiday phone call rather than making a holiday visit.

  • If your recovering loved one is in medication-assisted treatment with methadone or buprenorphine, don’t feel like you have the right to make dosage recommendations. Don’t ask “When are you going to off of that medication (meaning methadone or buprenorphine)?

Your loved one may taper off medication completely at some point, or he may not. Either way, that’s a medical decision best made by the patient and his doctor. Asking when a taper is planned is not your business.

  • Remember your loved one is more than the disease from which they are recovering.

Some people have diabetes and some people have substance use disorders. These diseases are only a small part of who they are.

Refrain from giving hilarious descriptions of your loved one’s past addictive behavior, saying, “But I’m only joking!” This can hurt her feelings, and keep her feeling stuck with an identity as a drug user. She can begin to believe that with her family, being an addict is a life sentence.

I hope this helps.

May all my readers have a Merry Christmas and Happy Holidays!

Deciding COVID Take Home Doses

(I am changing this patient’s description to protect identity)

We have only a few patients who refuse to wear masks. One of these people, an admission from a few months ago, has been dosed in his car since we don’t want him to endanger other patients by his refusal to wear a mask. He’s been dosing with us every day, but after the first three weeks I felt comfortable to give him Sunday and holiday toke homes.

Now he’s asking for the extended COVID take homes, which for a recent patient like him means up to four take home doses per week and coming to dose only the other three day.

But when his counselor first asked me about it, I snapped, “No! He says he doesn’t believe COVID is real and that’s why he refuses to wear a mask. Why should he benefit from COVID take homes?”

Even as I said this, it didn’t feel right.

Decisions about take homes, although ultimately decided by the medical director, shouldn’t be made on emotion. That’s why we have case staffing. So, I asked this counselor to present the issue at our case staffing session the next day.

I was pleasantly surprised at our staff. I heard some mature and considered responses.

One person said something to the effect that the take homes are for the benefit of the patient, whether that individual agrees with us about the risks of COVID or not. And those take-home doses also benefit staff and other patients, by limiting crowd exposure.

Yep, I thought, that’s the right answer.

Another person said she didn’t think this patient would misuse his take home doses, and he was compliant in all other matters, other than having continued positives for marijuana and not wearing a mask. And wasn’t that the main consideration, whether the patient can consume the take home doses as prescribed?

Right again, I thought.

One of the counselors pointed out that it would make nurses’ jobs easier by giving one less person to car-dose on those days he will get take home doses.

Yep.

Decisions about take homes shouldn’t be made with a punitive mindset. My reflex response to the patient’s counselor hinted of judgementalism, which is why it felt wrong. I was angry with the patient because he didn’t agree with me about COVID. Whether he agrees or not isn’t the point of the extra take homes, as my staff recognized.

So, this patient got his extra COVID take homes even though he doesn’t believe in COVID and I wish him well.

And I’m so proud of this staff of wonderful people I work with.

Injection of Transmucosal Buprenorphine Products

As I’ve said before on this blog, may people find my site by googling phrases like “inject buprenorphine,” so obviously people want information about that topic. I know what I’ve seen in my patients, but that’s anecdotal information, so I searched online for more scientific information.

Morbidity and Mortality Weekly Report, otherwise known as the MMWR, is published by the Centers for Disease Control and Prevention (CDC). In their August 14, 2020 issue, they discussed emergency department visits for complications from injecting buprenorphine products meant to be used sublingually (under the tongue). This formulation is the most frequently prescribed form of buprenorphine. [1]

The authors of the MMWR cited several studies pertinent to the topic. First, a study by Geller et al. looked at emergency department visits resulting from nonmedical use of prescription opioids. Of the 598 cases observed by one health system between 2016 to 2018, around one-third of those emergency department visits were for the treatment of intravenous use of sublingual buprenorphine products.

Of the patients who had complications from injecting buprenorphine products, two-thirds were male, and the average age was 33. Most of these visits (85%) involved the combination product buprenorphine/naloxone. In two thirds of the cases, patients were treated and released from the emergency department or left against medical advice, so most of these patients were not admitted to the hospital.

 In around a third of these patients, other non-pharmaceutical drugs were involved, such as cocaine or heroin.

In another study of one hundred and one emergency department cases of injection of buprenorphine products,  most of those patients had either skin abscess or cellulitis, but around 6% had serious infections such as endocarditis (infected heart valve), sepsis (blood infection) or septic arthritis (bacterial infection of a joint space). These last ailments usually require prolonged hospitalization and treatment with antibiotics.

