Skin Lesions from Injecting Buprenorphine: The Sign of the Cross

Skin lesions from injecting buprenorphine

 

 

Trapped in my house due to nine inches of snow and a slick driveway, last weekend I worked to catch up on my medical journals. An article in the January 2017 issue of The American Journal of Medicine caught my eye.

The article was titled “Curious Crosses: Injection-Induced Lesions” and it described the clinical course of a patient on buprenorphine monoproduct who sought care for recurrent, painful nodules. These nodules would erupt, exuding bloody pus. The article’s author described a fairly extensive work up of these lesions.

This patient was checked for all sorts of exotic diseases which can lead to skin eruptions of this sort, including tuberculosis, sporotrichosis and other fungal diseases, Sweet’s syndrome and Behcet’s disease.

Finally, one of this patient’s blood cultures grew Pantoea species. This was an important clue, because this bacterium is thought to be the cause of “cotton fever,” a syndrome of severe body aches, fever, and intense fatigue.  Cotton fever occurs in some drug users because cotton used to filter injected drugs often harbors Pantoea bacteria. Once the bacteria are injected along with the drug, they release an endotoxin, which produces the symptoms of cotton fever.

With this information, the patient was again questioned about injection drug use. The physicians already knew the patient had a history of intravenous drug use, but this patient told them he was doing well in medication-assisted treatment on buprenorphine.  The patient denied any ongoing injection drug use.

All pills and tablets meant to be taken orally contain fillers. These are usually inert substances that stabilize the active drug, and help the pill or tablet keep its shape. Substances that are formed with the active drug and serve to stabilize it are called “excipients.”

Buprenorphine sublingual tablets contain an excipient called amidon. As near as I can tell by internet search, this is a starch-type substance. This amidon, when injected, causes skin reactions and gives a distinct finding under the microscope.

Under polarized light microscopy, some substances refract light in a distinct manner that can help identify the substance. This property is called birefringence. Amidon is birefringent. Under polarized light microscopy, amidon crystals have the distinct shape of a Maltese cross.

Physicians treating the patient described in the article obtained skin biopsies of some of the patient’s sores. Polarized light microscopy showed the Maltese crosses from the amidon filler in buprenorphine, which more or less confirmed the diagnosis. Other substances can also cause Maltese crosses in skin biopsies, but of course, the most obvious cause in this patient was injection use of the prescribed buprenorphine monoproduct.

I got interested in this finding, and looked online to see if this had been reported before. It has.

In France, where injection use of buprenorphine monoproduct has been problematic, doctors have reported this distinct finding under light microscopy.

In fact, I copied the picture at the beginning of this blog from one of those articles (Schneider et al, “Livedoid and Necrotic Skin Lesions Due to Intra-arterial Buprenorphine Injections Evidenced by Maltese Cross-Shaped Histologic Bodies,” Archives of Dermatology, 2010;145(2):208-209.) In this case report, the patient was injecting into an artery, which is much riskier than into a vein, but the appearance of the Maltese cross in the same.

At the end of the report I found in the American Journal of Medicine, the authors said the patient continued to deny injecting his buprenorphine. All of the lesions he had upon admission were in locations where track marks are usually seen. During his hospitalization, no new lesions appeared on his skin.

The article’s authors state they reported their findings to this patient’s buprenorphine prescriber, who planned to discontinue buprenorphine in favor of other treatment options.

This case was interesting, informative, and reminds me to monitor patients closely when prescribing the buprenorphine monoproduct, often better known under its past brand name, Subutex.

I do prescribe the monoproduct buprenorphine, mostly for patients at the opioid treatment program where I work. In that setting, we do observed daily dosing. After getting their dose, the patients sit and are observed for however long it takes to dissolve the medication, and must show a staff member under their tongue prior to leaving the facility. We do this to help reduce diversion and promote proper use of the medication. We don’t grant take home doses unless and until patients have a degree of stability.

I have also prescribed buprenorphine monoproduct for some of my long-term patients in my office-based practice. If one of these patients, doing well for years, loses their medical insurance, I will switch them to the cheapest form of medication, which is the buprenorphine generic monoproduct. I do this only because I know them so well, and don’t want them to relapse, or have to switch to methadone at an opioid treatment program.

