Author Archive

Holiday Guide for Families

 

 

 

 

 

 

This post is written for the friends and relatives of people in recovery from substance use disorders.

What to do:

  1. Do invite your loved one in recovery to family functions, and treat her with the same respect you treat the rest of the family. If you have resentments from her past behavior, you can address this privately, not at the holiday dinner table. Perhaps given how holidays can magnify feelings, it’s best to keep things superficial and cheery. Chose another time if you have a grievance to air.
  2. Allow your relative some privacy. If the person in recovery wishes to discuss her recovery with the entire family, she will. Let her be the one to bring it up, though. Asking things like, “Are you still on the wagon or have you gone back to shooting drugs?” probably will embarrass her and serve no useful function.
  3. Accept her limitations graciously and without comment. Holidays can be trigger for drug use in some people, and your relative may want to go to a 12-step meeting during her visit. Other people in recovery may need some time by themselves, to pray, meditate, or call a recovering friend. Allow them to do this without making it a big deal.
  4. Remember there are no black sheep. We are all gray sheep, since we all have our faults. In some families, one person, often the person with substance use disorder, gets unfairly designated as the black sheep. She gets blamed for every misfortune the family has experienced. Don’t slip into this pattern at holiday functions.

What not to do:

  1. Don’t ask the recovering person if she’s relapsed. If you can’t tell, assume all is well with her recovery. If she looks intoxicated, you can express your concern privately, without involving everyone.
  2. Don’t use drugs, including alcohol, around a recovering person unless you check with them first. Ask if drug or alcohol use may be a trigger, and if it is, abstain from use yourself. If you must use alcohol or other drugs, go to a separate part of the house or to another location.  Being around drugs including alcohol can be a bigger trigger during the first few years of recovery, but any recovering person can have times when they feel vulnerable, so check with them privately before you break open a bottle of wine.
  3. If your family’s usual way of celebrating holidays is to get “ all liquored up,” then understand why a recovering relative may not wish to come to be with family at this time, and don’t take it personally. For some of us, remaining in recovery is a life and death issue, so please accept we will do what we must to remain in recovery, even if that means making a holiday phone call rather than making a holiday visit.
  4. If your recovering loved one is in medication-assisted treatment with methadone or buprenorphine, don’t feel like you have the right to make dosage recommendations. Don’t ask “When are you going to off of that medication? (meaning methadone or buprenorphine) Your loved one may taper off medication completely at some point, or he may not. Either way, that’s a medical decision best made by the patient and his doctor. Asking when a taper is planned is not your business.
  5. Refrain from giving hilarious descriptions of your loved one’s past addictive behavior, saying, “But I’m only joking!” This can hurt her feelings, and keep her feeling stuck with an identity as a drug user. She can begin to believe that with her family, being an addict is a life sentence.
  6. Remember your loved one is more than the disease from which they are recovering. Some people have diabetes and some people have substance use disorders. These diseases are only a small part of who they are.

I hope this helps.

May all my readers have a Merry Christmas and Happy Holidays!

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Continuum of Care for Opioid Use Disorder

 

 

 

 

 

 

“Continuum of care is a concept involving an integrated system of care that guides and tracks patient over time through a comprehensive array of health services spanning all levels of intensity of care.” (Evashwick, 1989)

Continuum of care isn’t a new concept. It’s a pattern of care that we use to treat patients with all sorts of chronic medical illnesses. For mild forms of a chronic illness, primary care providers manage patients’ illnesses. For more severe forms of the same illness, patients are referred to specialists, with more experience and training in that area of medicine. Ideally these shared patients flow back and forth between specialists and primary care providers as needed based on the severity of illness as it may fluctuate over time.

We ought to apply this same concept for the management of opioid use disorder. It’s a chronic illness which can have exacerbations and remissions over time, just like diabetes and asthma.

I try to follow this concept at the opioid treatment program where I work. Patients new to treatment often are ill, not only from the drug use, but also from neglected physical and mental health issues. They need more intense care. An opioid treatment program offers more structure and supervision than an office-based practice, so it’s a level of care that’s appropriate for such patients.