The MMWR article concluded by saying buprenorphine is an important component of the public health response to opioid use disorders, and that patients may benefit from syringe exchange programs, information about infection prevention practices, and linkage to recovery support services.

I’ve written about the intravenous use of buprenorphine products in past blogs (January 15, 2017 and November 1, 2015). Clearly, medication meant to be used under the tongue is not safe to inject. This medication isn’t sterile, and besides the actual buprenorphine, there are fillers and other substances in the tablets and films that aren’t meant to be injected into veins. These substances can clog the veins, causing clots, or cause infections that can lead to abscesses.

For one thing, buprenorphine mono- and combo- tablets are made with a substance called “amidon” which is a starch that helps the tablet hold its shape. This substance appears to cause specific findings when injected through the skin into veins and may cause the inflammation and irritation we see in patients who inject this product.

So why do people inject buprenorphine? There are several reasons, chief among them being buprenorphine’s poor sublingual bioavailability. Injection of a drug means, by definition, that 100% of the drug makes it to the person’s bloodstream. Sublingual use of buprenorphine, either in the monoproduct or combination product form, has at best around 40% bioavailability. Patients buying buprenorphine on the street often feel that they are wasting money if they use tablets sublingually as the medication was intended and are tempted to inject buprenorphine to make it go farther.

But there are other reasons. Some patients get just as addicted to the “rush” of injecting as they do to the actual drugs. Some people feel a euphoria as soon as they start the act of injecting – preparing the needle, etc. – even before the drug is in their bloodstream. This yearning for intravenous use can be a difficult part of the addiction to defeat. I’ve had many patients in treatment who still feel an obsession to inject their buprenorphine, even though we could increase their sublingual dose to provide a therapeutic blood level.

As the information from MMWR shows, people are injecting both the monoproduct and the combination product, though the monoproduct has higher black-market value and is more desirable than the combination product.  As the study showed, 85% of the patients presenting to the emergency department after injecting buprenorphine used the combination product.

I’ve asked patients how they can inject a product that’s supposed to put them into withdrawal. Most of them shrug and say they still get a drug effect, and that if it makes them sick, it’s for a short time only. This puzzles me, since I was sold on the idea that patients could not inject the combination product without serious adverse side effects. Or maybe that’s why the people who injected the combination products went to the emergency department – they felt sick with precipitated withdrawal?

From the MMWR data, I conclude that injection use of buprenorphine occurs frequently. On the one hand, it’s probably safer then injecting heroin, now loaded with either pure fentanyl or various percentages of fentanyl and its analogues. On the other hand, injection of buprenorphine carries increased medical risk seen with any type of intravenous drug use, plus the tablets appear to be particularly caustic to veins and other soft tissues and can cause serious health issues.

At our opioid treatment program, we used to do observed dosing with buprenorphine products just like we do with methadone. Pre-COVID, we asked our patients to sit in a designated area while their dose dissolved. We did this so that patients wouldn’t be tempted to leave our facility with medication in their mouth then spit it out in the parking lot so that they could inject it.

I’ve had a few patients tell me that they were able to do this despite our precautions, and they got substantial infections. This is probably because ordinary human saliva contains some bacteria that causes big problems when injected into the bloodstream

Since COVID, we allow patients to leave our facility as soon as they place medication under their tongues, to reduce the time patients are exposed to other patients. However, if a certain patient has struggled with intravenous buprenorphine use in the past, I’ll ask that patient to stay in the dosing cubicle until he has completed dissolved the medication, so that he won’t be tempted to inject medication. And the patient won’t get take home doses until he makes significant progress in recovery, to the point he’s not at risk of injecting medication.

Upon admission, if a patient admits to past intravenous buprenorphine use, I’ll talk to that patient about starting methadone instead of buprenorphine. Methadone isn’t often injected, at least not for pharmacologic reasons, since it has such good oral bioavailability.

I do not think patients who inject buprenorphine products are appropriate for office-based treatment practices. I think those patients need to be referred to opioid treatment programs, where we have the experience and ability to address this situation. I know some good practitioners who disagree with me about this idea, feeling that any treatment at all is preferable to no treatment. I understand their thinking is based on harm reduction principles, but I also know that with other chronic medical illnesses, we refer the most complicated patients to specialists. The specialists at treating opioid use disorder should be found at opioid treatment programs.

After all, OTPs have been treating opioid use disorders with medication for decades, long before our recent opioid crisis.  I’ve come to realize that even office-based providers of buprenorphine rarely refer patients to OTPs. Incredibly, many office-based providers hold the same stigma towards OTPs as other medical professionals, and this needs to change.

