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Bad Weather Take Home Doses for Opioid Treatment Program Patients

We’ve had some snowy days in my area, and this means administrators at our opioid treatment program must decide if we should provide extra take home doses to patients for the days when travel will be treacherous.

Because take home doses are closely regulated at opioid treatment programs, both for methadone and buprenorphine, we must get special permission from state and federal regulatory agencies to give extra take home doses. We do this by submitting what’s called an “exception request.” This is an online form where we describe why we are requesting an extra take home, and for whom it will apply. Part of our job is assuring the authorities we won’t give extra take homes to patients who can’t manage them safely.

Ultimately, it’s up to me, the medical director, to decide the risk level of each patient. Which is more dangerous, driving on snowy roads to get to the opioid treatment program to dose, or having an extra take home bottle of medication? I need input from the staff to make the best decisions, so this can be time consuming.

Admittedly, my program failed our patients this last week.

The trouble is, we must decide when to submit a request for extra take homes about 48 hours in advance. It may take a day to submit online and get the medical director’s signature, the state opioid treatment authority signature, and the federal agency signature. Then we must give out the extra take home one day before the harsh weather is predicted.

Sometimes it’s hard to forecast bad weather. Early this month, we got an extra take home exception for a day when ice was predicted. In our area, a few degrees can make the difference between ice and rain. As it turned out, no ice fell and it was a perfectly normal day for driving.

I think that over-reaction was in our minds when we were monitoring the weather last week. At first, weather was expected for late Tuesday night. We were expected to get 1-2inches. We discussed if we should submit an exception, and finally did so late Monday night. I signed it, and it was approved by state and federal authorities, but we chose not to enact the exception Tuesday morning, based on updated forecasts.

It was not the right decision.

Tuesday night, it began to snow during the wee hours. By early morning, we had 3-4 inches and it kept snowing until afternoon. Somehow the forecasted 1-2 inches turned into 8 inches, at least on my side of the Brushy Mountains.

I live in the Brushy Mountains, and have a very steep driveway. Really, really steep. Imagine the steepest paved road you’ve ever driven on, and crank that up a few more degrees and you have my driveway. Plus, it has two curves in it. The only way I can get my small Toyota down the driveway would be to ride it like a luge sled, so it stays in the garage during bad weather.

My fiancé has a four-wheel drive vehicle, so he takes me to work, or I call a co-worker to come get me and I walk down my driveway to the road.

A group of physicians who work at opioid treatment programs were discussing this issue of severe weather take home exceptions on our monthly conference call last week. We pondered the factors that help us decide:

  1. Since buprenorphine has a greater margin of safety than methadone, I’m willing to grant bad weather take home doses for buprenorphine patients, unless there are other concerns to be considered.
  2. Patients in the induction phase of treatment, the riskiest time in treatment for methadone patients, shouldn’t get extra take homes.
  3. Patients who already receive take home doses for Sundays and holidays are likely OK for bad weather days, too.
  4. Patients using alcohol or benzodiazepines are at higher risk, and may not be appropriate for extra take home doses.
  5. Patients who live in a home with other people with active substance use disorders may not be able safely to store their medication, and may not be appropriate for the extra take home.
  6. Patients who have had recent episodes of suspected diversion won’t get extra take homes.
  7. Patients who live around the corner, are healthy, and can easily walk to the opioid treatment program don’t need extra take homes.
  8. Patients who live in more treacherous terrain or longer driving distance may need take homes. Our opioid treatment program is in the foothills of the mountains, but some patients live in a spur off the Appalachian Mountains called the Brushy Mountains. We have some steep and winding roads.

That’s a rough idea of most of the factors that go into deciding who should get take homes and who shouldn’t.

Then there are transportation issues. I mistakenly thought Medicaid-funded patients, who ride a transportation service that contracts with Medicaid to provide transportation to medical appointments, could get their usual ride to the opioid treatment program. Later I found out they have only a few four-wheeled vehicles. On one of our worst snow days, they only transported dialysis patients and others with “life-threatening illnesses.” My patients weren’t transported.

So, now I know that I cannot count on this agency to get patients to treatment on bad weather days.

As a group, OTP physicians are re-evaluating criteria for extra take homes in these bad weather situations, along with some help from our SOTA (State Opioid Treatment Authority). I feel fortunate to live and work in a state with an active SOTA. These remarkable people are tireless in their quest to continually improve the quality of care for patients at opioid treatment programs. They are valuable allies for physicians.

