Older Patients at Opioid Treatment Programs, Part 2

 

 

Co-occurring medical issues complicate treatment of our patients at any age, but are more common in older (over fifty) patients.

Any of our older patients who report chest pain need an immediate workup for coronary artery disease (CAD). Since almost all our patients smoke or have smoked, CAD occurs frequently. Few of them know if they have high cholesterol or not, though most know if CAD has occurred in close family members, or if they have a personal history of diabetes or high blood pressure, which are other risk factors for CAD.

Some of our patients have used stimulants, which can cause certain types of heart disease including palpitations from cardiac arrhythmias. Long-term stimulant use can also cause cardiomyopathy, a disease that permanently weakens the heart muscle.

Methadone, but not buprenorphine, can cause a certain type of heart problem known as prolongation of the QT interval. To simplify, prolongation of the QT interval involves the electrical system of the heart. An extreme prolongation can put patients at risk for a potentially fatal heart rhythm problem. Patients with heart disease may need an EKG before and during methadone treatment to look for this specific problem. Minor heart ailments like mitral valve prolapse, or a murmur with no underlying structural problems may not be influenced by methadone at all. When in doubt, it’s easy to get an EKG.

Since my background is Internal Medicine, I feel comfortable reading and interpreting EKGs, as I did in primary care. I refer to cardiologists when there’s a problem. Most often, the cardiologists say that the benefit of methadone outweighs the risks of QT prolongation. That’s helpful, because my patients and I need information about the risk versus benefits of medication, to decide how to best move forward. Each patient is different, the patient must be part of the discussion of risk. Some patients don’t mind the extra risk, while others can be very bothered by it.

Respiratory problems can be made worse by methadone. Buprenorphine can also affect breathing, but to a lesser effect. However, almost always, these two medications reduce the overall risk of death when compared with uncontrolled use of illicit opioids in patients with respiratory problems.

The more severe the respiratory problem, the trickier methadone administration can be. Since opioids, including methadone and buprenorphine, can reduce respiratory drive, COPD with retention of carbon dioxide is one of the most worrisome conditions.

Patients who retain carbon dioxide have such severe obstructive lung disease, most often caused by cigarette smoking, that the patients have problems expelling carbon dioxide, a waste product of respiration. The CO2 accumulates, giving a chronically elevated level. This happens slowly, so that patients’ bodies make accommodations to keep the blood pH normal. Normal patients breathe faster when the body accumulates carbon dioxide, but patients with severe COPD can no longer do this. When respiratory depressants like opioids are used by these patients, there’s a danger that breathing will slow more, causing a potentially fatal build-up of carbon dioxide. In these fragile patients, it is best to use a much lower starting dose of methadone than usual, and to increase more slowly than usual. It’s also much more important to limit other sedative medications (like benzodiazepines, pregabalin, and others) that could further slow breathing.

Patients with kidney failure generally don’t need to have their dose adjusted. Methadone has no active metabolites, and is mostly metabolized by the liver. Less than one percent of the blood concentration of methadone is removed by dialysis, so the patient can dose daily as usual, with no adjustments needed after dialysis. However, the patient with end-stage kidney disease may be debilitated in general by their illness, so physicians need to be cautious when starting methadone, and follow the adage “start low, go slow” with dosing.

Methadone is stored in the liver and metabolized there, but it doesn’t harm the liver. However, if liver function is impaired, the metabolism of methadone may be slowed. This can cause a potentially fatal accumulation of this medication, so any patient with new-onset acute liver failure needs to be monitored more closely. In these patients, we may want to ask them to return to our OTP three hours after dosing, when the methadone level will be at its peak, to assess for sedation. Trough blood levels can be helpful in these patients too.

We used to worry that buprenorphine damaged the liver, and recommended patients with liver disease avoid buprenorphine. However, some big studies didn’t show any worsening of liver function in patients on buprenorphine, so again, the benefits outweigh the risks in most cases.

Two specific types of co-occurring medical problems challenge opioid treatment program staff regarding patient take home status: changes in mental status and mobility issues.

Let’s take mental status issues first.

Cognitive decline is always problematic with aging patients, and perhaps doubly so in patients with substance use disorders. Watching a patient who has done well on methadone for years become more forgetful and scattered in their thinking is so sad. Underlying causes vary. The decline could be due to a reversible cause, from onset of Alzheimer’s disease or other dementia, or other medical problems.

Because we see our patients so often, opioid treatment program staff – nurses, counselors, physicians, and physician extenders – may notice slight changes in cognitive function before their other medical care providers. It’s then up to us to convince patients to go to their primary care provider for a medical workup. We always hope a reversible cause will be found.

