Dealing With Disillusionment

 

“You know what? Let’s just switch every patient over to methadone and be done with buprenorphine!” I said angrily during case staffing last week.

This all started several weeks ago, when an angry patient was leaving my office. I don’t recall why he was unhappy with me, but on his way out of my office, he was venting about how he was being treated harshly, compared to patients doing much worse things. He said many patients leave our facility after dosing with buprenorphine with much of the medication packed between their teeth and lips. He said some people sold it, and some injected it, and that we were too stupid to see it.

I didn’t think much about it, but later that day at case staffing, we discussed asking patients to show us the area between teeth and lips, just to see if diversion in this manner was occurring.

I need to explain why we don’t want patients to leave with buprenorphine still in their mouths. Because we are administering this medication at an opioid treatment program, we must abide by different rules than an office-based buprenorphine practice. While physicians in office-based practices can prescribe as many days’ supply of medication as they see fit, different rules apply to opioid treatment programs.

In my state, buprenorphine patients still have to meet time in treatment requirements, same as methadone patients, before they can get any take home doses. Fortunately, our State Opioid Treatment Authority (SOTA) leaders are intelligent and reasonable people, and allow us to ask for take home exceptions early, at the four to six-week mark, for patients on buprenorphine who are doing well and have a couple of drug screens showing only the prescribed medications. This is because buprenorphine is so much safer than methadone.

But when patients first start, or if they’re still using other illicit drugs, or if their lives are unstable in some other way, they must do daily observed dosing with us.

Observed dosing means that they stay on premises while the medication is consumed. With methadone, it’s a quick swallow, and the patient says goodbye, and it’s done. With sublingual buprenorphine, our patients sit in a designated and monitored area until their medication is fully dissolved. We’ve had some patients walk out of the building with buprenorphine still in their mouths, and inject that buprenorphine. Because of that, we ask the patients to show a nurse under their tongue that the med has dissolved before they leave our facility.

But this idea that some patients may be packed medication between their teeth and lip was new. The nurses picked one day to ask all patients to show them their whole mouth – all around teeth, under tongue, after dissolving.

They discovered a handful of patients who had packed medication into a cheek, clearly with the intent of taking that buprenorphine outside the premises.

What did they intend to do with it? I don’t know. Maybe they planned to give part of their dose to a loved one. Maybe they planned to take it later, or maybe they planned to inject it. Maybe they sell the buprenorphine. I have no idea, but I have clear evidence that the patient isn’t taking the medication I’m prescribing.

I have an obligation to prevent diversion of medication I prescribe into the black market. If I know a patient is engaging in behavior that’s suspicious for diversion, I can’t in good conscience continue to prescribe that medication.

We could enter a discussion about how diverted buprenorphine is really a harm reduction method, by providing a safer opioid to the people in the community with opioid use disorders. But opioid treatment programs, called “methadone clinics” in the past, have long histories of stigma. Law enforcement types and regulatory inspectors do not want to hear about harm reduction. Some of these people barely tolerate our existence as it is. I support harm reduction, but I must deal with the world as it is now.

Diversion from an opioid treatment program can get that facility shut down.

When the nurse called me with a list of names of people engaged in diversion of buprenorphine, I had to tell her I will not prescribe any further buprenorphine for those patients. They must either switch to methadone or seek treatment elsewhere.

About half chose to leave and the other half chose to start methadone.

We felt like we had to start checking patients’ entire mouths every day, and found more patients who were diverting their medication. All in all, about ten patients were found to be attempting to divert.

I did not react well. I was furious.

Before you write a comment to me saying how unruly behavior is often a symptom of the disease of opioid use disorder, and that I shouldn’t take such things personally, and that the majority of patients were dosing correctly and that’s what I should concentrate on…yes, I know all of that.

But I had to go through a process to get there, and maybe writing about it is my way of dealing with these feelings.

I get particularly upset when a patient does something that threatens my view of myself as an effective helper. When it starts to look like I’m making it easier for some patients to inject themselves with buprenorphine, I feel anger initially, but underneath that emotion is a whole lot of fear.

