Archive for the ‘American Society of Addiction Medicine’ Category

I’m Back

 

 

 

 

 

 

I’m back to blogging, after a short break, during which I took my Addiction Medicine board re-certification exam. I think I did well on it, but with those sorts of exam one never knows for sure. If any of my readers are planning to take the exam soon, I have a bit of advice: it’s great to go to the annual Review Course hosted by the American Society of Addiction Medicine, but you should also read the textbook, “Principles of Addiction Medicine.”

I listened to both the 2018 and 2019 Review Courses online. Those courses are great if you want to know all the essentials of the field. However, many of the questions on the test went a layer deeper than the review courses covered.

For example, rather than just asking which receptor type a drug of abuse activates, the test would ask what subtype of that receptor was involved. I don’t find that sort of question to be clinically relevant, but then I’m not a researcher, just a worker on the front lines of the opioid epidemic.

So now I’m happy to back into my routine, seeing patients and doing the work I love.

However, this month I’ve had to confront issues that I thought were resolved months ago. For example, I’m vexed by new prior authorization forms. It seems that large insurance companies like Cigna might be asking smaller companies to do their management of prescription costs, a service euphemistically called “pharmacy benefit management.”

This is an example of a form I got last week:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

As you can see, it asks for chart notes, drug screen results, documentation that the patient isn’t on any other opioids, per the state prescription monitoring program, and a plan and evaluation/assessment for potential to taper.

This happens to be a patient of mine who has been in successful, relapse-free recovery for over nine years. She is extremely high functioning at her job, and a delightful patient. I provided all the information they needed to approve her generic buprenorphine/naloxone medication, but I don’t think that should be required for coverage. They approved it for only six months, so we’ll have to repeat this process twice per year.

I think it’s discriminatory to demand this of a patient in treatment for opioid use disorder, but not for diabetes. It also discourages providers from wanting to treat patients with buprenorphine products, since it requires considerable time and energy to respond to these prior authorization demands.

Another company, called Southern Scripts, working for a larger health insurance company, asked for this form to be completed on a patient prior to paying for his buprenorphine/naloxone tablets:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

After completing the form and asking for an expedited review, I got this letter:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

There’s no way I’m sending notes regarding a patient’s substance use disorder treatment to an insurer, so instead I wrote a summary letter, in which I described the progress this patient has made & how well he is doing, and that delay in coverage for his medications could have catastrophic medical consequences to his health.

In response to my letter, Southern scripts issued a six-month approval for coverage of his medication. So, in six months, we’ll do this whole thing over again, I guess.

We are now twenty years into this opioid epidemic. I thought we were all at the point where we realized that it’s not good public policy to have insurance companies erect barriers to treatment with buprenorphine products to treat patients with opioid use disorder.

I’ve saved the best for last.

I’ve dealt with my share of frustrations with pharmacists and pharmacies.

Readers know I went to electronic prescribing a month or so ago. Last week one of my patients, stable for years, went to get his refill from his pharmacy. I submitted it electronically, and put one refill on it, since I see him only every two months at this point.

When the Walgreen’s pharmacy refused to give my patient his refill, he called my Health Services Manager, who called the pharmacy. They said my patient’s refill had been cancelled, and that I would need to submit a new electronic prescription. Worried I’d made an error, I went to my E-prescribing program and found I did write for a refill. Confused, I asked my Health Services Manager to call the pharmacy back, to discover why they wouldn’t honor the refill.

They told him that Schedule 3, 4, and 5 opioids could not be refilled, and that a new prescription had to be submitted.

This is not accurate, of course.

I wasn’t in a mood to argue. I just re-submitted the prescription and my patient filled it. Of course, now on my e-prescribing software it looks like I issued two prescriptions for the same month, which I did. I’ll have to document in his chart about the problem with the pharmacy.

I had hoped e-prescribing was going to remove some of the difficulties I’ve encountered with the pharmacies filling buprenorphine products. Now, I’ve lowered my expectations.

