Opioid Use Disorder: Then and Now

 

 

 

 

I started working at an opioid treatment program in 2001, by accident. It’s a long story that I’ve told elsewhere, but once I saw data about the improvements for patients who start medications to treat opioid use disorder, I knew this was the field for me.

After a few weeks working in an opioid treatment program (OTP), I could help patients make huge and productive changes to their lives. Prescribing medications to treat opioid use disorder can have tremendous impact on the lives of people with this illness. Medications like methadone and buprenorphine reduce the risk of dying from an overdose at least three-fold, according to a recent study. [1] Methadone and buprenorphine used for opioid use disorders are also associated with improvements in physical and mental health, reduced risk of suicide, improvement in employment status, reduction in criminal activities, and increased life satisfaction for patients.

I started as a physician at a not-for-profit program in a southern city. I saw mostly patients using heroin, but also pain pills. We had patients drive from hours from more rural areas, and eventually this program expanded into seven additional programs, mostly located in the western part of the state.

By 2004, on Wednesdays I worked at a town of around 40,000 people. I saw patients who drove an hour or more for help. Some patients drove several hours from Tennessee. At this time, methadone was the only medication this OTP used. DATA 2000 had passed, and a few Suboxone providers prescribed in cities, but buprenorphine products weren’t widely available in smaller towns and rural areas.

Wednesdays were busy. We had dozens of people show up seeking admission, but because I was the only physician, I asked that we admit no more than 20 people per day. My requests were not honored, and I worked many long days, admitting up to 25 to 30 people on these days.

These were complicated patients, and it took time to unravel their medical, psychiatric, and drug use histories. We had limited staff, who already had more than fifty patients on their caseload. This exceeded state limits on the number of patients assigned per counselor and kept us under scrutiny by state authorities. It felt like the wild west.

I knew it wasn’t safe to admit so many people, but what was the alternative? There were no other opioid treatment programs around. That small city had one or two inpatient detoxification units, but as we know, the relapse rate is very high, as is the overdose death risk, for patients leaving these five -to -seven-day programs. Inpatient residential programs were difficult to access and weren’t acceptable to most patients anyway. If these patients didn’t get help with us, they probably couldn’t get any help. So, I worked long hours and did my best.

I felt a continued tension between trying to get people into treatment and taking good care of them once they were in treatment.

These people did not get the attention they deserved, but I’m comforted by data from “low threshold” methadone programs. These are programs that don’t require that patients participate in counseling services, and that don’t dismiss patients for positive drug screens. Data shows that patients entered in these programs do relatively well, despite receiving treatment that lacks the usual counseling requirements. [2]

That Wednesday waiting room was packed with urgency and misery. Imagine twenty or thirty people, in various stages of opioid withdrawal, impatient to see the doctor and get a dose of methadone that will help ease their suffering. I hated making people wait, but had to spend enough time with each of these complicated patients. Hiring additional physicians or physician extenders would have helped, but this program had a hard time keeping providers.

Almost all these patients were using OxyContin brand of pain pills. Patients described how easy it was to file off the time-release coating from “oxys,” as they were called, freeing the entire 20mg, 40mg, 80mg, (and for a time, 160mg) pill to be used at once. Most patients crushed the pill and either snorted it or injected it. Apparently, it easily dissolved in water, making it easy to shoot.

That’s a lot of opioid firepower to release all at once, and misused OxyContin killed many people. Sometimes people, not aware of how harmful this medication could be, thought that since it was prescription medication, it couldn’t hurt them.

Patients couldn’t be expected to know what their doctors didn’t even know. OxyContin was prescribed freely in most communities at this time. Some of it was prescribed by pain management physicians, but mostly it was prescribed by small-town physicians with little training in pain management. These physicians had been told by the so-called pain management experts that the risk of developing addiction was low, less than 1%. How wrong they were…

Our opioid treatment program never advertised services. We didn’t need to. Patients showed up because they were referred by friends or relatives. We had whole families in treatment. We might admit a husband and wife one week, only to admit their adult children the next week, plus cousins, an uncle, or a grandparent. Sometimes we would have three generations of a family in treatment.

Whole neighborhoods seemed to come for help. Addiction appeared to be part of the social fabric of the region, binding people together like a fondness for playing cards or baseball.

I remember in 2004, I admitted so many people from Gray, Tennessee, that I asked the rhetorical question, “What is going on in Gray, Tennessee? It looks like everyone in that town must have opioid use disorder.” As it turns out, the first opioid treatment program in Eastern Tennessee was opened in Gray, Tennessee…in 2017.