At the opioid treatment program, we can do daily observed dosing, to make sure patients take the dose I prescribe. We assess the adequacy of the dose by asking about withdrawal symptoms and observing withdrawal physical signs. We can monitor for side effects. We can do frequent drug screens, to provide information about the proper level of counseling needed. Counseling, both group and individual, are built into the system at opioid treatment programs.

At the other end of the spectrum, stable patients with years of recovery in medication-assisted treatment need less care. We still need to monitor for relapses, but they usually don’t need as much counseling, and no longer require observed dosing. They need the freedom that office-based practices provide.

Stable patients on methadone get more take home doses, but opioid treatment programs are their only option for treatment setting. Stable patients on methadone can’t get their treatment in primary care settings. It’s illegal for office-based physicians to prescribe methadone for the purpose of treating opioid use disorder. Primary care doctors can prescribe methadone to treat pain, but not if the patient also has opioid use disorder.

It’s different for patients on buprenorphine (Suboxone, Subutex, Zubsolv, Bunavail). Since 2000, it’s been legal to prescribe this medication from office-based settings for patients with opioid use disorder.

But that doesn’t mean this is the right setting for all patients with opioid use disorder.

I have an advantage, since I see patients in both settings, both opioid treatment program and an office-based practice. I have the luxury of being able to treat new patients in the opioid treatment program, and after they stabilize, talk to them about transitioning to the office-based practice. If a patient encounters a rough patch, I can ask them to return to the opioid treatment program for more intense treatment until they again stabilize.

I can use the same concept as used with other chronic medical illnesses.

Sometimes a new patient can safely be treated in an office-based program. This all depends on individual patient circumstances. One patient may have a fantastic support system at home, while another may have to put up with active drug use in his home. Obviously, the latter patient needs more support from treatment staff.

Sometimes patients on buprenorphine aren’t appropriate for office-based treatment, even after months of treatment.

Unfortunately, most patients with opioid use disorder aren’t placed in a treatment setting based on their needs. Most patients end up in whatever facility they enter for the duration of their treatment, which may not be the best thing for the patients.

It’s rare for an office-based practice to refer their patients who are struggling to opioid treatment programs. Many office-based providers, enthusiastic about treating patients with opioid use disorder, still regard opioid treatment programs with great suspicion. It’s partly due to lack of knowledge about OTPs. It’s also partly due to that old bugaboo that blocks so much of appropriate treatment for people with substance abuse disorders: stigma. Some providers believe all sorts of outlandish things about what takes place at opioid treatment programs.

It’s painful to admit, but some providers’ opinions are formed based on the actions of poorly run opioid treatment programs. Some opioid treatment programs provide little more than daily dosing of medication. In our business, those programs are referred to derisively as “juice bars,” meaning patients get a daily dose of methadone, which looks like red juice, and little more.

These programs taint the reputation of good opioid treatment programs which offer an array of services all meant to help the patient. This is a real shame.

So, what about me? Do I refer stable buprenorphine patients at our opioid treatment program to other office-based buprenorphine practices? Well…not so often.

I know plenty of excellent office-based buprenorphine providers across the state who are diligent and painstaking about the care they deliver. And I know some providers in my area who don’t meet that standard. I’m hesitant to refer to them.

For example, one nearby provider charts extensive patient visits. These notes include everything from history of present illness, complete review of systems, and complete physical exam for each visit. Yet I was troubled about how similar each visit was, and suspected there was a whole lot of “cut and paste” going on, and that the charted care wasn’t actually being delivered.

Recently a patient transferred from this practice back to me, at the opioid treatment program, for purely financial reasons. We requested a copy of her charts, as we do for all patients who have been seeing other practitioners. This is good medical practice, even if it hasn’t been all that helpful with this particular provider in the past.

I was reading the records, and was confused. I read in the exam section of her last visit, “Abdomen consistent with eight month pregnancy.”

How had I missed this, I thought. I’m no obstetrician, but even I should pick up an advanced pregnancy on exam.

I slid my eyes back to the patient, sitting on a chair near the corner of my desk. Her abdomen looked flat.

“Um, so…are you pregnant?”

“No! Why?”

