The Tenth Annual NC Addiction Medicine Conference: A Success

 

I just got back from Asheville, the location of the yearly spring conference on Addiction Medicine. This meeting is sponsored by the NC Governor’s Institute on Drug Abuse and the North Carolina chapter of the Society of Addiction Medicine, among others.

I’m glad I took an extra day off work to go to the pre-conference. Last year the preconference was one of the best parts of the whole meeting, and this year was the same. I went to the Motivational Interviewing (MI) preconference, and got a nice refresher on the basic principles of MI. I also got a chance to practice my skills during the session, which can be daunting while being watched by other people.

MI is like that. When done by someone extremely skilled at this counseling technique, it looks so easy. I tell myself, “I can do that, no problem.” Then when given an opportunity, I get brain freeze and it’s not so easy. Like any skill, the only way to get better is to do it and keep doing it, and maybe have a person who is skilled at MI give feedback from recorded sessions (with patient permission, of course). I know the counselors at my OTP submitted recordings to their clinical supervisor for feedback on how well they adhere to MI technique. This feedback can be key.

The first day of the conference proper kicked off with an address by Dr. Elinore McCance-Katz, MD, PhD, who is the Assistant Secretary for Mental Health and Substance Use, SAMHSA. She talked about the federal response to the opioid use disorder epidemic, which includes strengthening the public health surveillance, supporting research, providing Narcan, advancing the practice of pain management and improving treatment access, among other things.

Then she talked about SAMHSA’s response to the opioid epidemic, including the STR grants authorized under the CURES Act, then about the State Opioid Response act, which has a budget of $1.5 billion. She also discussed four or five other important SAMHSA measures.

I appreciate her passion. I wanted to stomp my feet and say “Amen,” when she endorsed using only evidence-based treatments to treat opioid use disorders. She said we should stop doing detox only, unless patients were provided with depot naltrexone injections before leaving detox. Then she said of lab testing in medication assisted treatment that cost thousands of dollars: “This is nonsense.” Yes. Thank you, Dr. McCance-Katz.

Next to speak was Kody Kinsley who gave the NC update on the state of addiction. He described how we have spent our grant dollars so far, and about how Medicaid will change in the future. He talked specifically about how Medicaid expansion could help our state. I don’t think he had to convince this audience. Most of us have seen how dismal medical care (not only substance use disorder treatment) can be for people with no insurance and no Medicaid.

He lost me when he started talking about SPAs. I didn’t know what he was talking about, but I quickly learned he wasn’t talking about places to go for massages and facials. I got so bogged down trying to decide what a SPA was that I missed much of the last part of his message.

A talk from Sandra Bishop-Freeman from the NC Department of Epidemiology and Public Health was scary as hell.

This isn’t a good time in history to be someone with substance use disorder in general, and opioid use disorder in particular. Fentanyl and its analogues are potent, and small packages of these products contain a great deal of opioid firepower. This means it’s easier to smuggle into the country. These fentanyl analogues are sometimes made into counterfeit pills, to fool authorities, but these counterfeits often end up on the street. A buyer may think he’s getting a Vicodin pill when it’s really fentanyl.

And now cocaine is being laced with fentanyl, fueling a twin epidemic. This is scary because cocaine has made a resurgence in my county, or maybe never left in the first place. But this fentanyl-laced cocaine could cause quick overdoses for people not intending to use fentanyl.

Then there’s news about a 1000% increase in deaths from methamphetamines, designer benzodiazepines, and combinations of Imodium and Kratom that are causing deaths.

It was a great and informative talk, but a bit depressing.

The last of the plenary speakers was Dr. Corey Waller, an entertaining and informative speaker. He talked about integrating substance use disorder treatment into hospital systems with specific and practical ideas about making this happen. In this talk and another later in the day, he inspired me to want to try again to work with my local hospital.

I love hearing new ideas and learning about current trends, and I also love seeing old friends and meeting new people working in the field. I was able to talk with four or five other doctors I’ve known for years, and catch up with what happening in their lives. That’s always fun.

I was one of three presenters at a morning workshop about updates and challenges of prescribing buprenorphine (and methadone) for patients with opioid use disorder. It went very well.

I can’t say I enjoy doing presentations, but there’s nothing like a presentation to force me to thoroughly investigate a topic, so I learn even if no one else does. And I feel good about doing the occasional presentation, because I’m doing my part to help educate new prescribers.