I fear I’m not really making any differences in the lives of these people, and that they all look at treatment as a joke. I’m afraid I’ve been deluding myself that medication-assisted treatment helps patients. I wonder if I should go back to primary care practice, where nothing I ever said or did seemed to make a bit of difference in the lives of people with chronic illnesses. I fear that the MAT detractors are right, and that I’ll end my days by regretting the action and advocacy I’ve taken over the past decades.

I feel disillusionment.

As you can see, my strong negative emotions sometimes trigger a runaway train in my mind. Thankfully, as I age and mature, the train slows much faster than it used to.

I’m better now. Thankfully, I can go back to the information that lead me to this field in the first place…the decades of scientific information that show beyond a reasonable doubt that while individual patients may fail to improve with MAT, overall it saves lives. Then I can look at the smiling faces of patients who have completely changed their lives while in treatment.

When I get to the point I can look at reality uncolored by emotion, I see the vast majority of patients at the opioid treatment program are doing very well. Nearly all have improved in some way, some more than others, of course. Some of them do have rocky starts, but can do well if we address the issues and get them to stay in treatment.

Early into the New Year, I’ve re-learned a lesson about disillusionment, fear, and the process of working through all of that to a more reasonable view.

I suspect many people in the helping professions deal with this process over and over. It can be challenging, but such jobs are rewarding as well.

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22 responses to this post.

  1. I go through exactly the same range of emotions that you have discussed every time I identify diversion attempts in my clinic. Early on, I viewed each one of these attempts as a personal affront and reacted as if it was. Now, I address each one of these episodes on a case by case basis, take a deep breath and then look at the vast majority of my patients who have truly turned their lives around. The biggest problem that I have now is finding that fine balance between being a patient advocate and being a ‘diversion detective’. Some days I do better than others in finding that balance. I have the luxury of precepting third year medical students during their too short exposure to addiction medicine. They participate in my clinics and do a great job at keeping me grounded because one of the things that I try to impart is the importance of a therapeutic alliance, even if I’m not particularly feeling it that day. One anecdote: recently I identified a case of urine adulteration that was partly my fault. I have a gentleman who has been in my clinic for over two years. Early on, he continually tested positive for THC and each time he came in, I lectured him on the increased likelihood of poor outcomes, increased risk of relapse etc, etc. After awhile, his onsite urine drug screens were negative for everything except buprenorphine and I felt I had finally gotten through to him. For some reason, after about a year, I sent off his urine to our lab, and lo and behold, urine creatinine of 4 and high buprenorphine levels and no norbuprenorphine; clear evidence of spiking and substitution. I confronted him with some degree of anger and gave him my usual diversion spiel and he tearfully told me that he had been doing it so I wouldn’t find the THC in his urine and discharge him! So I’ve had to go into a real harm reduction mode with him; not condoning his frequent MJ use, but realizing that discharging him would probably have a much worse outcome. They don’t teach this stuff in Addiction Medicine fellowships and one of the reasons that I counsel our fellows that while MAT isn’t rocket science, it can be very nuanced.

    Reply

    • Posted by Julian on January 29, 2018 at 11:36 pm

      What I don’t understand about MAT is the necessity to even do broad drug tests. Benzos and alcohol, yes, as they pose a risk when combined with the treatment being prescribed, but why care about anything else?

      Patients are there to quit Opioids, not necessarily to become teetotal. Forcing that on them is just going to push some people out of treatment. I also think it’s none of the Doctor’s business to be honest.

      Reply

  2. I just wanted you to know there are patients that appreciate people like you..its good to be human and have feelings..I would be worried if you didn’t have feelings…you care that’s why you do what you do.

    Reply

  3. Posted by Lovelace on January 28, 2018 at 4:33 pm

    Good stuff! I’m finding that the stigmata associated with methadone is morphing into ignorance. So many physicians simply don’t know anything about MAT. When I tell them the details of the OTP they become curious and want to know more. You’re doing a fantastic job Doc; helping not only desperate patients, but also helping physicians who are new to this area of practice.

    Reply

  4. Posted by Alan Wartenberg MD on January 28, 2018 at 4:48 pm

    Jana, I have been in the field, as a patient and as a provider, since 1971, the year my own addiction started early in my senior year of med school. I have myself done virtually every one of the awful things that make you furious (and made me furious at myself, and ashamed, but which I did repeatedly none the same). It is hard, and we have to work to forgive ourselves, just as we work to understand (and sometimes forgive) our patients. Your train slowed much faster and more efficiently than did my own!!