Opioid Use Disorder: Then and Now

 

 

 

 

I started working at an opioid treatment program in 2001, by accident. It’s a long story that I’ve told elsewhere, but once I saw data about the improvements for patients who start medications to treat opioid use disorder, I knew this was the field for me.

After a few weeks working in an opioid treatment program (OTP), I could help patients make huge and productive changes to their lives. Prescribing medications to treat opioid use disorder can have tremendous impact on the lives of people with this illness. Medications like methadone and buprenorphine reduce the risk of dying from an overdose at least three-fold, according to a recent study. [1] Methadone and buprenorphine used for opioid use disorders are also associated with improvements in physical and mental health, reduced risk of suicide, improvement in employment status, reduction in criminal activities, and increased life satisfaction for patients.

I started as a physician at a not-for-profit program in a southern city. I saw mostly patients using heroin, but also pain pills. We had patients drive from hours from more rural areas, and eventually this program expanded into seven additional programs, mostly located in the western part of the state.

By 2004, on Wednesdays I worked at a town of around 40,000 people. I saw patients who drove an hour or more for help. Some patients drove several hours from Tennessee. At this time, methadone was the only medication this OTP used. DATA 2000 had passed, and a few Suboxone providers prescribed in cities, but buprenorphine products weren’t widely available in smaller towns and rural areas.

Wednesdays were busy. We had dozens of people show up seeking admission, but because I was the only physician, I asked that we admit no more than 20 people per day. My requests were not honored, and I worked many long days, admitting up to 25 to 30 people on these days.

These were complicated patients, and it took time to unravel their medical, psychiatric, and drug use histories. We had limited staff, who already had more than fifty patients on their caseload. This exceeded state limits on the number of patients assigned per counselor and kept us under scrutiny by state authorities. It felt like the wild west.

I knew it wasn’t safe to admit so many people, but what was the alternative? There were no other opioid treatment programs around. That small city had one or two inpatient detoxification units, but as we know, the relapse rate is very high, as is the overdose death risk, for patients leaving these five -to -seven-day programs. Inpatient residential programs were difficult to access and weren’t acceptable to most patients anyway. If these patients didn’t get help with us, they probably couldn’t get any help. So, I worked long hours and did my best.

I felt a continued tension between trying to get people into treatment and taking good care of them once they were in treatment.

These people did not get the attention they deserved, but I’m comforted by data from “low threshold” methadone programs. These are programs that don’t require that patients participate in counseling services, and that don’t dismiss patients for positive drug screens. Data shows that patients entered in these programs do relatively well, despite receiving treatment that lacks the usual counseling requirements. [2]

That Wednesday waiting room was packed with urgency and misery. Imagine twenty or thirty people, in various stages of opioid withdrawal, impatient to see the doctor and get a dose of methadone that will help ease their suffering. I hated making people wait, but had to spend enough time with each of these complicated patients. Hiring additional physicians or physician extenders would have helped, but this program had a hard time keeping providers.

Almost all these patients were using OxyContin brand of pain pills. Patients described how easy it was to file off the time-release coating from “oxys,” as they were called, freeing the entire 20mg, 40mg, 80mg, (and for a time, 160mg) pill to be used at once. Most patients crushed the pill and either snorted it or injected it. Apparently, it easily dissolved in water, making it easy to shoot.

That’s a lot of opioid firepower to release all at once, and misused OxyContin killed many people. Sometimes people, not aware of how harmful this medication could be, thought that since it was prescription medication, it couldn’t hurt them.

Patients couldn’t be expected to know what their doctors didn’t even know. OxyContin was prescribed freely in most communities at this time. Some of it was prescribed by pain management physicians, but mostly it was prescribed by small-town physicians with little training in pain management. These physicians had been told by the so-called pain management experts that the risk of developing addiction was low, less than 1%. How wrong they were…

Our opioid treatment program never advertised services. We didn’t need to. Patients showed up because they were referred by friends or relatives. We had whole families in treatment. We might admit a husband and wife one week, only to admit their adult children the next week, plus cousins, an uncle, or a grandparent. Sometimes we would have three generations of a family in treatment.