In other words, I have to judge that the benefits far outweigh the risks.

Even with the medical problems illustrated in this interesting article, buprenorphine monoproduct has a place in the treatment of opioid use disorder. And this article reminds physicians we must use the monoproduct medication thoughtfully.

Many of the new patients I see entering treatment at the opioid treatment program have injected buprenorphine pills. I’ve seen some really terrible looking tracks, and now I suspect the scarring and inflammation may be due to these Maltese crosses from amidon crystals.

Revoking Methadone Take home Doses

 

My decisions to revoke take home doses provoke more anger and outrage from my patients than anything else I do. This is a sensitive issue, and it feels like I’ve had to make more of these difficult decisions recently. I get it – revoking take home doses is a terrible inconvenience for patients, and expensive as well, what with the extra drive time to the opioid treatment program. And yet, there’s no denying that patients can develop problems and start misusing their take homes, or even start diverting them for sale.

To understand patients’ fury at losing take home doses, I need to describe how hard it is to get those take homes in the first place. Patients don’t waltz into treatment and get take home doses right away.

For patients on methadone at opioid treatment programs, (OTPs), eight criteria must be met before the patient can get any take home doses.

1. Time in treatment
2. Urine drug screens negative for illicit drugs and alcohol
3. Ability to store medication safely
4. Stable home environment, stable social relationships
5. No recent criminal activities
6. Regular clinic attendance – doesn’t frequently miss days
7. No behavioral problems at the opioid treatment program
8. Rehabilitative benefits of take homes outweigh the risk of take homes

Of all the requirements, time in treatment limits patients the most. Many patients do very well right from the start, with no drug use, criminal activity or any other complications. Even so, they must come every day the program is open (often 7 days per week) for a minimum of three months. After that, they can be granted two additional take home doses per week, as long as all of the other seven criteria are met. After three more months, they get one more take home per week, and so on. Once they get to the take home level where they come only once per week, they have to be compliant and in good recovery for at least one year before being allowed to get take homes every two weeks.

Patients expend time, money, and effort to get these take home doses.

That’s for methadone. For buprenorphine (Suboxone, Subutex, Zubsolv, etc.) there is no federal requirement saying how long a patient has to be in treatment to get a take home dose. So long as buprenorphine patients meet the other seven criteria, they can get take homes from the start, as far as the federal standard is concerned. However, state requirements may be stricter than federal requirements. For example, my state didn’t drop the time in treatment criteria for patients in opioid treatment programs on buprenorphine, but is willing to grant exceptions on a case-by-case basis, as long as the request is reasonable.

Most patients manage their take home doses perfectly. This fact gets lost in the hoopla over the few patients who don’t take their take home medication as prescribed. The actions of a few rogue patients, when made public, taint the reputations of all our patients. Their actions unfairly perpetuate stigma and bias against medication assisted treatment.

At any given time, you can google “methadone overdose on take home” or something similar and read news stories about patients who sold or gave their dose to someone who died as a result. It makes big splashy headlines and causes people in the community to wring their hands and lambaste opioid treatment programs for allowing people to get take home doses at all. In reality, many more people have died from methadone diverted from pain medicine clinics.

Part of my job as an OTP medical director is to decide, with the help and input of all staff, when a patient is taking the medication I prescribe as I prescribe it, and when it’s being misused.

Now obviously most people won’t tell OTP staff if they plan to misuse their medication, or divert it to someone for whom it was not intended, so OTPs have to have ways to assure patient compliance. One of those ways is called a “bottle recall.”

In a bottle recall, a staff person, usually the patient’s counselor, calls the patient at the given contact number and asks them to return to the facility within 24 hours so we can see that they have all their bottles and that bottles to be taken later in the week are still sealed and full of medication.

Yes, there are ways to falsify bottle recalls. In the past, patients would pull the plastic bottles apart at the seams, remove the methadone, fill the bottle with red Kool-Aid or similar, and glue the bottles back together. Some patients’ efforts were easily detected, and some do a slick job.

Now that we have pressurized seals on the take home bottles, we think it’s more difficult to get into the bottle without being detected, but some clever patient will invent a way to thwart the pressure seals…or already has done so.