    Reply

  5. Posted by matt mcclure on January 28, 2018 at 5:32 pm

    What you feel is very real and valid. There have been a number of times when I was ready to throw in the towel and send all my patients to an OTP and be done. Unfortunately every year there are buprenorphine prescribers who do just that.
    Then the next patient that comes in has been doing very well, ‘gets’ recovery and have completely turned their life around. I currently have about 50 people in that category, they are the reason I keep at it, and hope that the other 40-50 get there with time. The second group is where my high turnover and frustration arises from.
    Great blog post in my view and I always appreciate your posts as well Dr. Wartenberg.

    Reply

  6. Posted by John on January 28, 2018 at 5:35 pm

    Respect,

    Reply

  7. I am a local advocate for everything there is to accomplish when it comes to Substance Abuse.
    The special thing about diversion with Suboxone, its the only diverted med to help addiction, as opposed to get high.
    I saw a study, and wish i could relocate, i believe it was a law enforcement agency. It showed how very little suboxone they pulled off the street compared to every other illicit substances.
    I wish you could take an anonymous survey as to WHY those patients were saving it? Relative’s and friends without insurance? Proving to others it worked and they too coyld be helped?
    Please email me about a case specific Suboxone arrest. This poster kid for how Suboxone when combined with therapy
    and… Was arrested due to constable ignorance. Even with proof of prescription, and His ongoing treatment the assistant prosecutor failed to do anything but reduce charges. Needless to say it is having a huge impact on talking those suffering into treatment.
    Ok. This was two posts in one.

    Reply

  8. Posted by Julian on January 28, 2018 at 8:47 pm

    I don’t know if I should out myself like this, but here goes.

    I am a legitimate Buprenorphine patient in Australia and I also buy diverted Buprenorphine. I wouldn’t buy some that had previously been in someone else’s mouth; mine come still sealed, so it’s from people who get takehomes I guess.

    I don’t buy it to inject, increase my dose, or to get high. I am using it to help me taper.
    I also hold onto some in case there’s an emergency and I can’t get to the dosing point for some reason (or they’re out, unexpectedly closed, etc).

    Here, at least for 12 months, I can’t get a month’s worth of takehomes. Takehomes start at 3 months and slowly increase (with no consecutive doses untill it’s unavoidable). It’s not about me, it’s the law. I am a long way away from having the monthly takehome option.

    I am trying to taper to a lower dose as my current dose is too high. I went up really high, really fast. My doctor’s solution to any problem/issue/discomfort I had was to up the dose and I ended up on 28mg, which I could quickly tell was far too much.

    This reduction is being done with my Doctor’s support, and subsequently, he has given me a prescription that allows me to vary my dose at the pharmacy (dosing point) by 4mg or 2mg a day. I am not reducing to come off, just to find the lowest effective dose with the least side effects.

    The biggest problem with this is that we only have 2mg and 8mg strips, so the smallest reduction I can make is 2mg. The first few 4mg drops were ok, but now I’m finding 2mg drops to (sometimes) be too much.

    Once again, the Buprenorphine guidelines get in the way. They state that dosing points must not cut the strips. They even state people should do their final jump from 2mg.

    I asked if there was anything my doctor could do to help and he said no. I went and got a second opinion from another doctor who said “you might just be stuck on Buprenorphine forever then”.

    So now I buy sealed strips on the street, and cut them into pieces. I request a 2mg dose reduction from the pharmacy, and top it up with the ‘illicit’ Buprenorphine so that my reduction is only 0.5mg, 1mg or 1.5mg – whatever I can cope with.

    I do feel bad doing this, but I see no other way out of my situation. Even if I waited the whole year I still need to take 1 dose at the Pharmacy and the other 29 at home. That could be dangerous if I was tapering and suddenly had to take a massive supervised dose.

    I am happy to admit what I am doing is legally wrong, but ethically and morally I am alright with it.

    The people selling their Buprenorphine are obviously doing the wrong thing, however, without them I’d be seriously stuck.