Whole neighborhoods seemed to come for help. Addiction appeared to be part of the social fabric of the region, binding people together like a fondness for playing cards or baseball.

I remember in 2004, I admitted so many people from Gray, Tennessee, that I asked the rhetorical question, “What is going on in Gray, Tennessee? It looks like everyone in that town must have opioid use disorder.” As it turns out, the first opioid treatment program in Eastern Tennessee was opened in Gray, Tennessee…in 2017.

Benzodiazepines were freely prescribed back then, and we had patients overdose and die while on methadone. I struggled then, as now, trying to decide if a patient using benzodiazepines heavily can safely be admitted to treatmen. Current recommendations say we shouldn’t limit access to methadone and buprenorphine for patients with co-occurring benzodiazepine use disorder, but I’ve had such patients die, and remain wary. Each patient’s risk must be carefully assessed. If patients have taken benzodiazepines regularly for years, a taper could take weeks or months, and sometimes can be done in an outpatient setting, while the patient is getting treatment with medications for opioid use disorder. Other patients can’t control their use of benzodiazepines in an outpatient setting and must be admitted to an inpatient medical detox unit. They must be monitored carefully while reducing or stopping benzodiazepines. Patients can have seizures during withdrawal, just like patients withdrawing from alcohol

Back in 2004, we didn’t have a prescription monitoring program in North Carolina. Our program didn’t become functional until 2007. By then, I was medical director for this program that had around 3100 patients scattered over their eight opioid treatment programs. In December of 2007, when I got authorized to use our PMP, I spent most nights and weekends looking at patients on the system. In the end, around twenty-three percent of all our patients were filling another major controlled substance. Those medications varied from methadone, OxyContin, Xanax, and clonazepam.

I was asked to submit a narrative of my experience to Brandeis’ Center of Excellence. This narrative was later sent to OTP prescribers in a SAMHSA “Dear Colleague” letter and can be read here: https://www.pdmpassist.org/pdf/Resources/methadone_treatment_nff_%203_2_11.pdf

Once we could see what other medications patients were taking, our overdose death rates came down rapidly. I will always believe PMPs are life-saving.

Now I check all entering patients on our state’s prescription monitoring program and check all established patients once per quarter. I don’t get very many surprises these days on the PMP.

Compared to 2004, patients have more options for treatment for opioid use disorders. Still, financial barriers are considerable, especially in office-based setting prescribing buprenorphine products, and far too few people who need treatment can get it.

Many more OTPs in this state now take Medicaid, helping more patients get treatment. We also have grant programs for patients with no Medicaid or other insurance, funded through the CURES program in the past, and now by the state opioid response grants. Most new patients can get started in treatment even if they have no money, thanks to these grants.

Our OTP was lucky to be asked to participate in a MAT PDOA grant. I forget what the initials stands for, but this grant pays for treatment for patients on probation or parole who have opioid use disorder. This grant, which lasted three years, is ending soon, and we’ve treated hundreds of patients with it. For many, it was their first treatment experience. Some did very well, and some not so well, but the recovery seed has been planted. Some patients need a few tries at treatment before they get traction into recovery.

In the OTP where I work now, I have tons more contact with established patients and know them much better than I did at the OTP where I worked in 2004. There’s still much room for improvement, but today I do more than just admit patients. I also have time to talk with the staff, which I think helps all of us understand our patients better and provide better care.

Now, almost no patient mentions the brand name OxyContin. Some patients are using oxycodone, but not one brand. There’s still some Opana use, and certainly heroin is used by many entering patients. Some patients come for help because they prefer using illicit buprenorphine over heroin or other opioids, because buprenorphine can keep them out of withdrawal for a day or longer. Instead of paying $30 for one 8-milligram tablet on the street, they come to treatment programs to get cheaper, legal help. Most, though not all, patients are also happy they receive counseling.