If the patient fails a bottle recall, we must eliminate all take homes, at least temporarily. Sometimes patients don’t give us a working phone number, sometimes they say they never got the call, they just dropped their phone in a mud puddle and it wasn’t working, they got the message but forgot to return to the clinic, they just went out of town and only got the message when they got back, are out of town and can’t make it back for a bottle recall…we hear many reasons for a failed recall. Many are legitimate, and it’s nearly impossible to sort reality from lies.

According to patients, take home medication has been lost, stolen, left in hotel rooms, spilled in the sink, run over by cars, eaten by family pets, black bears, and other animals, burnt up house fires, and dumped out by angry spouses and highway patrolmen. In one creative story, the patient said a tree fell on her house during a storm. The great wind that felled the tree also created a sort of vacuum in her house, and a whirlwind sucked her medication bottle up, up into the sky as she watched helplessly.

Another patient said he couldn’t come in for a bottle recall because he buried his bottles in the back yard and forgot where he buried them, because he had Alzheimer’s dementia. Of course, I asked why he buried them, and he said, “So my wife wouldn’t get into them.” No, he didn’t get any more take homes.

Of course weird things can actually happen, and that’s the problem. What should I do if a patient who appears stable and who appears to be doing well, reports loss of medication? It’s a judgment call. With the help of the rest of the staff, we discuss the past stability of the patient and the believability of the report. We can’t look into the hearts of all our patients and tell who has criminal intent and who doesn’t. People can’t be perfectly assessed. I do the best I can, and with the help of the rest of the staff, make judgment calls about take home doses.

As the prescribing physician, I have a responsibility to make sure every patient who gets a take home stores it safely and takes it as directed. If a patient is unable or unwilling to do this, I have to revoke their take homes, at least for some period of time, especially if there’s evidence my patient is selling or giving away their medication.

Diversion of take home doses to someone other than the patient for whom it was prescribed is always a concern at opioid treatment programs. But we don’t want to limit freedoms for patients doing well because of the illegal activities of other patients. As with so many things relating to human behavior, it’s an issue of balance. I admit we don’t always get it right.

Some anti-methadone activists would like to change the law, and force patients on medication-assisted treatment to come daily for their doses, and eliminate take home doses. That would reduce the problem of diversion, but cause a bigger problem. It would disrupt the lives of thousands of MAT patients who take their medication as prescribed as they go about their life.

In the other extreme, some pro-MAT people say patients should be allowed to be prescribed methadone and buprenorphine a month at a time, just like medication for other chronic illnesses like diabetes and high blood pressure. But the medications I prescribe, methadone and buprenorphine, have street value, and can cause euphoria in people unaccustomed to taking opioids. Therefore, because of the properties of these medications, sound medical practice tells us we have to have some safeguards in place to detect medication misused and diversion.

Thank you Nurses!

 

This will be the first blog entry about how much I appreciate nurses at the opioid treatment programs I work with.

I’ve been remiss. Some of the best people I’ve ever met have been nurses at opioid treatment programs. Nearly without exception, they have been bright, caring, and compassionate.

At my OTP, we are temporarily short-staffed with nurses, so the stress they deal with is even more evident than usual. New nurses are being hired, so help is on the horizon, but right now, things are tense. Our nurses try to dose patients as quickly as possible without making any dosing errors.

Being a nurse at an opioid treatment program isn’t an easy job. I’ve overheard one imprudent program manager, several years ago, make an unfortunate comment that being a nurse at an OTP was easy, and that “anyone” could do it. He had no medical background, so he can be forgiven for his lack of knowledge.

Not every RN or LPN can manage to do this job well; it takes a special heart.

First of all, the state of North Carolina disagrees that “anyone” can do the job of a nurse at an OTP. They insist you have a nursing degree, so there’s that.

Secondly, medical professionals of all types have jobs where mistakes can be deadly. The ordinary human errors that cause problems in other work environments can kill in our line of work. That’s a special kind of stress. We accept that stress as part of the price of working as a medical professional, and we also accept that other people can never understand what that feels like.

Over a decade ago, I knew a nurse who made a dosing error by mis-reading the physician’s induction order for a patient on methadone. She gave a somewhat higher dose than was ordered by the physician on day two and day three. The patient died on day three. Of course the family was devastated, and a lawsuit ensued, settling for an undisclosed amount. But that nurse will never be the same. She left the OTP and I don’t know if she’s still working as a nurse or not. But that illustrates what a nursing error at an opioid treatment program can mean.