But that’s a topic for a whole other blog.

Webisodes: Resources for Providers Who Work at Opioid Treatment Programs

I’m pleased to announce new resources for providers who work at opioid treatment programs. The Governor’s Institute of North Carolina and our state’s Department of Health and Human Services sponsored this work, which is a series of webinars addressing various topics encountered at opioid treatment programs. These webinars can be found here: https://addiction-medicine.org/training/otp/

Here are the topics:

Webisode 1: Safe Standard Inductions

Webisode 2:  8-Point Take Home Criteria

Webisode 3: Exception Requests

Webisode 4: Split Dosing

Webisode 5: Effective use of the NC CSRS (North Carolina Controlled Substance Reporting System)

Webisode 6:  Benzodiazepines, Alcohol, and Opioids

Webisode 7: Reinstatements

Webisode 8: Drug Testing

Webisode 9:  Standing Orders and Scope of Practice Issues

Webisode 10:  Admission Criteria and Exceptions

Webisode 11: Pain Management for Patients on Methadone or Buprenorphine

Webisode 12: Methadone vs. Buprenorphine

Webisode 13: Duties of an OTP Medical Director

Webisode 14: Interpreting Drug Screens

Webisode 15: Methadone, EKG testing and the QT Interval

Webisode 16: Medical Conditions that may Mimic Opioid Withdrawal

Webisode 17: Hospitalized Patients Returning to an OTP

Webisode 18: Special Dosing Orders for Tapers

Webisode 19: Neurobiology of Opioid Use Disorder

These webisodes were written by Eric Morse, MD, Lisa Wheeler, PA, and…me. We picked topics and wrote brief essays that became the scripts that Dr. Morse read on the Webisodes. Each time after one of us completed an essay, we emailed it to others for critique and adherence to current evidence-based literature.

Did we agree on everything? No, but we only disagreed on fine points, not on the underlying principles of good patient care. I’m pleased with the final product, as it represents our best efforts.

A few of the webisodes are dated because they were written pre- COVID. We’ve had changes in our state, allowing many more take homes under COVID exception provisions, so Webisode 2 is a little dated.

Dr. Eric Morse did the recorded presentations. I am allergic to video presentations, so I am very grateful he was willing to do these. Dr. Eric Morse is a fellowship- trained addiction psychiatrist, with over eighteen years’ experience working in this field. Dr. Morse did a wonderful job on camera, and the graphics that accompany the verbal information were clear and simple. These are short and concise webisodes, lasting between five to eight minutes.

I wrote about half of the webisodes and was surprised that I still learned much as I was writing.  I would write a paragraph, then wonder if there was newer data available, and I’d go back to do an internet search just to make sure. Sometimes I did find new data to include, improving my essay.

Nearly twenty years ago, when I first started working at an opioid treatment program, I was woefully underprepared. I did get a facility tour and several hours of information from a physician who was medical director at the time, which was great so far as it went. I could have used a manual to help me, and webisodes such as these would have been a godsend.

These days, we have all sorts of informational media: SAMHSA has published books, downloadable for free from their website, containing the basic information needed. TIP 63 is the latest iteration of this data. ASAM (the American Society of Addiction Medicine) has published guidelines for treating opioid use disorder with medications.

There’s the PCSS forum, sponsored by APPP, where providers can get a mentor to help guide them when using medications to treat opioid use disorders.

These webisodes are the latest educational supports available for free to any OTP providers and need to be watched if you are new to the field. Maybe they need to be watched even if you are “old” to the field like me. Sometimes I think I know something, but what I remember turns out not to be quite accurate

I am grateful to the Governor’s Institute and the NC DHHS for identifying this educational need and their support to fill the need. I especially appreciate Dr. Morse’s willingness to do the on-camera work.

Check out these webisodes and let me know what you think!

Book Review: “Drug Dealer, MD” by Anna Lembke, MD

I hated the title but loved the book.

I imagine some marketing hack told the author she needed a title that would grab people, and this is what they came up with. The book doesn’t talk much about the few doctors who turned out to be drug dealers. Rather, the book tells the story of pain pill addiction in our country, about how it happened and the contributing factors. Most importantly, it discusses how to prevent opioid use disorder and how to treat the patients who developed opioid use disorder.

I like this book because it’s concise. The author succinctly presents data without getting wordy or going off on too many tangents. Even with so many other competing books on the market, this one stands out. Published by Johns Hopkins University Press, it only runs to 152 pages. But since it was published in 2016, it missed the last few years of our opioid epidemic and how patients have switched to heroin, now that pain pills are scarce.

