The Good, the Bad, and the Ugly


The Good


Probuphine was approved by the FDA. I’ve written about this medication in several other blog posts. Probuphine is an implantable form of buprenorphine that lasts for six months. It will be suitable for buprenorphine patients who are stable at 8mg per day or less.

I think logistical problems will prevent this medication from becoming mainstream. I hear it must be implanted in a surgical suite, which makes little sense. Maybe it’s more involved than I realize, but I had been under the impression it could be done in an office setting, like Norplant.

I’ve also read that the physician must purchase and store the Probuphine implant, which adds financial risk and DEA scrutiny to a buprenorphine physician’s already crowded schedule.

As I’ve said before, I predict Probuphine will be administered at a few specialty centers, but isn’t likely to be done by most mainstream addiction medicine doctors. Still, it’s another option that hopefully will work well for patients on less than 8mg per day.

Watch your language

The field of Addiction Medicine is pushing for non-stigmatizing language to be used by treatment professionals. Words are important, and some words carry hidden and pejorative meaning in the general public.

For example, I’ve always cringed when I hear the term “dirty” or “clean” urine drug screen. I have to quash my desire to be sarcastic towards the speaker. The proper terms are “positive,” meaning a substance was found in the urine, or “negative,” meaning a given substance wasn’t found in the urine. Addiction Medicine gurus continue to emphasize the importance of using proper clinical terms. I enthusiastically agree with their efforts.

Now experts in the field want to get rid of the term “addict” and “opioid addiction.” They want to replace those words with terms such as “person with opioid use disorder,” and “opioid use disorder,” respectively.

I understand the reason behind these recommendations, and I agree with them, but it’s going to be tough to replace a two-syllable word with a ten-syllable phrase.

Besides, when I say the word “addict,” I suspect I mean something very different than the average person using the word. In my mind, the word “addict” has come to mean “person with the disease of addiction who is probably more likeable and interesting than an average person.”  But then, I chose to spend my career treating these people, so of course I think that way.

Contrast that to an average person in the community, to whom the word “addict” means a bum in the gutter with a needle hanging out of his arm. Most of the time, people are surprised when then encounter real addicts, or to use the new term, people with an opioid use disorder. Because since anyone can develop opioid use disorder, these people usually don’t look different from the rest of us.

Government Support for Addiction Treatment

When the President of the United States endorses medication-assisted therapies, we have arrived. That’s old news now, since he has been discussing MAT in some of his addresses since last year, as a way of addressing the opioid overdose epidemic. But now the promised money is starting to become available.

Available grant money fueled plans for new, collaborative opioid use disorder treatment programs in our state…

One primary care low-cost clinic just started working with their local opioid treatment center to provide needed primary care to patients in that OTP. Referrals should flow both ways, with the OTP sending patients to the medical clinic for needed healthcare, and the medical clinic will detect opioid use disorders in their patients, and refer them for treatment at the OTP.

An exciting initiative to connect people involved with the criminal justice system with appropriate medication-assisted treatment is in the planning phase. With this program, prisoners being released and people under parole and probation will be evaluated by addiction medicine doctors. Where appropriate, they will be offered methadone, buprenorphine, or naltrexone, to better treat their illness, and they will get increased counseling.

Prescription Monitoring Programs Work!

I had a few spare hours last week, and was able to look at around 125 of my 450 OTP patients. I discovered only one patient with some questionable findings, and she’s scheduled to talk with me this week.

What a change from 2007, when over 20% of all my OTP patients had serious prescriptions for opioids, benzodiazepines, and/or stimulants. These were prescriptions about which I knew nothing. Patients had filled prescriptions and there was no way for me to know about it, until our prescription monitoring program came online in mid-2007.By the time I got access late in the year, I found data indicating over a fifth of our patients were filling prescriptions that could harm them with the methadone I was prescribing.

Over the last nine years, our system has improved, making it ever easier and more accurate.

The Bad

All Use of Methadone is Toxic?

Perhaps in response to my blog post that was critical of the medical examiners in North Carolina, a medical examiner called me.

My complaint in the June 5, 2016 blog is that any patient who dies while on methadone maintenance is said to have died from methadone toxicity, regardless of clinical information.

This doctor and I had a cordial yet frustrating conversation. The physician introduced himself and said he was calling me because he had promised to do so after I spoke with him last year about a patient of mine who had died. When we last spoke, the toxicology results had just been sent off. He called yesterday to tell me that the level of methadone in this patient was toxic, and that along with the cocaine found in her system, he was reporting cause of death as “Methadone toxicity, cocaine toxicity.” I already knew this from reading incident report data, but I didn’t interrupt him. I was hoping he would give me additional information, but he didn’t.

When he was done, I informed him, again, that she had dosed at 130mg of methadone for months in the several years prior to her death. At her request, we started a slow taper. She came down on her dose by 5mg every couple of weeks, and she had been dosing at 60mg for several weeks prior to her death. I asked him how, with that information, could he still say she died from methadone toxicity?