Out of all we do at OTPs, the most critical moment of care happens when the nurse hands over the patient’s daily dose of medication. The patient must be quickly assessed for impairment by the nurse, and the correct dose of medication given. This must be done perfectly, day after day, patient after patient. Any mistakes made at this point can undo the rest of treatment.

Any time perfection is expected of you at your job…that’s stress. And just like nurses in all medical settings, they are also being asked to work faster and faster, to be ever more efficient.

I’m not saying the counselors don’t also have high-stress jobs. Lord knows they do. But their errors don’t have the same ability to kill someone.

Thirdly, the amount of documentation and record-keeping demanded from nurses at the opioid treatment program is mind-blowing. These documents are intermittently inspected by the state’s department of health and human services, by the DEA, by the state opioid treatment authority, by CARF, etc. Someone is always looking over their shoulder, because they are working with strong opioid medications.

I’ve seen many nurses who couldn’t cut it in the OTP. It’s fast-paced and exacting, and often they deal with difficult people. Sometimes patients get angry at the restrictions of the opioid treatment program, many of which are mandated by state and federal organizations. Patients often direct their anger at the nurses. I’m often amazed at their ability not to take these outbursts personally. I’m afraid I might harbor resentment, but they seem to start over every day.

This is not a glamorous field of nursing. On the totem pole of medical specialties, addiction medicine and especially opioid treatment programs are the part of the pole that’s underground. When these dedicated professionals tell their friends and families about the work they are doing, they are sometimes chided for not doing something more mainstream. Or their family thinks their job consists of “shooting up them addicts with methamphetamine,” as one nurse told me.

Of course, we in the addiction treatment field know these nursing professionals are likely helping more people at the opioid treatment program than they would at any office or hospital setting.

It takes strong character to do a difficult job well, especially when you don’t get a lot of praise from nurse peers who know little about this niche area of medicine

So today I am honoring the nurses who work at opioid treatment programs. Thank you for the work you do. You are appreciated.

 

 

Life Stories

I have half-finished blog posts about important topics like the refusal of jails to continue medication-assisted treatments during incarcerations, expanding access to buprenorphine and methadone treatment, and DUI arrests for patients on stable doses of methadone. And yet, today I feel the need for narrative.

Patients with addiction are fascinating survivors. They come from all backgrounds, and many have been through hell and back. Often, I’m amazed at how they make it through episodes of sheer destruction. Occasionally, I hear such weird stories that as soon as I get home, I write them down. I feel these stories should be recorded, for some reason. They are entertaining, they are peculiar, they are poignant, and they can be sad. These narratives describe the demolition of life, due to drug use, in an almost casual way.

Here’s one I just had to share, due to its weirdness. Names have been changed, but nicknames are the same. There’s some mention of drug use, of course, so don’t read this if you are triggered by such. However, the negative consequences are also described, so maybe that helps reduce any cravings.

“I remember my friend Billy. He had a snake pit. He’d go out on the river with a croaker sack and a light and catch water moccasins. He sold the venom, and made hat bands from the skins. He also robbed Indian graves.

“Mae and Billy lived together; she was his mama. Every year he’d root for the Crimson Tide University of Alabama, and she’d root for the Auburn War Eagles. U of A and Auburn would play every year around Thanksgiving.

“Mae was with her nephew Bob that year, watching the game on TV at his place, drinkin’ and smokin’ dope. Bob lived on a place near the Tuskegee National Forest. He grew tenth generation Pakistani/Afghanistani reefer there. People came all the way from New York for that reefer. It was so bushy that a pound went into a grocery bag. He had a barn, and would pull it up by the roots and hang it upside down in there. He fertilized that reefer with shit from his fighting roosters. He had Ruble Neck Red fighting cocks. He’s been in prison for a long time. Married a girl from Trinidad, had two beautiful children. Got on a bus with a suitcase full of meth, geeked out, got arrested, and got federal time of 46 years.

“Anyway, Mae was watching the ball game, raisin’ hell and getting’ drunk. Alabama was favored to win, and Auburn, who had been losing all season, actually beat Alabama. You never know.