I’ve change since 2004. I’m much more tolerant of continued drug use by patients. I cringe to remember that in the past, I tapered patients off medications to treat opioid use disorder because they wouldn’t stop using marijuana. I don’t do that now. I tell patients that though I’m not happy about their use of an illicit (in my state) drug, it’s not a deal-breaker for treatment. I still stress over patients’ use of benzodiazepines and alcohol, especially if they are on methadone.

Things change quickly in this field, and our OTP may look very different in the future than it does now. I pray that we continue to improve the quality of care for our patients and continue to reach ever more of the people who need help. I love my job, and after eighteen years, still believe I can do more to help people in one day at my OTP than I did in a week doing primary care.

  1. Sordo et al., “Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies,” British Medical Journal, 2017.
  2. Christie et al., 2013

The Sacklers: Rich People Problems and a Possible Solution

Heroin Spoon sculpture left outside Purdue Pharma

 

 

The Sackler family is having rich- people problems. No, let me correct that: they are having ultra-rich -people problems. They can’t find museums to accept their financial donations.

This family made its fortune, estimated into the billions, by making and promoting sales of OxyContin, the drug that started the opioid epidemic in North American.

I know some readers will quibble about that statement and tell me there are other reasons for our opioid epidemic. I know there were other factors: an FDA that was perhaps too cozy with drug companies, a nationwide push to do a better job of treating pain, so-called pain experts who used shaky data to support their safety claims for long-term opioid prescribing, and few prescription monitoring programs that could identify patients who were developing opioid use disorders by doctor-shopping. These were factors. But the opioid firepower in OxyContin tablets, easily available by removing a coating, fueled our opioid epidemic for more than ten years.

In April 2019, the New York Times ran an article about the Sackler family, their wealth, and their legal problems. [1]

Purdue Pharma, the drug company owned by the Sacklers, has been sued by various entities claiming OxyContin caused harm. As I’ve written about in previous blog posts, Virginia won a $600 million award against the drug company and its three top executives in 2007, after the company and executives pled guilty to criminal charges of misbranding. It’s a big verdict, but perhaps not so big, given the wealth of the Sackler family, estimated by Forbes to be about $13 billion.

In the past, the Sackler family distanced itself from the problems of their pharmaceutical company. Now, individual family members are being sued for their part in pushing OxyContin inappropriately. New York, Massachusetts, Utah, Connecticut and Rhode Island have all filed suits against members of the Sackler family. The New York Times says more than 500 cities, counties, and tribes have coalesced to sue members of the Sackler family.

These agencies claim some of the Sacklers are more involved in sales decisions that they would like the courts to believe. For example, according to the NYT, two years after the Virginia guilty plea, Mortimer Sackler, who was on Purdue Pharma’s board, wrote a memo inquiring why Purdue’s sales force wasn’t selling more opioids.

Either this man either didn’t understand his company’s guilty plea two years earlier, which is unlikely, given all he’s achieved in life, or he didn’t care. He wanted to make more money, at any cost.

The family, well-known for their philanthropy, has made big donations to various cultural and educational institutions. They’ve donated large sums to the Metropolitan Museum of Art, where they financed an entire wing: The Temple of Dendur. They’ve donated to the Louvre in Paris, the Guggenheim, and to colleges and universities.

Earlier this year, activists targeted several of these locations as protest sites, and asked museums to refuse money from the Sacklers, tainted as it is by association with the opioid epidemic. In February, protesters at the Guggenheim dropped paper slips made to resemble prescriptions from upper floors of that museum to protest acceptance of the Sackler’s money. Protesters also staged a “die-in” to represent the lives lost to opioid use disorder, and the Sackler family’s role in those deaths.

Last year, sculptor Domenic Esposito placed an 800-lb sculpture of a bent spoon containing heroin outside Purdue Pharma’s headquarters in Stamford, Connecticut, to protest the Sackler’s role in the opioid epidemic. The spoon was confiscated by police and eventually returned to its creator.