He didn’t have an answer, and just repeatedly said her methadone level was “toxic.” He read the level to me, and I told him that I have patients with trough levels  higher than that.  I told him toxic for an opioid-naïve patient may be just what one of my patients needs for stabilization.

I don’t think he ever heard what I was saying. He never got off the topic of drug levels, and implied perhaps she could have obtained methadone from another source.

I suppose this is possible, but unlikely. For this patient to have overdosed on methadone, she would have had to gotten a supply of the medication from another source. I know she didn’t get a prescription for it, since I checked the state prescription monitoring database. And why would she buy illicit methadone off the street when she could just ask to go back up on her dose if she were in withdrawal?

I appreciate that this doctor took the time to call me. He didn’t have to do that, and it probably wasn’t an easy conversation for him. I don’t doubt he’s conscientious at his job.

I only wish he could have heard what I was saying.

What I heard him was saying was more of the same: the medical examiners will base their decision about cause of death on the methadone level, and will not consider any clinical information from me, or presumably from any another other opioid treatment program physician, if a patient dies under my care.

This increases the risk of being a doctor at an opioid treatment program. Because no matter how cautious we are, we treat a group of people who die at higher rates than age-matched controls. Nearly all of our patients smoke cigarettes. Of course they can die from methadone overdose, but they also die at higher rates from cancer, heart disease, liver failure, and other medical problems created from a life time of drug use, including nicotine.

But we now know in advance that methadone will be blamed no matter what. And that’s bad news

The Ugly

Heroin Comes to Town

Last week, several people who should know and have no reason to lie told me heroin can be bought in Wilkes County. I am really sad to hear this.

Heroin has already invaded many small communities. It crept in after black market prescription opioids pain pills became scarce. Indeed, at my state’s yearly Addiction Medicine conference, most OTP doctors said they’ve been treating heroin use disorder for several years.

For some reason, the people I admitted to our opioid treatment program have thus far been around 98% pain pill addicts. Last week, more than half of the new patients were using heroin. One patient came to treatment because the first time he used heroin, he overdosed, nearly died, and woke up in the ambulance. That scared him enough to propel him into substance use disorder treatment.

You may question if heroin addiction is that much worse than pain pill addiction. I think it is, though I could be wrong about this. With pharmaceutical grade pain pills, the user has an idea, usually, of how strong the product is. There’s not much variation from one pill to another. But with heroin, the batch one day could have only a few percent of pure heroin, or 100% pure heroin. There’s no way to know. There’s no way to gauge how strong it is, unless the user dose a “tester shot.” This is when the user uses a small amount of the purchased heroin to see how strong it is. This tester shot is recommended by Harm Reduction Coalition as a way to reduce overdose risk.

Heroin manufacturers usually don’t care about quality control. The heroin could be cut with God knows what else. Some of these substances cause special problems, since they weren’t meant to be injected into the human body.

Quinine, for example, has been found as a contaminant. I’m not sure why it’s used to dilute heroin, but it is. Quinine can cause kidney damage, bleeding disorders, and severe allergic reactions. Some experts believe many heroin overdoses are really fatal allergic reactions to products used to cut the heroin. In the street parlance, adding substances to a drug is called “stepping on it,” meaning diluting it so it can go farther and make the seller more money.

Other regular heroin contaminants include caffeine, talcum powder, powdered milk, chalk, or flour.

Recently there’s been a tendency to include fentanyl in the heroin product, making it an even stronger opioid. This has caused many overdose deaths, particularly in the Northeast. I strongly suspect that’s what my patient with the near-fatal overdose injected.










9 responses to this post.

  1. Posted by dahau7 on June 14, 2016 at 1:51 pm

    In the future, we will see more Fentanyl and less Heroin. It may be passed off as Heroin, and even retain that street name, but it will be produced in labs, not poppy farms. That is the reason we are seeing Fentanyl laced Heroin – Fentanyl is cheaper, and easier, to produce. Market forces make this a certainty.


  2. Posted by Alan Wartenberg MD on June 14, 2016 at 2:57 pm

    I once testified in a medical malpractice case in Virginia, where (at least at the time) the medical examiners office had a “boilerplate” disclaimer on cases where toxicology was used, and basically said that a level of dependency-producing medications could not be considered “therapeutic,” “toxic” or “lethal” without considering the tolerance of the patient and had a paragraphs long discussion of that issue. I think Dr. Burson is being overly kind to that particular medical examiner who, in fact, does NOT know what he is doing, at least regarding the issue of methadone toxicity. What he IS doing is endangering the practices of many physicians treating both pain patients and people with opioid use disorders, and causing families to initiate inappropriate lawsuits that endanger the accessability of treatment for both conditions.

    Also, to make the ugly even uglier, we are now seeing levamisole as a cut, not only for cocaine, but in heroin in the northeast, with 2 cases of levamisole induced vasculitis being reported in our area.