“Now Mae and Billy lived in a little house in East Tallassee. Billy watched the game, got drunk, and passed out on their living room floor. Mae came back home from the forest, playfully kicking Billy, shouting “War Damn Eagle!”

“Billy kept a 410 shotgun in the corner of the living room, like the majority of people living in Tallassee do. Billy woke in a drunken stupor. He and his mama were alike and would get in your face and holler, and have big verbal altercations with no follow through. But this time he got up, grabbed the 410 shotgun, pulled the trigger and blew his mama’s head off. Duck shot, squirrel shot. Bits of hair and skull and brains splattered all over the wall. Billy set the gun down, called the Tallassee police, and said “Come get me. I just shot my mama’s head off.” He was sentenced to forty years and died a few years ago.

“He’s the one that turned me onto Mepergan red capsules.

“That boy would shoot anything. He used those jelly reds, Placidyls…they had a terrible taste. You’d pull that thick syrup out, try to mash the plunger, but it was so thick…

“One time Billy and I were cruising around, and he pulled the keys out of my car, trying to be funny. I lost power steering and skidded to a stop, mad as hell. I pulled him out of the car, and told him I was gonna whip his ass. So he pulls a knife and cuts me on my left arm, aiming for my head. I grabbed the knife and started chasing him. I was high on a combination of Budweiser and Placidyl and I got mean. My hand was bleeding but I wanted to catch him. Somebody grabbed a hold of me and took me to the hospital, or I’d have bled to death. Billy came to the hospital to see if I was OK. He thought he’d killed me.

“Billy didn’t carry a knife for a long time after that because I told him if I ever see you with a knife again I’m gonna kill you.

“We were both young then, about nineteen or twenty. You may think we were bad kids, but we weren’t. We got into our share of mischief but it was all in fun. Except that about his mama, but he was at least forty years old by then.

“I don’t think Billy meant to kill his Mama. He loved his mama.

“Sissy opposed his parole. She was one of a group of four people who stole gold from a gold show at the civic center. They were arrested at the Florida border. They looked suspicious, with their Uhaul draggin’ the ground. She flipped and got a little jail time.

“She was with two guys and another girl when they were caught. Benny the bondsman was the other girl’s father. He probably masterminded that gold theft. He was a shady character.

“When I was in jail, a guy got busted in Montgomery for trafficking coke, and it turned out he was in a car owned by Benny. Benny was actually a Montgomery police officer for years before he became a bondsman. I think he might have been in the Klan. Benny was 5 foot two and bald. My initial knowledge of him was through my ex-brother in law. Benny financed part of his cocaine business.

“My ex-brother in law was called Hatchet, because of his face. He always had a whole bunch of pretty women following him around with his Corvette and boats. I went to his houseboat once and there must have been a dozen beautiful women. I don’t care what anybody says, that money will bring them in.

“Anyway, Hatchet ended up in prison. They seized all his houses. He had a little bit in his mama’s name, but they ended up seizing millions of dollars of property.

“It turned out that he became the warden’s boy at Kilby. That means he did yard work for the warden, washed his car, stuff like that. But they found a big plot of marijuana close to the swamp by the wardens’ house. They couldn’t prove it was Hatchet that planted it, but…he couldn’t go back out to the warden’s house after that. He served five years of a fifteen year sentence and got out. I don’t know if he’s ever worked. He gambles a lot.

Hatchet’s the one who turned me onto IV cocaine. I hauled dope out of Miami a few times with him. He’s the one who taught me how to shoot coke. After I shot that cocaine for the first time, I got sick. I was runnin’ around in the back yard, puking and gagging. Me with this long hair, in the middle of the night. Hatchet says “Come on back in here, man. You’re gonna call attention to us, makin’ all that noise out there.” It was loud.

“Most of those guys I ran with back in those days are either dead or in prison. There’s a few like me who were lucky enough to find recovery.”

…and more from the same recovering addict…

“Uptight Miller was an old heroin addict form the Vietnam era, and he could play some blues on the piano. He worked at the Coates’ funeral home at night and we’d all go in there and do dope and drink. I assisted with embalmings. You had the needle thing that busted the organs and you suck all the organs out, poke the big needle and the hose in, and put formaldehyde in them.

