New Ideas and Common Themes at Addiction Medicine Conferences

This blog is about some of the common themes covered at the three recent Addiction Medicine conferences.

Overdose drug deaths:

All three conferences presented general statistics about how the rates of drug overdose deaths increased during 2020, coinciding with the COVID pandemic. Most overdose deaths are polysubstance; that is, decedents are found to have opioids and some other class of drug in their systems at the time of death. Many of these overdose deaths have opioids such as fentanyl and stimulants, either cocaine or methamphetamines.

We think of overdose as being a process associated with sedation and gradually slowed breathing until respiratory arrest occurs, with eventual cardiac arrest. However, the stimulants kill more often by causing cardiovascular events: strokes, heart attacks, or fatal cardiac arrythmias, even in young people without previous medical problems.

We know that stress is a common trigger for drug use, and the statistics show increased consumption for all types of drugs, including alcohol, during the COVID 19 pandemic.

Medications for opioid use disorder during incarceration:

All three addiction medicine conferences had sessions on this topic. In the past, prisons and jails have refused to allow patients to continue their medications to treat opioid use disorder. However, with recent successful lawsuits brought by inmates demanding appropriate medical care, jails and prisons are being forced to re-think their procedures. I sense that jail and prison medical staffs see the writing on the wall and are starting to consider changing their usual anti-methadone/buprenorphine protocols.

There are several ways to get treatment to patients who are incarcerated.

During the ASAM conference, I went to a session where the speaker, a provider of medical care in a prison facility, described how their facility got certified as an opioid treatment program. She outlined all the steps required of her facility and said it was a tremendously difficult process. Though SAMHSA and national agencies have asked jails and prisons to be able to treat patients with opioid use disorder with medications, she said it is those very institutions that make it so difficult to get the approvals needed to become an opioid treatment program.

I heard other sessions about how a mobile clinic, based out of a brick-and-mortar existing opioid treatment program, can be a novel way to dose incarcerated patients. Other people at the conferences talked about having OTP staff transport medication to a jail facility and leave it with medical staff there, using a chain-of-custody form to document in the approved fashion.

There are many possibilities and opportunities to get creative about how to provide methadone or buprenorphine to existing patients and to start these treatments for new patients.

Oh, and by the way…jails should NOT refer to clonidine and clonazepam and other comfort medications that they give for opioid withdrawal as “medication-assisted treatment.” That’s not medication assisted treatment, though it can be of some value to some patients.

Micro-dosing of buprenorphine:

Some providers are interested in a process intended to make it easier to transition patients from full opioids to buprenorphine. This would be helpful because it would eliminate the need for patients to go into withdrawal before buprenorphine could be started. For most short-acting opioids, twelve to twenty-four hours of abstinence from opioids are required to be in enough withdrawal to start buprenorphine. If buprenorphine is started too soon after a full opioid it can cause precipitated withdrawal.

This year at the conferences, lectures and discussions about a procedure known as “micro-dosing” was discussed to achieve transition more easily.

This involves starting buprenorphine at small doses and gradually increasing until the patient it at a full dose of buprenorphine, at which point the patient can stop using other opioids. I’ve read about several difference “recipes” for micro-dosing, but most schedules involve giving .25 to .5mg on day one, then increasing to .5 to 1 milligrams on day 2, and so on, slowly increasing the dose over the next five or so days until the patient is at the 12mg range. Supposedly the patient won’t feel precipitated withdrawal if buprenorphine is started in this way.

Providers also want to try using micro-dosing to help patients get off methadone and on to buprenorphine in an easier manner. Traditional methods of transition require patience and planning. For example, a patient on methadone 100mg per day would be reduced by 5mg per week until he is on 40mg, stay on that for a week, miss two days of dosing, and start buprenorphine on the third day if COWS  (Clinical opioid withdrawal scale) score is at least a 12. I’ve transitioned many patients this way over the past ten or so years.

But micro-dosing is reportedly a faster way to achieve transition. That may be appealing to certain patients who are facing situations where they need to transition quickly.

Micro-dosing appeals to some office-based buprenorphine prescribers who want to accept patients on methadone from opioid treatment programs. It’s possible this could be used, but the office-based physician still must coordinate care with the medical director of the opioid treatment program.  I’ve heard a few office-based practitioners talk dismissively about getting the OTP involved, saying the providers are hard to reach. That might be true in a few cases, but all OTPs are mandated to have 24-hour telephone accessibility. This number is recited on the voicemail options. Usually when a provider says he or she couldn’t reach me on the phone, it’s because they never tried, assuming I could not be reached.

I’m open to the idea of micro-dosing. But I also wonder about the practicality of this quicker procedure. How well does it really work? The initial studies say it works well, but why take the risk of precipitating withdrawal when we already have reliable methods of transitioning from methadone to buprenorphine? I do understand that sometimes patients are inpatient and want the transition to go more quickly than with the traditional method.