    Anyway, this is just an opinion from the other side of the fence. I hope it provides a different perspective.

    Reply

  9. I think the patients that are diverting aren’t there for the right reasons or are still having a rough start. At least they are in treatment, they could be doing worse always .

    Reply

  10. Posted by Gail Scott on January 28, 2018 at 9:20 pm

    Boy did I need to see this today…I’m an addictions counselor at an OTP, previously worked as a pharmacist and a big fan of MMT for opiate addiction. A client I had seen early Friday had 4 weeks of negative urines & I complimented her on her hard work (she happens to have her masters in social work) of staying clean. However, upon checking her urine screens, she has no EDDP in her urine samples, meaning she’s bringing in fake urines. My first response was “HOW COULD SHE DO THIS TO ME?” I brought myself under control rapidly but this post meant a lot to me.

    Reply

  11. Dry mouthing or dry pocketing goes on in every clinic.they all eventually end up making each patient open their mouths and show gums and under tongue .it becomes part of the process. And is a great deterent.you’ll see people transfer clinics right after you do it.then catch some ,then after that you’ll only catch one every now and then or newbies… Sorry you gotta do it but its jus a added step to protect you n your clinic and the patient/client from themselves.

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  12. I wish we did not even call treatment medication assisted treatment. We do not call it that for any other illness that is treated by way of medication. Personally I think it further stigmatizes the illness. We need you and more like minded persons in the field. Of course you have feelings and get frustrated as hell with us we are aggravating, hard to deal with people, no doubt. ( I am on suboxone 9 months sober, relapsed after 6 years) Its so difficult to train our minds to think differently in the area of addiction/recovery…. Dealing with elderly, Alzheimer, and, mental illness is extremely frustrating too BUT for some reason because there is NOT a choice we struggle more with substance abuse disease.. Im an addict and I struggle with it when helping others.. Thank you for your service and for making a difference. YOU ARE MAKING A DIFFERENCE….. 🙂

    Reply

  13. Posted by Tony Goodman on January 29, 2018 at 4:55 pm

    That’s the truth!

    All the best,

    Tony togood464@gmail.com

    >

    Reply

  14. Posted by Sean McKinnon on January 30, 2018 at 1:43 am

    I wonder if any of those who were caught “diverting” simply had to be at work/school/catch a bus etc… I know some people have trouble dissolving the medication. Maybe they were just trying to leave but fully intended to continue to let the medication dissolve?

    Reply

  15. Posted by Craig on January 31, 2018 at 3:37 am

    What little buprenorphine that a person would be able to get out of their mouth would just be a big wet blob,I do not see what the big deal is if some buprenorphine is diverted to the street,you cannot overdose on it being you are an opiate addict and only reason a addiction wants it is to keep from being sick,that’s it,it can help more if it is diverted if you really think about it,what is the big deal???

    Reply

  16. Posted by Martin on January 31, 2018 at 10:36 am

    Not all buprenorphine formulations are the same. E.g. Zubsolv disintegrates very rapidly and would probably be difficult to cheek. Perhaps disintegration properties would be an important factor worth looking into when selecting dosage form for OTPs with monitored dosing?

    Reply

    • Posted by craig on February 5, 2018 at 8:03 pm

      what difference would it make about the formulations????if you put the strips,pills,whatever in your mouth for just a few minutes it is gonna turn into a big blob of nothing that is useless,i mean it wouldnt be enough left to sell to anybody who the heck would buy something like that and take chance of getting hepatitis,aids,whatever,i sure would not,and if i was gonna inject something it sure wouldnt be buprenorphine,it would be a full blown opiate,this is made into a huge deal when it is really nothing at all.

      Reply

  17. Posted by Tracie Walker on February 4, 2018 at 3:58 pm

    Dr Burson. I enjoy your blogs and has made me understand addiction and medication more clearly. I know this is off the subject matter but I am inquiring about the increase abuse ad Neurontin. I know that it helps a lot of people and is non-narcotic but it seems those already with an addiction are predisposed to an addiction to Neurontin. Would love to see a blog on this subject. Thank you

    Reply

  18. Reblogged this on My Sharing Blog.

    Reply

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