“And of course anyone who works in a funeral home has to pass out in a casket at least once.

“Uptight went over there one night and a friend of his, Wade, was there and they were acting funny. I don’t know why, but Wade blindsided me and I turned around and grabbed him, and fell on the coffee table. It broke and I got that leg and bopped Wade in the head with it, and got out of the door. I got away.

“Well, I rode around for a few hours, and got to where we hung out up at the Big Bear shopping center, and Eddie Ray came by. He was a real badass. He could take down somebody twice his size. He just went crazy.

“He’s the one that was trying to wire some dynamite under his girlfriend’s hood and it blew his hand off. I don’t guess he liked her. He could still play the guitar by wrapping a clothes hanger around his nub and picked the guitar that way.

“Anyway, I told him I was at Uptight’s and he jumped on me. Well Eddie Ray went ballistic and said I’m gonna whip both their asses. He knew Uptight’s bed was beside the window. He went thru the window, grabbed him up and beat the hell out of him right there in his front yard.

“Eddie Ray, God rest his soul, died diving off a bridge into a creek. He jumped too far, landed on a stump, and broke his neck. It’s crazy for him to die by jumping in a swimming hole.

“Upright and I made up. I had a date with a girl named Rita, but I wasn’t really impressed. Then he went out with Rita, even though he was married. I don’t know what Rita did to him but it was a week and his wife was told to move out and he moved Rita in and they got married. Undoubtedly she did something for him.”I did not make up any of the above; I’m not that imaginative. It all came from recovering addicts.

Personally, I can’t get enough of the crazy stories of active addiction. Some people may call them war stories, and I guess that’s what they are. However, I think they can serve to teach us about the insanity of addiction, so long as we remember the endings, like the arrests, violent deaths, and fatal accidents.

Avoid Burnout

There’s a high turnover in the field of addiction treatment. That’s not good, because people with the most experience leave the field for more attractive work environments. I’d like to offer some ways of avoiding undue stress that leads to burnout.

Before we get to stress, it’s important to talk about why there’s burnout in this field. Many people think it’s all from patient behaviors, but that’s not the only reason.

True, it’s not always easy to work with patients in treatment for drug addiction. Addiction can cause all sorts of behaviors that can interfere with treatment, and trigger anger on the part of treatment providers. In patients with addiction, old behaviors don’t disappear overnight, and we have no right to expect them to do so. For humans, change takes time.

Program administrators can cause stress for program workers. Administrators who aren’t familiar with what happens on the front lines of addiction treatment may make unworkable changes to how treatment is to be provided. As an example, I once worked for an opioid treatment program who instructed a nurse to operate three dosing windows at the same time, by herself, to reduce wait time for patients to dose. I am not making this up. Obviously this was unworkable and unwise, yet the nurse was required to “prove” the unworkability before this lame idea was discarded.

Addiction treatment providers don’t make a great deal of money. Addiction treatment professionals earn an average income of $38,000 per year, with a range of $24,000 to $60,000 per year depending on experience, credentials and treatment setting.

Counselors at OTPs have tremendous workloads. State and federal regulations say OTPS can have no more than fifty patients assigned to each counselor. Even within that limit, there’s not enough time to attend to all patient needs. And besides time spent with the patients, the time spent on documentation and paperwork is overwhelming.

In the past, addiction counselors tended to be in recovery themselves, with their personal experience as their only credential. Now there’s a push for the substance abuse treatment field to become more professionalized. The pressure to prove competency causes ever-increasing paperwork to pop up like mushrooms after a rain. And the documentation forms change all of the time. Just as workers get used to one form, it’s changed again.

To paraphrase Terri Moyers, a world-renowned addiction treatment professional, the substance abuse field is addicted to documentation and they are in denial.