“Well you don’t look pregnant,” I added, not wishing to offend her. “It’s just that this last note says you’re eight months pregnant.”

She sighed and rolled her eyes. “The baby is seventeen months old. I guess they just never changed it in my chart.”

I looked back at each note. Sure enough, the exams for each date all read, “Abdomen consistent with eight month pregnancy.” For many months. Clearly, this was cut and paste charting. It’s not quality care, and may be illegal if the provider charged for services not delivered.

This confirmed my worst suspicions about the level of care provided at that practice, so I don’t think I will be referring patients to them.

In this country, we do have obstacles to providing a continuum of care for patients with opioid use disorders. We have some office-based practices that aren’t well-run and have little oversight. We have substandard opioid treatment programs providing little more than medication dosing, and we have undeserved stigma against opioid treatment programs that have been providing quality care for many years.

In fact, opioid use disorder may have the least organized continuum of care of all chronic diseases.

What’s the answer? Better communication and better education among medical providers.

I’m doing my part.

I go to many conferences, to learn the latest data and standards in my field. I also meet other providers at these conferences, even though by nature I’m a bit of a recluse. I’ve given talks, both to community groups and at medical meetings, to do my part to pass on what I know. I don’t enjoy public speaking, but find that once I get involved in my topic, I lose my fears.

All providers of care for people with opioid use disorders need to do this – we must meet each other, talk to each other, and learn from each other.

Here are a few wonderful opportunities to interact and learn:

ASAM conferences: the American Society of Addiction Medicine holds several conferences per year at the national level, and these are excellent for learning and meeting the leaders in the field. You can read more at their web site: www.asam.org

 

In my state of North Carolina, you can get some valuable information from the Governor’s Institute, at https://governorsinstitute.org/ and also their blog: http://www.sa4docs.org/

You can attend webinars, get clinical tools, and obtain mentoring from the Providers’ Clinical Support System MAT, at https://pcssmat.org/

If you are a provider in North Carolina and want CME hours while you teleconference with peers and mentors, you can participate in the UNC ECHO project. You can read more about that here: https://uncnews.unc.edu/2017/02/15/unc-chapel-hill-initiative-will-combat-opioid-use-disorders-overdose-deaths/

Write to me if you want to participate and I can forward you to the people that can make that happen.

Harm Reduction and the Clothing Police

“Oh I know that’s not a marijuana leaf on your cap!”

 

 

Image result for marijuana on cap in rhinestones

I had just ushered a young lady into my office. She entered treatment the week before, and I wanted to check on how she was feeling. When I called her from the waiting room, I noticed a rhinestone design on her cap with one part of my brain. I like bright sparkly things, so it caught my eye. But by the time we walked the short distance to my office, it dawned on me what the design was, and I confronted her about it.

“What? Yeah, it’s marijuana. Sorry. I didn’t even think about it.”

“What part of you thought it would be OK to wear clothing promoting drug use to your drug addiction treatment program?” I continued.

Usually I’m more complacent about clothing our patients wear. Some programs have minimal dress codes: no pajamas, nothing too revealing, must wear shoes, no obscene tee shirts… I’ve never gotten too worked up about clothing, thinking that as long as they came into the building, it was a victory.

But for some reason, on that day, I went a little nuts. What can I say, I have bad days too.

My patient was apologetic, but said it was the only cap she had. I told her she could turn it inside out, which she did without hesitation.

Before you are tempted to write in about how marijuana is really a medication and will be legal someday, let me tell you this: I don’t care. I’d feel the same way if I saw a large, legal, liquor bottle outlined in sequins, or a big sequined Opana pill on a shirt. It’s a symbol of drug-using culture.

Today, I’m conflicted. One part of me still thinks it’s not OK to wear clothing promoting any kind of drug use, and this includes alcohol. After all, we are treating patients in whom drug use has caused significant problems. Some of them could be triggered by symbols of drug culture. Is it too much to ask our patients to think about the message they send with their clothing?

Other addiction treatment professionals endorse similar ideas. If our patients are to return to mainstream society, don’t we have an obligation to educate them about traits that may still associate them with active drug use?