Also, what about the nuts and bolts details of micro-dosing? The lowest commercially available sublingual films or tablets are 2mg dose units. The manufacturers counsel against cutting their products because they’ve never done studies to show the active ingredient is evenly distributed over the entire film/tablet. Of course, our patients cut both the films and the tablets all the time. However, what might be fine for a patient already on a stable buprenorphine dose might not be OK for a patient doing a micro-dosing induction, where more precision is desired.

One of the papers I read about micro-dosing said they had a pharmacy with a sharp cutting device cut the tablet form of medication into .25 and .5mg doses.

I’m going to wait for more studies before I undertake any micro-dosing.

Racial inequities in medical care including addiction medicine care:

Minority populations have worse health outcomes than the general population, and substance use disorders are no different. The ASAM national conference had one whole morning plenary session dedicated to racial inequalities in healthcare.

The AATOD conference had sessions discussing racial disparities in the course of illness in minority patients with substance use disorders compared to non-minority patients with the same.

At one session, a psychiatrist presented data collected 2013-2015 that overdose deaths among blacks showed the highest rate of increase in overdose deaths than any other group. This increase was largely driven by increases in metropolitan deaths. A more recent study by Furr-Holden et. Al., published in March of 2021 in Addiction, showed the steepest rate of increase in opioid overdose deaths was greater for African Americans than any other ethnic group, from 2013 -2018. Preliminary data shows even worse data through the COVID pandemic.

Outcome data shows that access to life-saving treatment medication improves survival in patients with opioid use disorder, but access is limited by various factors among African American patients. These factors could include location of the closest treatment facility, transportation problems, affordability, and the like. In other words, if treatment is available geographically but other obstacles get in the way, the patient may still not be able to access treatment.

All of this was good information and it prompted me to have a discussion with our OTP’ program director about how much we are doing to reach minority communities in our area, and what possible obstacles to treatment might exist that we haven’t considered. We decided the best way to determine what obstacles exist was to ask our existing minority patients. We plan a confidential survey, asking their opinions about how are doing and what we could do better to reach and engage minority communities.

We’ve got a few things in our favor. We have reasonably diverse staff, with a wide range of ages and prior work experiences. Five of our twelve counselors are members of minority groups. Nursing staff has less diversity, with no racial minorities and only one male.

Next week: I will write about the extent of law enforcement interference with buprenorphine prescribing in Tennessee, using a recent case as an example.

5 responses to this post.

  1. Posted by Nacole on May 4, 2021 at 5:20 am

    I can’t wait to hear next weeks blog. I was a patient of one dr that was raided, the Memphis psychiatrist, whom now is in federal prison. And the other drs in the Memphis area looked at us patients as “reg flags” and no one wanted to take us! We lost several patients to suicide because the government didn’t keep their word and make sure resources were available to all those affected by their raids. It has been horrid in TN!

    Reply

    • Posted by Sparky on May 5, 2021 at 5:11 am

      Agreee 100% Tennessee sucks bigtime when it comes to buprenorphine treatment,they are some of the dumbest people in government of any state in the country,they are seemingly wanting people to die from overdose in tenn because of all their stupid idiotic regulations and oversight of drs,yes Tennessee sucks lolololol

      Reply

  2. Posted by Sparky on May 4, 2021 at 1:30 pm

    The only brand that would be suitable for microdosing would be zubsolv,they have lower amounts available than 2mg,in fact they have a 0.7mg and a 1.4mg dose that come in a full tablet,it doesn’t have to be cut,they have these lower doses for people wanting to taper down to lowest dose possible

    Reply

  3. Posted by Stephen beck on May 9, 2021 at 1:29 am

    Law enforcement is one of the biggest obstacles to proper treatment of our patients. Plus it never ceases to amaze me that there are no public service announcements or government outreach programs to help get people onto treatment. And as much as i like Aa/na they ate still mostly misguided about MAT. Tough to help people using 1940’s treatments . Great blog by the way. I always learn so much. Thank you.

    Reply

  4. Posted by Margo Williams on May 11, 2021 at 10:17 pm

    This don’t really have a comment on the Dr. that was raided. I just want people to know that methadone treatment works!!!! I have been in methadone treatment for 20 years. I am currently on a 50mg dose daily. (At one time I was up to 80mg) This program saved my life. I was going to hell a hand basket! Lol! When I started my treatment I couldn’t hold a job, I was a mess. I was arrested for writing my own prescriptions for Loratab. I have since opened a flower shop, worked it for 10 years, & sold it a few years ago. I was board at home so I opened a vintage furniture shop. I will be 70 in August and owe my past success to the methadone clinic. I pray it never closes!! I really enjoy reading your blog & wish there were more out there like you. You really do care!! God Bless you!

    Reply

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