OK, so there are stresses working in the field. Maybe the field will improve someday. Until then, here are some ideas about dealing with burnout:

1. Take care of your physical health. We tell patients to do this, but are we setting good examples? Eat right, go to the doctor for routine medical health screens, get to the dentist periodically, and get enough sleep. We all know what to do.
2. Have a life outside of work. This is big. I have to remind myself of this one frequently. Don’t let work become your whole identity. When you are at home, is your mind also at home, or are you thinking about a work situation? Try to keep your mind and your feet in the same place.
3. Have a creative outlet. Right now, I make pillow covers out of recycled leather. I love it; I enjoy the process of creating, and it’s fun to give them as gifts, too. This last Christmas, everyone on my gift list got a pillow or two. My house is filling up again with pillows, so they can expect more pillows this year. I’ve even started selling them on ETSY, a website that sells arts & crafts https://www.etsy.com/shop/OoolaLeather?ref=search_shop_redirect
In times past, I’ve made quilts. I seem to be drawn to the textile arts.
What is your artistic outlet? It could be something you’ve never considered as art: cooking, decorating your house, or making home renovations, or something else.
4. Don’t take things personally. We all have bad days, and another person’s nasty response to you may have nothing to do with you. Make allowance and let it roll off.
5. Don’t stuff your feelings, either. If there’s a situation at work that you don’t like, don’t wait until you explode in anger to say something about it. Go to your supervisor or other appropriate person and state your feelings about what’s going on. You’re more likely to be heard if you’re calm and logical and not spew-y.
6. Don’t have unrealistic expectations. Drug addicts use drugs. Expect this to happen during the treatment of the disease. Relapse is never OK, but if the patient is lucky enough to live through it, help them figure out why it happened so they can avoid a similar situation in the future.
7. Do some kind of aerobic exercise if your physical condition permits. Besides health benefits, exercise can make a huge difference in my ability to handle stress. It doesn’t have to be heavy exercise; even going for a walk can reduce stress.
After I broke my leg last spring, I couldn’t exercise like I was used to, and I really missed it. I felt much better after my leg healed enough to do some of my normal activities.
8. Nurture your spiritual health. This doesn’t necessarily mean participation in an organized religion, although for some people it may. For me, anything that connects me to other people and to the God of my understanding is spiritual. I feel better and more centered when I regularly make time for prayer and meditation. Obviously people find different things that nurture them spiritually.

Despite the stresses, many of us prefer to work in the field of addiction treatment, for various reasons. For those people, working in the field of addiction treatment is an avocation, not just a vocation.

For me, I love to see the positive changes in patients’ lives, and to feel like I had some small part in that. In this field when addicts find recovery it isn’t just their lives that improve; families and then communities benefit, too. I didn’t see that when I worked in primary care.

I have the best job in the world.

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

This was a tough blog to write. I want to thread the needle; I want to relate some solid help from 12-step recovery sources without angering some of my faithful readers who become angry with any mention of 12 step recovery, and don’t feel they help people with opioid addiction.

So you’ve been warned.

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 do 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, which are 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 making a plan of 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.

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 contact with the other person.

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.

Addiction taught harsh lessons at an exorbitant price, so we should learn from past mistakes.

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.

Smuggling Suboxone

I was intrigued by an article I saw on my internet homepage. It was titled: “When Children’s Scribbles Hide a Prison Drug”

http://www.nytimes.com/2011/05/27/us/27smuggle.html?_r=1&hpw

 This article describes unique ways Suboxone is being smuggled into jails. Law enforcement officials associated with both state and county jails from Maine and Massachusetts were interviewed. They say prisoners and their accomplices make Suboxone into a paste and smear it over the surfaces of papers sent to prisoners from their families. The article mentions the paste being spread over children’s coloring book pages, and under stamps. Suboxone films have been placed behind stamps or in envelope seams. Correctional officers now have to inspect material coming in the mail to prisoners much more closely.

 I had several thoughts. First, yet again, I’m struck by the creativity and cleverness of addicts. If only they could channel this energy in the right direction, amazingly good things could come to them, instead of the continued hardships brought by addiction.

 Then I felt sad that such actions described in the article would taint the reputation of a medication that has the potential to save lives, when used appropriately. Such illicit use of Suboxone gives ammunition to those who would prefer that office-based treatment with Suboxone didn’t exist.

 Then I wondered, how many of these prisoners have a legitimate prescription for Suboxone, but are denied their medication by prison officials? How many are legitimate patients of methadone clinics, also denied their medication while imprisoned, who know that Suboxone will alleviate some of the opioid withdrawal they are feeling? How many of these people are addicted to opioids, not in any kind of treatment, but who know Suboxone will treat their withdrawals?

