“Bosch” Full of Tired Clichés

Season 5: Bosch and the Opioid Crisis

 

(Spoiler Alert – If you haven’t seen “Bosch” Season 5, this blog post will describe events of the last episode.)

I am disappointed in Harry Bosch. Or more specifically, I’m disappointed by the writers of the “Bosch” series.

“Bosch” is now in its fifth season on Amazon Prime. I’ve always enjoyed the series, based on the books written by Michael Connelly about the adventures of a Los Angeles homicide detective names Hieronymus (“Harry”) Bosch, played on the series by Titus Welliver. I thought the writing was smart and well-paced, with interesting plots that were better than average.

This season, the writers must have thought hey, let’s do something relevant, like a case related to the opioid use disorder epidemic. I would have liked that. The trouble is, this season portrays the opioid use disorder epidemic as it was about ten years ago.

There’s plenty more going on during the season which still makes the show worth watching, but I was constantly eye-rolling at the tired clichés about people who become addicted to prescription opioids, pill mills, and approaches to treatment.

In this season, Bosch investigates the murder of a pharmacist, who had dealing with thugs who run a sophisticated pill-mill operation. Oddly, these criminal masterminds have gathered a group of people who are addicted to pain pills and shuttle them from one pill mill to another, then to multiple pharmacies to fill these prescriptions, to obtain vast amounts of oxycodone pills.

Then the crooks dole them out to the poor addicts who are physically and mentally broken down, and meek as mice. For some reason, they do whatever the bad guys tell them to do, though clearly, they could score more oxycodone on their own.

Then for some reason, the crooks put them on a small private plane and fly them to a camp in the dessert where they are housed in shoddy trailers or old buses until they are flown back for another pill mill-pharmacy outing.

California has had a prescription monitoring program for years. That system would detect people trying to see multiple providers for multiple prescriptions. This scheme could have worked before the prescription monitoring program, but not now. But the writers appear to have ignored this awkward detail.

And flying these people to and fro doesn’t seem practical to me. Private planes are expensive, no? Why fly them to and from the pill mills and pharmacies, then back to the desert camp? Why not house them in a cheap motel at the edge of town? I get that the bad guys want to keep them quiet, but all that flying about seems inordinately expensive.

It’s not even that weirdness that makes me angry. It’s how the characters of the people with addiction are portrayed. They are downtrodden, doing what they are told by the thugs. They are submissive and controllable. After getting a bottle of prescription OxyContin, they turn over the entire bottle, only to be given one or two pills doled out over time by the bad men.

Naw, this doesn’t play. A group of six or eight people with opioid use disorder would certainly be more formidable than this. In fact, given the survival skills of the average person in active addiction, I’d expect them to be running the desert camp after a day. Guns or no guns, these people are in withdrawal and very motivated to get out of withdrawal. These bad guys would be no match for them.

Part of my prediction is based on how the bad guys are shown to be bumbling fools by the end of the season. At one point, one of them, armed, is supposed to throw Bosch out of the plane. Of course, Bosch, unarmed, turns the tables throws the thug out of the plane instead. Then at the end of the season, three of these hardened thugs come to Bosch’s lovely little home in the Hollywood hills for a sneak attack. They are armed with automatic rifles. Bosch, with a handgun, and takes them all down. These guys must be the worst shots in the world, because they spewed bullets galore, but missed Bosch completely.

Then the writers have Bosch trying to help one woman, using outdated methods. Elizabeth is a lovely yet troubled woman grieving the murder of a child. She has a heart of gold but prostitutes herself for one OxyContin 80mg with one of the bad men just to feel better. Of course, Bosch must help her. This lady is a veteran, like him, and he obviously has a soft spot for her in his hard-bitten heart.

He takes her for help to small seedy agency that helps veterans. He doesn’t take her to the Veterans Administration medical system, which now has excellent treatment programs for opioid use disorder using medication-assisted treatment. No, he takes her to a cold-turkey, you-must-suffer, just-for-veterans, hole-in-the-wall kind of facility. When Bosch remarks that he wants to say goodbye before he leaves, the proprietor of the “facility” says he’d better go now, before she chews her fingernails off.

This show perpetuates that tired idea that a person with opioid use disorder must suffer in order to be redeemed, gain recovery, and be worthy of respect again. This is not only an outdated concept, but dangerous. We’ve known since the 1950’s that a detox alone doesn’t do much good unless it’s followed by other treatment, but Bosch offers none of that information. The expectation is that if Elizabeth is tough and brave, she will beat her addiction.

Addiction isn’t like that.

In another scene, J Edgar, Bosch’s partner, is talking with this same woman, and she asks for relief from withdrawal. J. Edgar says a doctor will see her soon. She scoffs, “What and give me, Suboxone? I might as well snort Splenda.”

So, the show also downplays the effectiveness of medication-assisted treatment.

*SIGH*

I hereby announce that I am available for consultation on television and movie scripts. I can keep shows relevant and current with information about opioid use disorder and its treatment. Hollywood, I can help you.

Call me. We’ll do lunch.

 

 

Dealing With Disillusionment

 

“You know what? Let’s just switch every patient over to methadone and be done with buprenorphine!” I said angrily during case staffing last week.