For example, is it possible my patient wasn’t aware of the message she sends with her bedazzled marijuana cap? If my patient wanted to go for a job interview, for example, would wearing this cap work against her? Maybe it depends on the job, but overall I would say the cap would hurt her chances of being hired.

On the other hand, if we view the situation with a harm reduction eye, isn’t it good enough at this point that my patient is getting treatment for her addiction? If a patient wants to get help for some aspect of addiction, isn’t that good enough? Maybe it’s unreasonable to expect a patient in treatment for a short time to start viewing her wardrobe with a recovery-oriented eye. Maybe such issues can be addressed later, in counseling, or maybe not, but perhaps I should concentrate on more important issues. Like helping her get through the day without illicit opioids.

A harm-reduction model would recommend meeting that person where she is now, in her THC-wearing mindset. Harm reduction is an idea that says any change that reduces the risk of drug use is success, and that we need to accept her as she is. We should respect our patient’s choices and help in any way she is willing. Any reduction around the risk of her addiction is an acceptable goal, even if it doesn’t conform to what I may view as “real” recovery.

The question is, or course, where do we draw the line? If it’s OK to wear clothing glamorizing drug use, is it OK to allow patients to tell glamorized stories of drug use in the waiting room? Is it OK to allow patients to use drugs on the premises? Is it OK for patients to use drugs on the premises? What about dealing drugs?

I endorse harm reduction principles, but have come to realize I have limits. The longer I’ve been doing this job, the more enthusiastically I approve of harm reduction principles. However, I still draw the line when one patient’s behavior affects the other patients. That’s why I won’t tolerate drug dealing on the premises, patient violence (against other patients or staff), or drug use on OTP grounds. But that’s a hard call to make, and it’s a decision best made at case staffing with input from other staff.

Harm reduction is a difficult idea for many of us. What one person sees as harm reduction, another sees as enabling. Here are some other quotes I’ve heard from other people. I’d like to give credit, but my memory’s not that great.

 

“Don’t allow the perfect to be the enemy of the good.”

“The enemy of the best is the good.”

“It’s OK to meet a person where they are, but it’s not OK to leave them there.”

“I don’t promote drug use. I don’t promote car accidents either, but I still think seatbelts are a good idea.”

“Dead addicts don’t recover.”

 

Readers, any thoughts?

The Bridge

 

 

 

 

 

 

 

 

 

A little over a year ago (October 2, 2016), I blogged about a new device being marketed to reduce opioid withdrawal symptoms. I didn’t give the name of the device, because of a lack of data showing it works. Earlier this month, the FDA authorized the company that makes the device to start marketing it, for use in easing opioid withdrawal symptoms.

This device, called the NSS-2 Bridge, is a little bigger than a hearing aid, and is attached behind the ear. The device delivers electrical impulses to three electrodes placed around the ear. The cost for a five-day course of treatment with the device is around $500, and the manufacturer says it eliminates opioid withdrawal symptoms.

Mistakenly, I thought the FDA only approved medications and medical devices after multiple studies showed the treatments were effective. That doesn’t appear to be correct. Instead, according to an article in Forbes magazine online, the FDA is relatively quick to authorize medical devices that appear to have low or moderate risk to the consumer, even if there’s limited data to support their efficacy. This may be particularly true for devices purported to help in any aspect of treatment for opioid use disorder, since so many people are desperate for relief. [1]

I hope this device works as well as it is advertised. A safe device that controls opioid withdrawal symptoms…that sounds great.

But after suffering through several courses in medical statistics, I learned not to assume a given treatment will work unless it’s backed by solid research. There have been far too many products promoted with great fanfare to desperate people that later were found to be no more effective than placebo.

So what evidence did the FDA consider when deciding to approve advertising for the NSS-2 Bridge for the purpose of reducing opioid withdrawal? There’s only one small study, published earlier this year in the American Journal of Drug and Alcohol Abuse.

This retrospective pilot study of 73 people showed the Bridge device significantly improved withdrawal symptoms. Patients had an average COWS (clinical opioid withdrawal scale) score of 20 before the device was placed, and the average score dropped to 7.5 twenty minutes after the device was turned on. After an hour of use, withdrawal scores went down to an average of 4.