Because that’s the bottom line: we all want the best and safest care possible for our patients.


Buprenorphine Monthly Injection: Sublocade












Late last year the FDA approved Sublocade, the brand name of a monthly buprenorphine injection, marketed by Indivior, the same company that sells Suboxone brand sublingual films. Sublocade is expected to be commercially available by February or March of this year.

This medication is indicated for patients with moderate to severe opioid use disorder who have stabilized on transmucosal buprenorphine products for at least seven days. Sublocade comes in a pre-filled syringe, and is injected into the subcutaneous tissue over the abdomen. This viscous liquid forms a solid deposit containing buprenorphine, and the medication is released over a month, giving therapeutic plasma levels of buprenorphine.

Thus far, we have two studies, one a randomized controlled trial and another that was an open-label study, that both show Sublocade, compared with placebo, was significantly more likely to result in fewer positive drug screens for illicit opioids and in fewer self-reports of illicit opioid use.

Of note, the manufacturer warns against attempts to inject this preparation intravenously, because the solid mass that forms can block a blood vessel, or travel in the vessel to the lungs, possibly causing death from a pulmonary embolus. To reduce the risk of this bad outcome, the medication will only be distributed to healthcare professionals, and not to patients.

Sublocade comes in two doses; a 300mg dose and 100mg dose. Patients should receive 300mg per month for the first two months, then drop to 100mg per month. This is the indicated dose for patients on the equivalent of sublingual buprenorphine 8 to 24mg per day. If patients have inadequate response after dropping to 100mg, the dose may be increased to 300mg in some patients, if the physician feels this is indicated. At the manufacturers website, they say Sublocade delivers a dose adequate to block opioid receptors to the degree that if other opioids are used, they will have no effect.

Steady state is established after 4-6 months of treatment. Steady state is a term describing the pharmacokinetic state where the drug’s intake is in dynamic equilibrium with the drug’s elimination from the body. Usually this occurs after four to five times the drug’s half-life. After steady-state has been achieved, buprenorphine may be detected in patients for up to 12 months after dosing stops. It is unknown how long buprenorphine will remain detectable in urine testing.

After this medication is stopped, the patient should be monitored for opioid withdrawal symptoms for several months, since blood levels will drop slowly.

Indivior recommend checking liver function tests at baseline, then monthly.

Because of the possible harm of intravenous use of this product, Indivior created a REMS (Risk Evaluation and Management Strategy) protocol. Healthcare settings seeking to dose Sublocade and pharmacies wishing to dispense Sublocade must be certified by the REMS program for this medication.

I tried to go to the website mentioned on the Indivior website regarding the REMS requirements, but the link wasn’t working for me.

I’m excited about this new option because it can reduce diversion of buprenorphine products. At the opioid treatment program, we have a fair number of patients who attempt to divert or misuse sublingual forms. At present, if I have unmistakable evidence a patient is trying to divert medication, I can no longer prescribe it. I can offer to switch the patient to methadone, but that’s unattractive for several reasons to many patients. But if we can administer subcutaneous buprenorphine, it gives us another option. It would be difficult to divert, and it isn’t as complicated to administer as the Probuphine implants.

I do have some concerns. First, how do the financial aspects work? Since it can only be dispensed to the healthcare provider for administration to the patient, I suspect the facility or physician owner of the practice will need to buy the medication and pay up front. What if a patient’s insurance company refuses to pay? What if a patient refuses to pay, or only pays part of the drug cost? Could the physician lose money treating patients if this happens?

Currently, with sublingual buprenorphine products, the physician isn’t in the middle. The patient pays the pharmacy directly.

I was thrilled to learn that North Carolina’s Medicaid program will pay for this medication, without even requiring a prior authorization. That’s wonderful, but many private buprenorphine practices don’t treat Medicaid patients, due to low reimbursement rates. But this will be good for facilities who do accept Medicaid as payment.

I’m amazed our state can afford this. Perhaps they got a much better deal from the drug company, Indivior, than the quoted priced of $1500 to $1800 per month. One month’s worth of generic monoproduct buprenorphine, dosed at 16mg per day, costs about $105 per month at the cheapest retail pharmacy, according to That means this new subcutaneous injectable formulation costs fourteen times more than the cheapest form of buprenorphine on the market.