Medications can cause changes of mental status in our patients. The classic drugs of misuse have typical signs and symptoms, but sometimes mental impairment can be caused by other medications: toxic levels of anti-convulsants, bingeing on drugs like gabapentin, pregabalin or muscle relaxants, or interactions between medications. Benzodiazepines are infamous for causing mental slowness and even associated with increased risk of dementia.

Patients diagnosed with chronic mental decline, like that seen with dementia, are most difficult to manage. With these patients, take home doses are a quandary.

A patient with dementia may gradually lose the ability to manage take home doses appropriately. Sometimes our first clue that something’s wrong with a patient can be when they come to dose days earlier than they are supposed to. They are confused about what happened to their take home doses, or why they came back to the facility early.

This is such a dilemma. We don’t want the patient to feel as if we are punishing them by revoking take homes, but we can’t in good conscience allow them to walk out of our OTP with take homes if they can’t remember if they’ve dosed today. It’s a safety issue.

Patients with significant memory problems must come to the facility to dose every day, which can be a hardship. If their mental decline has been accompanied by physical decline, problems are compounded. Sometimes patients have dependable relatives living with them who can help them take their medications at the appropriate times, but that’s not always possible.

If patients’ illnesses worsen to the point they can no longer be taken care of at home, what do we do? How can we continue their care while in a nursing facility? That gets tricky. If the facility or a relative is willing to bring the patient each day, we can do that. If that’s not practical due to physical frailty, sometimes the nursing home is willing to dose our patients, but regulations say OTPs can only dispense medication to the patient for whom it is prescribed. That is, a relative or personnel from the nursing home can’t come to pick up the patient’s dose and take it to him, as can be done in a pharmacy.

Finding solutions which are practical and workable that don’t violate any OTP regulations can be problematic.

Even getting patients on methadone and buprenorphine into assisted living facilities can be complicated. Last month on the AT Forum website (http://atforum.com ), an article was referenced that recounted the difficulties of finding nursing facilities willing to accept patients on buprenorphine or methadone. [1]

This article said some facilities have policies against admitting patients being treated for opioid use disorder with buprenorphine or methadone. The article said this stance was probably based on a bias against MAT in favor of abstinence-based approaches to treating opioid use disorder. Some experts believe this is illegal, because it violates the Americans With Disabilities Act.

Mobility issues from falls, broken bones, orthopedic conditions, or recent surgeries sometimes collide with my assessment of the patient’s stability from opioid use disorder. What if a patient deemed too unstable (or too new to treatment) for anything other than one take home per week has a sudden medical issue that limits his mobility? This situation occurs more than you might imagine.

We used to be able to dose patients in their cars if it was difficult for them to walk into the facility. Now, the DEA opposes this, worrying a nurse carrying a dose of methadone to a car in our parking lot could be intercepted by someone with criminal intent. I agree this could happen, but the rare occasions when we’ve had to dose patients in their cars, we sent two staff: one nurse to carry and administer the medication, and a witness (usually the patient’s counselor) to witness it being given to our patient and no one else. This also protects our nurses against accusations they mishandled the dose in any way. But the DEA says we can no longer do this.

Some OTPs take a hard line and say if you can’t walk into the OTP, you are not appropriate for treatment. That seems unkind, particularly if a patient has done well with us in the past, and is now having a temporary medical issue limiting mobility.

I think the best approach is to get input from the patient’s physician and try to decide action that’s in the best interest of the patient.

First, I talk to the patient’s physician for specific recommendations of the patient’s mobility. Then I talk to the patient, usually with a counselor, and we ask about family members who could help the patient take extra take home doses as directed. We can ask for state and federal exceptions for extra take homes, so long as we do all we can to ensure patient safety, and describe the situation to officials, to give a better idea of our thought processes and safety concerns.

Sometimes I am surprised, and the other physician wants the patient to get up and walk around, particularly after surgery, for a better outcome. If that’s the case, no extra take homes need to be provided.

Some patients are so debilitated that being around other people presents a health hazard. We had a patient on heavy cancer chemotherapy. When her white blood cell count was extremely low, her doctor recommended she avoid crowds. This occurred during the height of cold and flu season last year, so we requested extra take homes for her, to keep her from having to come to our OTP and sit in a waiting room with other patients.

Her oncologist and I had to weigh the risk of extra take homes against the risk she could contract a simple viral illness that could kill her in her immune-suppressed state.

These types of situations will occur with frequently given the overall aging of the U.S. population, and the aging of patients on medication-assisted treatment. We need to remember this aging is a good thing – patients getting help with MAT are surviving, and living until old age

  1. https://www.statnews.com/2018/04/17/nursing-homes-addiction-treatment/

 

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One response to this post.

  1. Posted by Sean McKinnon on May 21, 2018 at 1:09 am

    I believe the DOJ has since gone after some nursing home or assisted living facilities for refusing to take MAT patients.

    Reply

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