These patients were ultimately transitioned to maintenance medications.

After reading this pilot study, I have questions. For example, the Bridge was being used to help patients get through the opioid withdrawal of early medication-assisted treatment. But if the device gets rid of withdrawal symptoms, how do physicians and patients find the dose of medication that suppresses withdrawal? And at what point did the researchers start the medication?

So far as I can tell, there’s no randomized placebo-controlled trials of this device. This type of trial is more reliable to find out if a treatment works or not.

In the Forbes article, Dr. Nora Volkow, the Director of the National Institute on Drug Abuse (NIDA) agreed, saying, “The only way that you can determine the extent by which this device has potential clinical effects is by doing a randomized controlled trial.”

She also went on to say that we shouldn’t perpetuate treatments that aren’t proven by evidence that they work, because patients with opioid withdrawal are desperate, and have a serious disease.

Thank you, Dr. Volkow. You’ve summed it up nicely.

The company that makes NSS-2 Bridge, Innovative Health Solutions (IHS), gave a sales presentation to a group of doctors several years ago. At that meeting, I asked some challenging questions, like why is the company marketing the device before they’ve done the necessary research. I didn’t get a satisfactory answer. The salesman claimed they didn’t have to do more research because it worked 100% of the time. At that time, the company’s credibility took a big hit with me. I don’t know of any legitimate treatment that works for 100% of patients.

Then another doctor said our company has enough patients to power a large study, if IHS wanted to do a good study. The salesman said great, but then indicated the patients would still have to pay for the device.

No, no, no. That’s not the way research works. The manufacturer of the product funds the research, or should be willing to do so, if they believe in their product.

Just think – if that company had started a randomized controlled trial two years ago at that meeting, they might have good data by now, showing if the product works or not. But maybe that’s what they want to avoid.

I will not be prescribing the Bridge until/unless I see randomized controlled studies of this product, proving it works. Because I don’t trust products with better marketing than research.

  1. https://www.forbes.com/sites/ritarubin/2017/11/18/this-device-is-the-first-marketed-to-treat-opioid-withdrawal-but-evidence-it-works-is-lacking/#7383ed1826df

News You Can Use

 

 

 

 

 

 

 

 

 

 

 

 

 

Tidbits From the latest issue of Journal of Addiction Medicine

Don’t Forget the Family

I finished reading the latest issue of the Journal of Addiction Medicine this weekend, and as usual there’s much good stuff in it. One article that captured my interest was about family involvement in substance use disorder treatment.

Family members of patients with substance use disorder can powerfully influence the course of treatment of their loved ones.

I’ve known about the studies that support this for years, yet I must admit I haven’t gone out of my way to involve family members unless my patients request this.

The journal article reminded me we have research that shows family members can help prevent substance use disorder, can halt the development of these disorders, and can affect the prognosis once a substance use disorder is established. This article, by Ventura et al., reminds readers that involving family members in evidence-based interventions can improve health outcomes for the entire family.

That is, not only do these interventions improve the health of the person affected with substance use disorder, but also improve the health of all family members. Family members of affected patients show decreased healthcare expenditures as the patient’s treatment outcome improves.

It’s not fair to blame family members for actions which may worsen the substance use disorder of the affected person. They aren’t professionals. They are trying their best to deal with the insanity brought into the home with substance use disorders. They may not know the best way to support their affected loved one. Instead of judging these family members for their actions, better outcomes are seen when we educate them, and help them get care for themselves.

It’s tough to include families. Sometimes, our patients refuse us to include family in their treatment, and that is their right, and must be honored. Sometimes family members have their own substance use disorder that needs treatment. It’s also time consuming to involve family members, and many treatment professionals already feel their time is stretched. Some families are hostile to medication-assisted treatment of opioid use disorder. Explaining the reason why MAT is not just “substituting one drug for another” takes time and patience.

But if we can overcome these obstacles, involving the family in treatment can make a substantial difference in the lives of all family members, and not just the affected person.