That’s quite a difference. I’m assuming the state’s willingness to pay this expense is based on expectation of a marked decrease in diversion of this medication. Apparently, the lump of buprenorphine can be cut out if it’s done within the first 14 days, but that seems an unlikely extreme for patients. In other words, with the monthly injection, the medication will reach the patient for whom it is prescribed.

At this point we could launch into a discussion about whether diversion of buprenorphine – possibly the safest opioid available – is a good or bad thing. Law enforcement types see diversion as bad, but arguing a pure harm reduction viewpoint, one could say that diverted, black market buprenorphine might be saving lives by giving people with untreated opioid use disorder a safer option. Note that I said safer, not safe. But that whole debate is an entire blog post so I’ll keep the focus on this new way of delivering buprenorphine.

About half of my office-based patients are self-pay, with no Medicaid or private insurance. They pay out of their own pocket for my office charges, and pay for their medication at their pharmacy. I think Sublocade’s price will make it an unworkable alternative for these people. About half my patient have private insurance, and most have Blue Cross/Blue Shield. I plan to make some phone calls, to get information about their payment policy for Sublocade.

I’m eager to try this new preparation at the opioid treatment program. It sounds like this will be workable for Medicaid patients.

But that brings up my second concern: how can I get patients to come for weekly counseling sessions if they only get medication once per month? I was pondering this idea in a group Email yesterday when I was informed (by someone who knows these things) that soon, a competitor of Indivior will be releasing a weekly injection form of buprenorphine. He envisioned weekly injections for new patients, with gradual decreasing of frequency of visits as the patient stabilizes, eventually moving to monthly treatment and counseling sessions, when clinically appropriate.

I like this idea. This sounds workable. And as I emailed him…let’s hope there’s a price war, with both companies lowering their prices to attract patients.

I’m happy about any new options for patients, and I’m eager to use this product. I just hope cost won’t be a deal-breaker for patients and their insurers.


The STOP Act of North Carolina
















In mid-2017, North Carolina Governor Roy Cooper signed the STOP (Strengthen Opioids Misuse Prevention) Act into law, and as of January 1, 2018, additional portions of the Act became effective.

The STOP Act has several parts, all of which are intended to reduce the epidemic of opioid use disorder by limiting excessive and inappropriate opioid prescribing.

Beginning last July, the STOP Act required physician extenders (nurse practitioners and physician assistants) working for pain management practices to consult with their physician supervisors prior to issuing any Schedule II or III opioids. Then, they must also consult with their physicians every three months while the opioid prescriptions continue.

Prior to this law, extenders had no requirements to consult with physicians prior to issuing these opioids or continuing them. Still, defining the meaning of the word “consult” is a little fuzzy…does it mean a face-to-face conversation, a phone conversation, or email communication? The NC medical board website doesn’t offer much concrete guidance about this.

Beginning last July, the STOP Act also said hospice organizations were to start telling families of patients who passed away while on strong opioids where the leftover medications could be disposed safely. The STOP Act also encouraged the distribution of naloxone kits for opioid overdose reversal, and streamlined the process by which prescribers could enroll delegates to query our state’s prescription monitoring program more easily.

By September 1, 2017, pharmacies were supposed to be reporting all controlled substance medications that they dispensed by the end of the business day. I don’t know if there are any penalties for not meeting that requirement, but I think we still have a way to go towards meeting this standard. Pharmacies also need to correct data quickly if they confirm it’s been entered in error.

This requirement pleases me a great deal, given my interactions with pharmacies over the years. On numerous occasions, when I’ve called about a goofy-looking entry for one of my office-based buprenorphine patients on the North Carolina Controlled Substances Reporting System (NC CSRS, our state’s prescription monitoring program), I’ve been told by pharmacists (usually a CVS) that the error can’t be corrected because it’s a system glitch. Now I can tell them they are required to fix the error!

But one of the most debated portions of the STOP Act took effect January 1, 2018. This was a provision that limits prescriptions for opioids for acute pain conditions to no more than a five-day supply. For post-operative pain, opioid prescriptions can be for up to seven days.

This doesn’t mean a physician can’t write a second prescription when needed. It only means the physician must see the patient again and carefully consider whether to write a second prescription, rather than OK more opioids with little thought.