    • Thank you Dr. Wartenberg!! Given your experience and excellent reputation in this field, it feels very good when you validate one of my chief complaints. It does cause anguish to the families, to be told the treatment killed their loved one.


  3. Posted by Theodore D Fifer MD FACS on June 15, 2016 at 12:16 am

    Hi Dr Burson,
    I just finished the Probuphine® Course as an implanter/ prescriber. Braeburn did not give us any information even implying that the implant procedure is restricted to surgical suites. They were quite specific about implantation being an office based procedure. All of our instructors were surgeons.
    As a surgeon I saw no reason whatsover that the implantation should be restricted to surgical suites and above.
    I hope this resolves your concern.
    Best Regards for your work
    Theodore D Fifer MD FACS


    • Thank you for this useful information. It was hearsay. Nice to hear from someone who took the course.
      How do you order, store, charge, etc for Probuphine?


  4. Posted by Matthew C McClure, D.O. on June 17, 2016 at 3:41 pm

    Regarding terminology, I use expected or unexpected. If someone is taking buprenorphine and it isn’t present then that is an unexpected result rather than a negative UA. A person on Adderall with be expected to have amphetamine present rather than a positive drug screen. Positive often seems to equate to dirty and negative with clean.
    My Sub practice is seeing more people that have transitioned to heroin over the last few months. I wonder if it is an unintended consequence of prescribers getting more strict or what seems at times manufacturing reasons to kick people out of their practice.
    I appreciate your blog, and often the comments that follow. Keep up the good fight.
    Oops; not fight, work.


  5. Posted by Theodore D Fifer MD FACS on June 20, 2016 at 12:21 am

    The implants are packaged singly, 4 to a kit. Storage is USP controlled temperature, (basically room temp). Each implant is 26mm long and placed in a very shallow subcutaneous plane as they are intended to be removed in their entirety at the end of six months. At that time significant amounts of buprenorphine remain in the implants so they should be handled and disposed safely.
    Braeburn has adopted a policy of purchase before implant so presumably the inserter should have the finances arranged prior to implantation. Braeburn also offers to help with obtaining reimbursement vs. price reduction in event of difficulties. The issue of coding was skirted by the presenters.


  6. Posted by Diana on January 26, 2019 at 7:09 pm

    I agree that heroin users are at higher risk of unintentional OD due to batch variability (although my patients tell me that this is a bigger problem with white-powdered heroin than the black tar or brown powder heroin common in my area). However, I’d disagree that pts in recent years have a good idea of the purity/dosage of black-market pills. When pts were able to get scripts from pill mills and fill them at pharmacies, that was true. But according to my pts, that ended a while ago. Now, most of the opioid pills on the street are counterfeits that are just as likely to contain fentanyl and fentanyl analogues as heroin. A patient told me recently that he had to give Narcan to several friends who’d bought black market Norcos that turned out to be fentanyl (when I looked up fentanyl’s PO bioavailability, I was surprised to see that it was around 1/3. I’d been taught that fentanyl had really poor PO bioavailability).

    I think heroin users are much harder to transfer to MAT b/c they tend to have such a higher baseline opioid tolerance. My understanding is that this is a function of economics. Oxycodone, morphine, hydrocodone, etc, have always been expensive on the black market, whereas heroin is, relatively speaking, cheap. That’s been my impression based on pt interviews (I always ask patients what they use, what it costs, why they switched from pills to heroin, etc.)

    My average patient had a habit in the $30-60/day range. According to many pts I’ve interviewed, $60 on the street will buy them an 100mg generic morphine ER tab, three 20mg OC ER pills, or 6-10 Norco 10/325 tabs. Different pts quote different prices for different pills, but it seems like they all agree that $60 will get a patient somewhere in the range of 80-120 MMEs.

    But in my area, $60 buys 1.5 – 2 grams of tar or brown powder heroin. Hard to know purity, but I had a patient with a chemistry PhD who used to test purity (which predated the incursion of fentanyl), and she said street purity of tar heroin averaged 25 – 40%. Even if it’s only 20%, 1.5 grams of heroin will contain 300mg of diamorphine. That’s ~900 MMEs (and if they’re injecting, as most begin to do once they switch to heroin, it’s >2500 MMEs).

    That’s an enormous difference in baseline opioid tolerance for patients with the same sized habit in dollar-value. In my experience, the vast majority of patients taking prescription opioids could be transitioned onto SL buprenorphine with minimal discomfort. But most heroin users have been pretty uncomfortable their first few weeks on bupe, and not many of them have stuck it out. A few have done great on bupe, but most have required MMT. And their higher baseline tolerance meant that it took a frustratingly long time for their OTPs to up-titrate them to a minimally effective dose.

    As repugnant as I found pill mills, from a harm reduction standpoint, I sometimes think our pts with OUD were better off in the pill-mill era.


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