 

Ondansetron for opioid withdrawal:

An article by Chu et al. described a study that looked to see if ondansetron (often known better under its brand name Zofran) could lessen withdrawal in patients on chronic opioid therapy. Because of previous studies that show some symptoms of opioid withdrawal may be mediated through the serotonin system, the authors hypothesized that ondansetron, as a serotonin receptor antagonist, could reduce opioid withdrawal.

This was a small study, with only 33 subjects, who participated in this double-blind, randomized crossover study. The subjects all had chronic back pain, and were changed from whatever opioid they were on to sustained-release morphine prior to the study. Then precipitated withdrawal was induced in these subjects with intravenous naloxone. Subjects’ withdrawals were treated with either placebo or ondansetron, and then both objective signs and subjective symptoms were measured.

The study showed no difference in withdrawal symptoms when ondansetron was given, compared to placebo.

That’s disappointing, but important to know.

Media Maintains Methadone is Menacing Mountains

 

NEWS CAT

Last week, a colleague of mine directed my attention to local news coverage of the opioid use disorder epidemic. It’s a four-part series titled “Paths to Recovery.”

Anytime the press covers opioid use disorder and its treatments, I feel hope and dread. I hope the report will be fair and unbiased, and give the public much-needed information. And I dread the more likely stigmatization and perpetuation of tired stereotypes about methadone as a treatment for opioid use disorder.

Overall, the four segments of this news report had some good parts, and some biased parts. It was not a particularly well-done series, and could have benefitted from better editing. It was disjointed and contained non-sequiturs, which I suspect confused viewers.

In the introduction to the first segment, the report says their investigators have spent months digging into treatment options in the area. Their conclusion: there’s a variety of options and treatment is not one-size-fits-all. The report goes on to give statistics about how bad the opioid use disorder situation has become, and they interviewed a treatment worker who says we’re two years in to this, and the community doesn’t grasp the seriousness of the situation. They also interviewed some harm reduction workers, and discussed naloxone rescue for overdoses and needle exchange.

So far, so good, except that of course we are more like two decades into the opioid crisis, not two years.

Part two of this series was “Mountain methadone clinics.” As soon as I saw the dreadful alliteration, I cringed, fearing the content of the segment.

This report didn’t say good things about methadone. In fact, one physician, supposedly the medical director of a new opioid treatment program in the area, says on camera, “Methadone is very dangerous. It has some effects on the heart. The rhythm of the heart, it has some drug interactions.” He went on to say that at the right dose, people could feel normal, and that it replaced the endorphins that were lacking, but I worry people will remember only that a doctor said methadone was a very dangerous drug.

Methadone can be dangerous, if you don’t know how to prescribe it, or if you give a person with opioid use disorder unfettered access to methadone. But in the hands of a skilled and experienced physician, at an opioid treatment program with observed dosing, methadone can be life-saving.

The news report outlined the failings of existing methadone programs in the area, saying staff had inadequate training, and failed to provide enough counseling for patients. It said one program made a dosing error and killed a patient, while another program had excessive lab errors.

All of that sounds very bad.

No positive aspects were presented as a counterpoint to that bleak picture. I felt myself yearning for an interview with a patient on methadone who has gotten his family back, works every day, and is leading a happy and productive life. Of course, those people are hard to find, since they are at work and harder to find by the media, even reporters who have supposedly been “working for months” on this story.

And then…of course they interviewed patients who had misused methadone. One person criticized his opioid treatment program because they allowed him to increase his dose to 160mg per day, and he said “…that’s a lot. I didn’t need that much…” and goes on to admitting to selling his take home medication. Another patient said the methadone made him “sleep all the time.” Another patient said methadone made him “high all the time.”

There will always be such patients…ready to lie to treatment providers to get more medication than needed, break the law by selling that medication, and then blame it all on the people trying to help them. Unable to see their own errors, they blame it all on someone else, or on the evil drug methadone.

Every program has such patients. But these people can also be helped, if they can safely be retained in treatment long enough, and get enough counseling.

Even though these patients are few, they get far more media attention compared to the many patients who want help and are willing to abide by the multitude of rules and regulations laid on opioid treatment programs by state and federal authorities. These latter patients are why I love my job. I see them get their lives back while on methadone. They become the moms and dads that they want to be. They go back to school. They get good jobs and they live normal lives. They don’t “sleep all the time,” as the patients on this report said.