I had some material to cover toward the end of the session, and I thought the other two physicians would use up the bulk of our time. In other words, I didn’t think I would have to talk for very long. But the two other physicians were gracious and wanted to allow me enough time to talk, so they left me with a half hour.

That worked out well, because after my fifteen minutes talking about how opioid treatment programs and office-based buprenorphine providers could work together, we still had fifteen minutes for audience questions. And this audience asked some great questions, covering our most difficult issues: misuse of monoproduct versus combo product; co-occurring use of benzodiazepines either by prescription or illicit; law enforcement investigations of buprenorphine prescribers; when – if ever – to terminate treatment for noncompliance; maximum dose for buprenorphine products; the cost of treatment and grant funds, to name but a few.

During lunch, Dr. Frederick Altice gave an informative and concise presentations on Hepatitis C. He made me wish I had enough time to treat our patients at the opioid treatment program who have Hep C, instead of needing to refer them to the nearest FQHC (federally-qualified health center). It’s getting very easy to treat these patients, with liver biopsies and interferon being a thing of the past.

Late in the afternoon, I facilitated our closed opioid treatment program session. This session is meant only for providers working at OTPs, and we usually talk about topics specific to treatment at OTPs. This year, the topic was advocacy.

This topic was based on a case that I blogged about September 16, 2018. They provider involved in the case, Lisa Wheeler, PA, gave an excellent and passionate presentation about the specific case, but went farther into the issue. She explained how and why stigma exists, and the negative consequences we see when provider-based stigma cuts into patient care.

She presented the full case, explaining how a patient of hers, brand new to treatment, was diagnosed with endocarditis and told that per hospital policy, she couldn’t get a second surgery on an infected artificial heart valve. She was also denied visitors and was forced to give up all electronics in order to be admitted for treatment, leaving her with no cell phone or internet access and very lonely indeed.

Lisa Wheeler also gave us the glorious follow up of the case: she – eventually, after long hours of advocacy by Lisa and other people – was transferred to UNC Chapel Hill where she underwent life-saving cardiac surgery. She now is doing very well, healthy, with seven months of recovery.

Then we had a general discussion about other cases we’ve seen where healthcare providers denied care to patients on medications to treat opioid use disorder. Of the twenty or so providers in the room, many had similar cases.

We talked about what we can do to combat stigma, and came up with some general ideas. Sometimes just calling our colleagues, to try to educate them in a friendly way, can be the best approach. We can be informal and friendly, and educate in a gentle way. We need to remember that many providers didn’t get much education about substance use disorders and their treatment during medical school or residency. Those of us working in this field can be a source of information for other providers, who often change their approach when they have more facts.

When bias is egregious and causes harm to patients, sometimes it’s necessary to get more outspoken with advocacy. We identified the Legal Action Center, located in New York City, as a group with some materials that can be useful. They have a MAT “toolkit” with sample letters, to be adapted to specific situations, such as if a patient is charged with driving while impaired while on a stable dose of methadone or buprenorphine. There’s a sample letter to send to a patient’s lawyer, to help explain MAT with its benefits. ( https://lac.org/mat-advocacy/ )

In the end, a handful of providers agreed to form a committee to try to form better advocacy ideas. I’ll keep you informed how that goes.

The entire conference was great, and I’ve only described part of the first day. I could go on & on, but in the interest of keeping this blog post to a readable length, I’ll end with an exhortation to my readers: if you provide treatment to people with substance use disorders, you need to go to this yearly conference. Now there’s also an “Essentials” conference in Raleigh in the fall, which presents a second opportunity to learn.

You can go to this website for more details: https://addictionmedicineconference.org/

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2 responses to this post.

  1. Posted by Alan Wartenberg MD on March 30, 2019 at 3:29 am

    Sounds like a great conference. Dr. McCance-Katz was the Medical Director of the Substance Abuse agency in Rhode Island for a short time, and does have a passion for our cause. However, her passion has been tempered with her necessity to comport her statements with Trump administration policy. The Trump decision to go after the Affordable Care Act, with its expansion of Medicaid and provision of health insurance to those with pre-existing conditions, and eliminate subsidies that have allowed millions of others to obtain health insurance, will undo a great deal of the good done by the funding for the treatment of OUDs and other SUDs. We cannot treat people with SUDs in a vaccum. They need a wide variety of physical and mental health assistance, and well as educational, social, housing and other assistance, all of which this administration is working very hard to unravel.

    Reply

    • You’re right, of course. Many patients were able to get treatment because of the ACA. Repealing it will mean people will have to drop out of treatment.

      Reply

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