This all started several weeks ago, when an angry patient was leaving my office. I don’t recall why he was unhappy with me, but on his way out of my office, he was venting about how he was being treated harshly, compared to patients doing much worse things. He said many patients leave our facility after dosing with buprenorphine with much of the medication packed between their teeth and lips. He said some people sold it, and some injected it, and that we were too stupid to see it.

I didn’t think much about it, but later that day at case staffing, we discussed asking patients to show us the area between teeth and lips, just to see if diversion in this manner was occurring.

I need to explain why we don’t want patients to leave with buprenorphine still in their mouths. Because we are administering this medication at an opioid treatment program, we must abide by different rules than an office-based buprenorphine practice. While physicians in office-based practices can prescribe as many days’ supply of medication as they see fit, different rules apply to opioid treatment programs.

In my state, buprenorphine patients still have to meet time in treatment requirements, same as methadone patients, before they can get any take home doses. Fortunately, our State Opioid Treatment Authority (SOTA) leaders are intelligent and reasonable people, and allow us to ask for take home exceptions early, at the four to six-week mark, for patients on buprenorphine who are doing well and have a couple of drug screens showing only the prescribed medications. This is because buprenorphine is so much safer than methadone.

But when patients first start, or if they’re still using other illicit drugs, or if their lives are unstable in some other way, they must do daily observed dosing with us.

Observed dosing means that they stay on premises while the medication is consumed. With methadone, it’s a quick swallow, and the patient says goodbye, and it’s done. With sublingual buprenorphine, our patients sit in a designated and monitored area until their medication is fully dissolved. We’ve had some patients walk out of the building with buprenorphine still in their mouths, and inject that buprenorphine. Because of that, we ask the patients to show a nurse under their tongue that the med has dissolved before they leave our facility.

But this idea that some patients may be packed medication between their teeth and lip was new. The nurses picked one day to ask all patients to show them their whole mouth – all around teeth, under tongue, after dissolving.

They discovered a handful of patients who had packed medication into a cheek, clearly with the intent of taking that buprenorphine outside the premises.

What did they intend to do with it? I don’t know. Maybe they planned to give part of their dose to a loved one. Maybe they planned to take it later, or maybe they planned to inject it. Maybe they sell the buprenorphine. I have no idea, but I have clear evidence that the patient isn’t taking the medication I’m prescribing.

I have an obligation to prevent diversion of medication I prescribe into the black market. If I know a patient is engaging in behavior that’s suspicious for diversion, I can’t in good conscience continue to prescribe that medication.

We could enter a discussion about how diverted buprenorphine is really a harm reduction method, by providing a safer opioid to the people in the community with opioid use disorders. But opioid treatment programs, called “methadone clinics” in the past, have long histories of stigma. Law enforcement types and regulatory inspectors do not want to hear about harm reduction. Some of these people barely tolerate our existence as it is. I support harm reduction, but I must deal with the world as it is now.

Diversion from an opioid treatment program can get that facility shut down.

When the nurse called me with a list of names of people engaged in diversion of buprenorphine, I had to tell her I will not prescribe any further buprenorphine for those patients. They must either switch to methadone or seek treatment elsewhere.

About half chose to leave and the other half chose to start methadone.

We felt like we had to start checking patients’ entire mouths every day, and found more patients who were diverting their medication. All in all, about ten patients were found to be attempting to divert.

I did not react well. I was furious.

Before you write a comment to me saying how unruly behavior is often a symptom of the disease of opioid use disorder, and that I shouldn’t take such things personally, and that the majority of patients were dosing correctly and that’s what I should concentrate on…yes, I know all of that.

But I had to go through a process to get there, and maybe writing about it is my way of dealing with these feelings.

I get particularly upset when a patient does something that threatens my view of myself as an effective helper. When it starts to look like I’m making it easier for some patients to inject themselves with buprenorphine, I feel anger initially, but underneath that emotion is a whole lot of fear.

I fear I’m not really making any differences in the lives of these people, and that they all look at treatment as a joke. I’m afraid I’ve been deluding myself that medication-assisted treatment helps patients. I wonder if I should go back to primary care practice, where nothing I ever said or did seemed to make a bit of difference in the lives of people with chronic illnesses. I fear that the MAT detractors are right, and that I’ll end my days by regretting the action and advocacy I’ve taken over the past decades.

I feel disillusionment.

As you can see, my strong negative emotions sometimes trigger a runaway train in my mind. Thankfully, as I age and mature, the train slows much faster than it used to.

I’m better now. Thankfully, I can go back to the information that lead me to this field in the first place…the decades of scientific information that show beyond a reasonable doubt that while individual patients may fail to improve with MAT, overall it saves lives. Then I can look at the smiling faces of patients who have completely changed their lives while in treatment.

When I get to the point I can look at reality uncolored by emotion, I see the vast majority of patients at the opioid treatment program are doing very well. Nearly all have improved in some way, some more than others, of course. Some of them do have rocky starts, but can do well if we address the issues and get them to stay in treatment.

Early into the New Year, I’ve re-learned a lesson about disillusionment, fear, and the process of working through all of that to a more reasonable view.

I suspect many people in the helping professions deal with this process over and over. It can be challenging, but such jobs are rewarding as well.

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.

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.