Many people fear this law, worried they won’t get adequate pain control. However, it’s important to understand that this requirement will not apply to hospice patients and those in palliative care. This requirement is only for acute pain episodes: kidney stones, acute injuries, broken bones, and the like.

This portion of the STOP Act doesn’t apply to chronic pain conditions, either. Patients who are being prescribed opioids as part of an existing program to treat chronic non-cancer pain won’t fall under the five- and seven-day provisions.

However, parts of the STOP will eventually require prescribers to query the NC prescription monitoring program before starting opioids to treat chronic pain. Prescribers will need to review the patient’s prescriptions for at least the preceding twelve months. After beginning an opioid prescription, the physician will need to query the NC CSRS at least every three months., though there’s no deadline to start doing this yet.

Then in January 1, 2020, electronic prescriptions will be required for all targeted controlled substance prescriptions (Schedule II and III opioids).

Some people think the STOP Act is too severe, and will put patients at risk for under-treatment of pain. When medical practice is limited by legislation, opponents of the Act say, physicians are less able to use their clinical judgment and patients are all treated the same.

But this legislation is based on some crucial information.

In 2016, the Centers of Disease Control and Prevention (CDC) issued the CDC Guideline for Prescribing Opioids for Chronic Pain. This document, among other recommendations, stated that opioids are not the ideal way to treat chronic pain conditions, and that non-opioid treatments are preferred. Those guidelines also recommended that if opioids are used, reasonable goals should be set, and patients need to be informed about the risks of opioids. The Guidelines also gave specific recommendations for how to start opioid at a low dose, with short-acting agents, and ways to monitor patients to make this prescribing safer. [1]

Then last year, the CDC released information showing the risk of developing opioid use disorder increases with increased duration of opioid prescribing. This article, “Characteristics of Initial Prescription Episodes and Likelihood of Longer Term Opioid Use – United States, 2006-2015.” Shows us thought-provoking data based on a very large population study.

This interesting data showed that the risk of long-term opioid use increases sharply after the first five days of treatment, and again after the first thirty days of treatment. Therefore, limiting that first prescription to five days, as North Carolina legislature has done, makes good sense. This law is science-based, which isn’t always seen in legislation.

Treatment initiation with a long-acting opioid was associated with higher probability of remaining on opioids for longer than a year, underlining the importance of using short-acting opioids for acute pain situations.

More interesting, using tramadol initially to treat acute pain was associated with a significantly higher risk of remaining on opioid long-term. We need more studies to help clarify this, since many physicians perceive tramadol to be a lower-risk drug than simple opioid agonists like oxycodone or hydrocodone.

The authors of this article also looked at the cumulative dose of opioids given, and noted an increase in the likelihood a patient would remain on opioids long-term once they had consumed more than 700 morphine milligram equivalents.

This study was well-done. It was a random sampling of over a million patients over age 18 on a commercially insured health plan who were prescribed at least one opioid prescription between 2006 and 2015. Cancer patients, patients with a history of substance use disorder, and patients starting buprenorphine were excluded from the study.

Critics may ask how this data is relevant. They may say, for example, that just because a patient remains on opioids for more than a year doesn’t necessarily mean that person will develop opioid use disorder, and that’s true.

But at a population level, more opioid prescribes means more overdose deaths. Over the past fifteen years, the number of milligrams of opioids prescribed quadrupled. Mirroring that rate closely, our nation’s opioid overdose death rate quadrupled right along too.

Less available prescription opioids will mean less available to fall into the wrong hands. We know from NSDUH data that more than fifty percent of the time, the first opioids a youngster takes for experimentation are obtained from a friend or relative.

I support this law, and I’m hopeful the law will mean fewer medicine cabinets have leftover opioids lying about. I’m hopeful this will reduce youthful experimentation, which will reduce the risk for opioid use disorder.

Let’s stop making new patients, as we help established patients along their road to recovery










“We will not regret the past, nor wish to shut the door on it.”





I’ve written a version of this blog before, and I thought this would be an appropriate time to redo and re-post it. After all, the end of the year is a time of reflection. Not one of us is perfect; we’ve all fallen short of our own ideals this year. But a new year stretches before us, with plenty of room for the grace of change.