Benzodiazepines were freely prescribed back then, and we had patients overdose and die while on methadone. I struggled then, as now, trying to decide if a patient using benzodiazepines heavily can safely be admitted to treatmen. Current recommendations say we shouldn’t limit access to methadone and buprenorphine for patients with co-occurring benzodiazepine use disorder, but I’ve had such patients die, and remain wary. Each patient’s risk must be carefully assessed. If patients have taken benzodiazepines regularly for years, a taper could take weeks or months, and sometimes can be done in an outpatient setting, while the patient is getting treatment with medications for opioid use disorder. Other patients can’t control their use of benzodiazepines in an outpatient setting and must be admitted to an inpatient medical detox unit. They must be monitored carefully while reducing or stopping benzodiazepines. Patients can have seizures during withdrawal, just like patients withdrawing from alcohol

Back in 2004, we didn’t have a prescription monitoring program in North Carolina. Our program didn’t become functional until 2007. By then, I was medical director for this program that had around 3100 patients scattered over their eight opioid treatment programs. In December of 2007, when I got authorized to use our PMP, I spent most nights and weekends looking at patients on the system. In the end, around twenty-three percent of all our patients were filling another major controlled substance. Those medications varied from methadone, OxyContin, Xanax, and clonazepam.

I was asked to submit a narrative of my experience to Brandeis’ Center of Excellence. This narrative was later sent to OTP prescribers in a SAMHSA “Dear Colleague” letter and can be read here: https://www.pdmpassist.org/pdf/Resources/methadone_treatment_nff_%203_2_11.pdf

Once we could see what other medications patients were taking, our overdose death rates came down rapidly. I will always believe PMPs are life-saving.

Now I check all entering patients on our state’s prescription monitoring program and check all established patients once per quarter. I don’t get very many surprises these days on the PMP.

Compared to 2004, patients have more options for treatment for opioid use disorders. Still, financial barriers are considerable, especially in office-based setting prescribing buprenorphine products, and far too few people who need treatment can get it.

Many more OTPs in this state now take Medicaid, helping more patients get treatment. We also have grant programs for patients with no Medicaid or other insurance, funded through the CURES program in the past, and now by the state opioid response grants. Most new patients can get started in treatment even if they have no money, thanks to these grants.

Our OTP was lucky to be asked to participate in a MAT PDOA grant. I forget what the initials stands for, but this grant pays for treatment for patients on probation or parole who have opioid use disorder. This grant, which lasted three years, is ending soon, and we’ve treated hundreds of patients with it. For many, it was their first treatment experience. Some did very well, and some not so well, but the recovery seed has been planted. Some patients need a few tries at treatment before they get traction into recovery.

In the OTP where I work now, I have tons more contact with established patients and know them much better than I did at the OTP where I worked in 2004. There’s still much room for improvement, but today I do more than just admit patients. I also have time to talk with the staff, which I think helps all of us understand our patients better and provide better care.

Now, almost no patient mentions the brand name OxyContin. Some patients are using oxycodone, but not one brand. There’s still some Opana use, and certainly heroin is used by many entering patients. Some patients come for help because they prefer using illicit buprenorphine over heroin or other opioids, because buprenorphine can keep them out of withdrawal for a day or longer. Instead of paying $30 for one 8-milligram tablet on the street, they come to treatment programs to get cheaper, legal help. Most, though not all, patients are also happy they receive counseling.

I’ve change since 2004. I’m much more tolerant of continued drug use by patients. I cringe to remember that in the past, I tapered patients off medications to treat opioid use disorder because they wouldn’t stop using marijuana. I don’t do that now. I tell patients that though I’m not happy about their use of an illicit (in my state) drug, it’s not a deal-breaker for treatment. I still stress over patients’ use of benzodiazepines and alcohol, especially if they are on methadone.

Things change quickly in this field, and our OTP may look very different in the future than it does now. I pray that we continue to improve the quality of care for our patients and continue to reach ever more of the people who need help. I love my job, and after eighteen years, still believe I can do more to help people in one day at my OTP than I did in a week doing primary care.

  1. Sordo et al., “Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies,” British Medical Journal, 2017.
  2. Christie et al., 2013
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4 responses to this post.

  1. Posted by G Michael Mahoney on July 16, 2019 at 9:19 pm

    What is the Christie et al article cited here?

    Sent from iPhone

    >

    Reply

  2. That is a beautiful post about your wok in the OTP field. What are your thoughts on administrative withdrawals for on-going stimulant use, say greater than 6 months?

    Reply

    • As more people use heroin with fentanyl in it, the less I taper patients from methadone or buprenorphine products. For the most part, I’ll try to retain these patients in treatment rather than start a medical taper. It’s a difficult decision, particularly if the patient is going downhill rapidly and still refusing more intense counseling.

      Reply

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