The author uses some patients’ stories to underline points of information in the book but doesn’t overdo this. Her first chapter is about the nature of addiction, with descriptions of risk factors for initiation of substance use, and risk factors for the development of substance use disorders.

In Chapter Two, the author told about the overprescribing we saw in this country, beginning at the end of the twentieth century. She described how the internet functioned as a supplier, though most other experts say the internet wasn’t a prominent driver of the opioid epidemic in its early years.

By Chapter Three, the author, a well-known and respected Addiction Medicine specialist, expressed interesting ideas about the role of “illness narratives” in some patients. By this term, she means some people with physical and psychiatric differences get labelled as having an illness, rather than being accepted as normal human variations. She uses the example of back pain, which she says in the past might have been looked at as a normal part of human existence, which now is termed a chronic pain disorder. The implications of the illness narrative are that pain should be viewed as something dangerous that must be got rid of, rather than endured, exposing the afflicted person to the dangers of opioids and opioid use disorder.

As an example of psychiatric differences, she uses the normal human tendency to become distracted, which in an extreme form is now labeled as an illness: Attention Deficit Disorder. This label of illness, she says, implies the need to medicate the condition. This illness becomes part of the person’s identity and thus their “personal illness narrative.” She says it’s tempting for people to blame their illness as the cause for life’s failures and disappointments.

Later in the book, in Chapter Six, she describes the dilemma of people who have adapted an identity of an ill patient, calling them “professional patients.” She makes a case that people who have been granted disability benefits have a financial incentive to stay sick, in order to maintain their benefits. They may become so psychologically attached to their role as a sick person that the thought of recovery and wellness is frightening.

Most of all I enjoyed reading Chapter Four, titled, “Big Pharma Joins Big Medicine.” She did an excellent job of skewering Big Pharma’s great deception: marketing which masqueraded as education. Big Pharma identified physicians they could influence to parrot Pharma’s lies and coronated them “thought leaders.” These professionals were paid speakers’ fees to give talks to other prescribers, extolling the benefits and lack of risks of opioids.

What hard-working and underappreciated doctor wouldn’t be flattered to be called a “thought leader?” Along with hefty speaking fees, I can see how pharmaceutical companies seduced some physicians, encouraging them to present Big Pharma’s message about how safe opioids were for chronic pain treatment, even though there wasn’t data to support those claims.

In a few paragraphs, the author succinctly describes how the FDA failed to prevent drug companies from marketing opioids for the treatment of chronic pain, despite the lack of studies about safety. She also deftly describes a new study technique that’s bound to skew data about opioids, called “enriched enrollment.”

Then in Chapter Five, the author describes stereotypic behaviors of patients who try to manipulate doctors into prescribing the medications that they want. The author prefaces these behaviors with a sentence saying the terms aren’t meant to denigrate drug seeking patients, but that’s exactly what she proceeds to do.

For example, she describes patients who try to filibuster and talk past the allotted time for the appointment as “Senators.” She describes patients who flatter doctors by telling they are so much wiser/compassionate/competent than any other doctors as “Sycophants.” Other patients are described as “Exhibitionists,” who display dramatic emotions and physical scars to underscore dire need for opioid medication.

I recognize all these behaviors, both in patients I see with substance use disorders and in primary care patients; however, to place labels on the behaviors of people caught up in the desperation of active addiction is unseemly. The book would have been better if this section was omitted. However, in that same chapter, the author neatly summarizes the basic principles underlying the treatment of opioid use disorder with methadone and buprenorphine.

Chapter Eight was the most interesting. This chapter is titled, “Pill Mills and the Toyota-ization of Medicine.” In this chapter, the author talks about physicians who work at pill mills, who have long ago given up the illusion of working to help people. They are in a business to give pain pills to people who want them, no matter if it’s in the patients’ best interest, in order to make a lot of money for themselves.

But then she starts talking about how medicine has become a business, and that pill mills are only extreme examples of how medicine has changed into an industrial business. Physicians have less autonomy as their practices are bought by hospital corporations. Treatment options for all illnesses are more often determined by hospital administrators, insurance companies, and treatment guidelines promulgated by agencies like the Joint Commission (used to be called JCHCO).

Doctors are expected to meet productivity quotas and see ever more patients in a day. I’ve heard practice administrators use the euphemisms “practice maximization,” and “increased patient throughput.” The author of this book describes how she was given monthly feedback about whether she was hitting the billing targets that had been set for her. If she wasn’t meeting these targets, set by her employers, she had more to worry about than caring for her patients.