This blog post contains what I feel are helpful concepts from 12-step recovery groups. I know 12-step recovery isn’t for everyone. Some people tell of bad experiences with 12-step groups. And I know millions of people have been helped by these groups, too. So, take what you like from this blog entry, leave the rest, and if you read something helpful, I’ll be happy. If not, try again next week because my topics fluctuate.

I talk to many recovering addicts who voice regrets about their past. The stories vary; the patients’ main theme is regret for behavior during active addiction. I understand those feelings, and feel tempted to tell patients how to deal with these feelings… but I don’t say anything, for fear that I’ll sound too “preachy.” Who am I to tell someone that they can examine past regrets, learn from previous mistakes, make amends when needed, and face the future with a clean slate? Isn’t that a conversation for a priest, imam, rabbi, or pastor?

Yes, it is. And yet, this person is in my office. Many times, my patients tell me they feel unworthy to join or rejoin a religious community, and feel judged by such groups. Some of my patients’ perceptions could be colored by their own shame, but I fear many of them are accurate in their perceptions. Addiction is still regarded as a sin by some religious groups. Other groups know addiction isn’t a sin but a disease, which can cause us to do and say things we regret, which are contrary to our values

Twelve step groups like Alcoholics Anonymous and Narcotics Anonymous have mechanisms for dealing with past regrets and ruptured relationships. These groups didn’t invent anything new. They use the same approach as other spiritual and religious groups, an approach which is also sound psychological advice. However, the twelve steps provide a handy framework for handling regrets.

First, in Step 4, the recovering person assesses past behavior, called a “moral inventory” in recovery parlance. That inventory is shared with themselves (ending denial), another trusted person, and the god of their understanding. Patterns of behavior emerge, giving information to be used in steps 6 and 7, where the person becomes willing to give up old behavior and ask the god of their understanding for help with this.

In step 8, the recovering person lists the people he has harmed while in active addiction. With the aid of a sponsor or trusted spiritual advisor, in Step 9 the recovering person makes plans for how best to make up for past behavior.

Amends can be as simple as saying, “I’m sorry,” to someone for past bad behavior, or amends can be more extended, like resolving to be fully emotionally present for loved ones.

Sometimes direct amends aren’t possible, if the person has moved away, died, or unable to be located. A more general amends can be made instead. For example, if a person shoplifted to support their addiction, it may be impossible to remember where and what was stolen. Part of the amends process is not to repeat the old behavior, but a more general amends may involve volunteering in the same community to help society in some way, like donating to a food bank or giving time to help a child in need.

If the recovering person feels guilty about stealing money, amends may include apologizing for the past behavior, and planning re-payment. For example, I know a person in recovery now for over 16 years who sends a check for $25 each month to a governmental agency to whom he owned money after a criminal conviction. He may never get the full amount paid off, but he’s taking action to fix what he broke.

Addiction taught harsh lessons that came at exorbitant prices, so we should learn from past mistakes. Our pasts contain gold mines of information that can help us in the future. Recovering people can move forward by planning amends for past actions, but also should consult a sponsor or spiritual guide for help. For example, if an addict stole money from a drug dealer, it should not be paid back, especially if it puts the recovering addict at risk. In some situations, the best amends may mean having no further contact with the person who was wronged.

Some recovering addicts have long lists of bad behavior to make amends for, and other recovering addicts’ lists may contain only a few people. Many addicts harmed only their immediate family, by not being completely emotionally available to their spouses or children during their addiction. Some recovering people feel just as bad about that as others feel about committing armed robbery for drug money.

The point of amends isn’t how bad the behavior was, but how the recovering person feels, and how he can leave behind guilt and shame and move forward.

Addiction, like some other diseases, affects behavior. Rather than living with regrets, recovery means facing regrets, learning from them, fixing what we can, and then moving on. It doesn’t matter what you call it: making amends, cleaning your side of the street, getting right with the god of your understanding, or some other term.

Therefore, in this end-of-the-year time of reflection, I’m going to take some time to evaluate my own life, shortcomings and all. I plan to reflect, learn from the past year, then pray to the god of my understanding to help me change into the person I want to be in 2018. I understand I will never be perfect, but I hope I can become a little bit better.

As we hear in 12-step meetings, “Progress, not perfection.”



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!

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:


In my state of North Carolina, you can get some valuable information from the Governor’s Institute, at and also their blog:

You can attend webinars, get clinical tools, and obtain mentoring from the Providers’ Clinical Support System MAT, at

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:

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?