But not one such patient was interviewed for this report.

As I watched this segment, I thought back to an interview the A. T. Forum did with Dr. Vincent Dole, one of the original researchers to study methadone for the treatment of opioid use disorders. This was in 1996, before our present opioid crisis gained momentum.

A.T. FORUM: It seems that, over the years, methadone has been more thoroughly researched and written about than almost any other medication; yet, it’s still not completely accepted. How do you feel about that?

  1. VINCENT DOLE:It’s an extraordinary phenomenon and it has come to me as a surprise. From the beginning of our research with methadone we were able to rehabilitate otherwise hopeless addicts that had been through all of the other treatments available. I expected methadone would be taken up very carefully by the addiction treatment community, but with some enthusiasm. Instead of that, we’ve had endless moral and other types of objections which are really irrelevant to the scientific data.

I was surprised, because my background in research had led me to expect that the medical community was a very critical but nonetheless objective group that would respond to solid, reproducible data. Instead I find that we still get the anti-methadone argument of substituting one addictive drug for another.

This is ignoring the scientific data showing that, as a result of methadone treatment, people who have been hopelessly addicted and anti-social and excluded from any normal life or family, are in a wonderful way becoming responsive to social rehabilitation and today constitute a very large number of people who are living normal lives. The fact that people, especially medical practitioners, would dismiss that as unimportant simply staggers me!

[http://atforum.com/interview-dr-vincent-dole-methadone-next-30-years ]

 

What would Dr. Dole think now, twenty more years later, during a terrible wave of death from opioid use disorders, about the continued stigmatization of methadone?

Then next segment was about buprenorphine, and how it can be prescribed in a doctor’s office, making it a better choice for patients. It wasn’t a bad segment, and contained some useful information. Physicians who were interviewed had nothing but good things to say about buprenorphine.

Or rather, they had good things to say about Suboxone.

The brand Suboxone was heavily promoted by this piece. Not once did the reporter use the drug’s generic name, buprenorphine. Every time, the medication was called by its brand name, Suboxone, and every picture of the medication was of Suboxone film. No mention was made of the other brands: Zubsolv, Bunavail, Probuphine, or even that there are generic combination buprenorphine/naloxone equivalents for Suboxone film, for less than half the price.

I know buprenorphine is kind of a mouthful for non-medical reporters, but still, I thought it was odd to use only the name of one brand: Suboxone. It’s as if this was a commercial for that drug company. Indivior, the manufacturer of Suboxone, must be delighted with this coverage. To me, it felt like an advertisement rather than journalism.

Another segment was about sober recovery homes. The investigative reporter talked to owners of sober recovery houses and the tenants at those homes. She said NC has no regulations or standards for recovery homes. She talked on screen to a patient advocate who says patient brokering is going on in Asheville, as well as lab scams at recovery homes where the patients’ best interests aren’t at the heart of the way these homes function.

She talked to Josh Stein, NC Attorney General, about passing laws to better regulate these sober homes, and he agreed that if these laws were needed, they should be passed.

No controversy with that one.

There was a segment about how there’s not enough beds in residential facilities for patients with opioid use disorder who want help. I agree, though I’m not sure this is breaking news for anyone. I don’t think there’s ever been enough beds to meet the treatment need.

Overall, I was left with a bitter taste after this reportage. The news program missed an opportunity to educate viewers about all evidence-based treatments for opioid use disorder, but ended up doing an advertisement for Suboxone and denigrating methadone.

Buprenorphine and methadone both work under the same principle: they are long-acting opioids which, when dosed properly, prevent withdrawal and craving while also blocking illicit opioids. While buprenorphine is a safer drug with fewer drug interactions, it isn’t strong enough for everyone. Methadone has countless studies to support its use to treat opioid use disorder, showing it reduces death, increases employment, decreases crime… but why go on, since facts don’t seem to matter as much as sound bites.

In my opinion, WLOS bungled an opportunity.

Depraved Indifference or Reckless Disregard?