Giving patients what they want is the quickest way to get on to the next patient, further exacerbating overprescribing. It takes much less time to write a prescription than to talk to the patients about non-opioid ways to treat pain, and about the emotional issues that make pain worse. And this applies not only to opioids, but other medications. What physician hasn’t buckled at least once to the demands of a patient insisting that a Z-pack always gets rid of her viral illness? It’s easier to write the damned prescription than it is to have a conversation about how antibiotics don’t work for viral illness, and how inappropriate use of antibiotics causes antibiotic resistance.

I commiserate with the time pressures she describes.

On my 40th birthday, nearly two decades ago, I was told by a practice administrator that I was too slow. I was “only” averaging six patients per hour, and I’d have to pick up the pace if I wanted to keep working there.

Driving home that evening, I was shaking with anger and fear. I knew I couldn’t deliver quality care seeing more than thirty-six patients per day. I felt defective, like there must be something wrong with me because I couldn’t (or wouldn’t) keep up the pace of my colleagues.

I made up my mind that I needed to look for some other type of work in the medical field. I told my physician friends I was open to new ideas, and a few months later I was asked to fill in for a friend who was going on vacation. He was the medical director of an opioid treatment program. Deeply skeptical at first, I eventually found this to be my niche. It’s intensely satisfying to work with patients and see the tremendous life changes that I never saw while practicing primary care.

I feel sorry for doctors who never found their way out of the production line. I’m not saying opioid treatment programs never push providers to see more patients in less time, but I haven’t experienced near the pressure in OTPs that I have working in primary care.

The author then talks about another driver of the opioid epidemic: patient satisfaction scores. Many medical practices conduct surveys of patients after visits, to get feedback on what patients like and what they don’t like. They are asked about their physicians.

 Initially, these surveys were said to help providers pivot to a more patient-centered frame of mind, to sensitize them to patient concerns. Now, patient satisfaction scores are considered a “quality measure.” Providers with higher patient satisfaction scores are assumed to have provided better care, despite some evidence to the contrary. Physician pay is often linked to these satisfaction scores, giving doctors another reason to prescribe what the patient wants rather than take the time to have a difficult discussion about substance use disorders. Providers know giving patients what they want gives better satisfaction scores, and indirectly, better pay for themselves.

Then there’s the whole internet “Grade your doctor” websites. The author describes her trauma of reading a bad review online that was found by her son, and her angst in wondering who it could be who left such unkind remarks about her as a physician.

Back when there were one or two sites for physician grading, the internet could have been a factor that had an impact, but now there are at least twenty sites for this. I think this dilutes the effect of any one site, reducing the influence they have.

In Chapter Nine, titled, “Addiction, the Disease that Insurance Companies Still Won’t Pay Doctors to Treat,” the author describes the problem that persists in the U.S., despite passage of the Parity Law in 2008. The Parity Act, which said substance use disorders and mental health disorders must be covered by insurance companies to the same extent as other medical illnesses, has not assured equal coverage. This is a frustration that most providers of care to patients with substance use disorders face daily.

Though coverage for medical care of substance use disorders isn’t great, coverage for the medical complications of those disorders is much better. The complications of intravenous drug use, for example – endocarditis, osteomyelitis, cellulitis – are usually covered if the patient has medical insurance. Yet most medical insurers still don’t cover care delivered at opioid treatment programs or cover it poorly.

In the last chapter of the book, the author gives reasons to hope that our nation’s opioid problem may improve at some point. She points to better education of medical students, residents, and practicing providers about prescribing skills. More providers in training are being taught addiction medicine basics, and addiction medicine fellowship training programs have been started.

She hopes substance use disorders will be viewed as the chronic illness that it is, rather than a moral issue or a short-term medical problem. She says providers need to be allowed to spend more time with patients to give better care. She describes new models of care for patients with chronic pain, using both non-opioid medications and non-medication treatments, which have been successful.

I really wish she would have re-iterated the benefits of medications in the treatment of opioid use disorders in that last chapter. But at least this author did write three pages about the benefits of medications like methadone and buprenorphine in the middle of the book, and that’s more than most of the recent popular books about opioid use disorder have done. I thank her for that.

But then…she is an addiction medicine specialist, so maybe I’m justified to be a bit disappointed by this.

But this book is succinct, the data is accurate, the patient stories typical for many patients, and she does a wonderful job of documenting factors that merged to cause our present opioid problem.

For any person interested in opioid use disorders, I strongly recommend this book.