At least one study supports the idea that many people use Suboxone illicitly not to get high, but to prevent withdrawal. Dr. Schuman-Olivier studied 78 opioid addicts entering treatment. Nearly half said they had used Suboxone illicitly prior to entering treatment. Of these people, 90% said they used to prevent withdrawal symptoms. These addicts also said they used Suboxone illicitly to treat pain and to ease depression.

Many law enforcement personnel and members of the legal community have strong biases against medication-assisted treatments. They don’t understand that addiction is a disease, and that methadone and buprenorphine are legitimate, evidence-based treatments. They have difficulty letting go of their idea that addiction is a choice that deserves blame, and have a punitive stance towards addicts. They have low opinions of addicts who are using drugs, but often have no better opinion of a recovering addict who has sought treatment and is doing well on replacement medications, like methadone or buprenorphine.

 But no matter what law enforcement personnel think they know, when they deny prescribed, life-saving medications, I believe they’re practicing medicine without a license.

The article mentions one woman who, with the aid of the Maine Civil Liberties Union, sued because her Suboxone treatment had not been continued while she was in jailed for a traffic violation. She settled out of court, but her lawyer made the excellent point that if inmates are denied their medications, they will try unlawful means to get it.

Other patients and their families have brought successful lawsuits against the jail facilities. In at least two cases, in the same Orange County, Florida jail, patient/prisoners were allowed to go through withdrawal for so long that they died. The estate of one person won a three million dollar judgment against the county. (1, 2)

I’m glad to see these lawsuits. I’ve heard appalling stories from many methadone patients, who were denied their medication while incarcerated. I’ve heard tales of jailers taunting these prisoners, when they became sick. There is no defense for such cruelty.

Orange County now works with local methadone clinics. If a prisoner is a current patient of a clinic, his clinic will send a week’s worth of medication in a locked box via courier. Nurses at the jail have the key to the box, and administer each day’s dose. The jail doctor consults with the medical director at the methadone clinic. Prisoners still have to pay out of pocket to get the medication, so the only cost to the jail is the time required for personnel to administer the medication. It’s certainly much cheaper than paying three million to the estate of a dead prisoner, not to mention much more humane.

I wish the county jails around the methadone clinic where I work would approach the problem of opioid addiction and treatment in a collaborative way. Sadly, only seven state prison systems offer medication-assisted treatment with methadone or buprenorphine.

Rikers Island, in New York City, gives us another example of how such a system could work. There, opioid-addicted prisoners charged with misdemeanors or low grade felonies can be enrolled in a program known as KEEP (Key Extended Entry Program). This program treats opioid addicts with methadone and counseling. Upon release from Rikers Island, these patients are referred to methadone treatment centers in the community. Seventy-six percent have followed through with their treatment, post-release. The results of this program show significant reduction in reincarceration and significant reduction in criminal activity. (3)

Drug courts trying to save money would be well-advised to look at the Rikers Island program. Studies have shown a cost savings of at least four dollars for every one dollar spent on methadone treatment. This money is saved because methadone patients require fewer days of hospitalization and other healthcare costs, and also because of reduction in criminal activity and incarceration costs. (3, 4)

I know from comments written to this blog that there are many more people abusing Suboxone than I previously imagined. For sure, some of the prisoners getting smuggled Suboxone are misusing it. But I don’t think the majority are using for anything other than prevention of withdrawal, since they are usually not offered any other effective treatment for this medical condition.

1. “Outrageous: the death of Susan Bennett raises serious questions about the competence and quality of the jail’s nursing staff” Orlando Sentinel, editorial, March 27, 1998.
2. Doris Bloodsworth, “Inmate begged for methadone” Orlando Sentinel July 12, 2001.
3. Par`rino, Mark, “Methadone Treatment in Jail,” American Jails, Vol: 14, 2000, issue 2, pp 9-12.
4. California Department of Drug and Alcohol Programs, 2004, California drug and alcohol treatment assessment (CALDATA) California Department of Alcohol and Drug Programs. California Drug and Alcohol Treatment Assessment (CALDATA), 1991-1993 [Computer File]. ICPSR02295-v2. Ann Arbor, MI: Inter-university Consortium for Political and Social Research [distributor], 2008-10-07. doi:10.3886/ICPSR02295