 

 

 

 

 

I have a weird affinity for old “Law and Order” reruns. I’m not talking the lesser “Law and Order” spin offs like Criminal Intent and SVU…I prefer the originals. With a total of twenty seasons, there’s almost always an episode being broadcast on one channel or another.

I recently watched – for perhaps the third or fourth time – an episode about a man with serious mental illness who killed a woman by hitting her on the head with a rock. This man had auditory hallucinations due to schizophrenia. As he described it, his “bad uncle up in Yonkers” told him to kill people. Of course, he wasn’t guilty, by reason of insanity.

But the show rambled on, and detectives discovered this person was recently released from jail at Riker’s Island, where he hadn’t received much in the way of medical care. He hadn’t been properly treated for his schizophrenia, due to cost containment strategies of the company that provided medical care for prisoners. After he served his sentence, this sick man was dropped off with no medication and no plans for follow up medical care.

Jack McCoy, indignant and outraged (as he so often is on “Law and Order”), decided to charge the owner of the healthcare company with manslaughter. The physician assigned to treat the schizophrenic man was initially investigated, but he was able to prove he was threatened with being fired if he used expensive drugs or sent patients to the hospital. So then the owner of the company became the focus of Jack’s ire.

I don’t remember the exact count he was charged with, but the jury found him guilty, and he was sentenced to about a year’s incarceration. – in the very jail that his company contracted with to provide healthcare. The chief District Attorney, Nora Lewin, jokes that his immune system had better be good, because prisoners there don’t receive good health care.

I was thinking again about numerous news reports of patients with substance use disorders who die in jail, and it made me wish we had a few Jack McCoys in various locations.

Do you remember the case of David Stojcevski? I blogged about this horrible case on 10/20/2015, and again 2/25/2016. As a reminder, David was sentenced to thirty days in jail for non-payment of traffic tickets. He died on the seventeenth day of his sentence from what the autopsy said was “Acute withdrawal from chronic benzodiazepine, methadone, and opiate medication.” He had been on physician-prescribed methadone, clonazepam, and alprazolam, but was denied all of these medications during his incarceration. He was also not treated for the predictable withdrawal from these medications.

The family released videotape of his immense suffering (he had been moved to a “monitored” cell when he began to exhibit delirium) and are suing Macomb County, Michigan, where this jail was located. They are also suing Correct Care Solutions, the healthcare provider contracted to attend to the health of inmates.

The Justice Department investigated to see if criminal charges should be levied against the people who allowed David to die by denying him medical care. They investigated the charge of “deliberate indifference” on the part of jail staff and Correct Care Solutions personnel. Last year, the U.S. Attorney for that area announced they couldn’t find evidence for criminal intent on the part of jail workers and Correct Care Solutions that met the standard of beyond a reasonable doubt, so criminal charges were not brought.

Several days ago. the FBI was forced to release part of the documents regarding their investigation.

From the little that was released, the FBI discovered David had no intake of food during the last five days of his life, and that there were no medical visits from medical staff for the last 48 hours of his life. One guard said he got the impression from medical staff that they believed he was “faking” withdrawal symptoms.

The physician employed by Correct Care Solutions, after observing David, said he was not having seizures, and that he was faking those symptoms. An FBI physician said David should have been started on a withdrawal protocol, and that his fifty-pound weight loss and dehydration should have raised alarms. His opinion was that David died because of deliberate indifference to his medical needs.

The FBI’s records on their investigation showed there were medical visits that weren’t documented, or had poor documentation. Other news reports say 12 people have died in that county jail since 2012.

Even though there will be no criminal charges against the people who should have prevented David’s death by providing routine medical care, and the family’s civil case will proceed – at a snail’s pace.

I don’t understand the decision of the Justice Department. How can jails and prisons legally deny medical care to inmates? Isn’t that against the law? And if an inmate dies from lack of medical care from a completely preventable cause, shouldn’t that be illegal? Doesn’t this violate the 8th Amendment?

There’s a phrase I learned from “Law and Order.” It is res ipsa loquitor, and means “the thing speaks for itself.”

Surely the death of David Stojcevski from a treatable condition speaks for itself.

My question is this: how much louder do similar tragedies need to speak before changes are made to the disgraceful way inmates are treated?