Because of the political pressure from protesters, this summer, the Metropolitan Museum of Art decided not to accept further money from the Sackler family, as did the Guggenheim and the National Portrait Gallery in London.

Thus the ultra-rich problem of having no outlet to make charitable contributions.

The Sacklers defend their actions in manufacturing and promoting sales of OxyContin, saying they were mislead like everyone else into thinking that prescription opioid pain pills, when prescribed for pain, put patients at very low risk for developing opioid use disorder. They say they were taken in with the bad science of the age like other health agencies, and that it’s not fair to blame them for the opioid epidemic.

I find the Sackler’s proclamations of ignorance to be implausible, for several reasons. I can remember attending a course called “Pain and Addiction: Common Threads,” around 2004. At that course, a physician associated with Purdue Pharma chided physicians in the meeting who were trying to tell the presenters about how easy it was to inject or snort OxyContin. My memory may be inaccurate, but I know those meetings were recorded. I think I once possessed cassette tapes of a 2003 meeting, made by a company working for the American Society of Addiction Medicine. I surely wish I hadn’t discarded these old tapes; it would make for some interesting listening, given all that has happened since.

In Barry Meier’s prescient book, “Pain Killer,” he described how small-town physician Dr. Art Van Zee tried very hard to tell Purdue Pharma representatives about the devastation he was seeing and treating in opioid-addicted patients. Meier’s book was published in 2005, so Dr. Van Zee’s efforts had to be taking place around 2003.

In 2003, a Purdue Pharma representative testified before Congress that the company knew people were misusing their medication, and that they were re-formulating their medication to make it more abuse-resistant. But Purdue Pharma didn’t make that change until 2010, seven years of profit later.

Richard Sackler, once Purdue Pharma’s CEO, called people who misused OxyContin “scum of the earth,” “criminals,” and “victimizers,” in an article in the New York Daily News published in May of this year. Sackler has since said he made those uninformed statements decades ago, and that he understands more about opioid use disorder now and recognizes his lack of sensitivity to people suffering with opioid use disorder. [2]

This evidence indicates Purdue Pharma knew about the problem of misuse. The Sackler’s claim they had no knowledge of the death and destruction associated with their medication just isn’t credible. If the Sackler family didn’t know about the destruction their medication was causing, they’d have to be stupid or living under a rock. You don’t get to be billionaires by being stupid.

However, the Sacklers may be politically tone-deaf. In one of the biggest shows of chutzpah in the world, Purdue Pharma at one point considered getting into the opioid use disorder treatment market by manufacturing buprenorphine products to sell.

Yes, that’s right. In a full circle of greed, Richard Sackler got a patent in 2018 for a new form of buprenorphine in a wafer form. Since it dissolves in only a few seconds, it claims an advantage over tablet and film forms of the product now on the market.

This incredible development leads to the point of this blog: I have a solution for the unfortunate Sacklers, who have a bunch of money they want to give away but can’t. They say they want to help fix this opioid epidemic, and they now have a patented form of the product.

I say let the Sacklers, through Purdue Pharma, manufacture buprenorphine for the treatment of opioid use disorder and provide it free of charge to any patient who needs treatment. All the patient would have to do is see a physician, who prescribes Purdue’s buprenorphine product. The patient takes this prescription to any pharmacy to receive free treatment medication. Purdue could pay the small pharmacy fee for stocking and dispensing the medication. More patients could access treatment this way.

Everyone wins with my idea. The Sacklers get to give away money in a method that provides direct amends to the very patients they have harmed. Physicians no longer have to agonize over which form of buprenorphine to prescribe so that the patient can afford it. Patients get treatment that saves lives.

My idea has the advantage of removing middle-men. If Purdue Pharma and/or the Sackler family are found guilty in future lawsuits, they could pay their fine in the form of free treatment medication. This method avoids pitfalls with money gathered from civil fines that must be filtered through layers of government. Sometimes such money gets spent well, and sometimes not. With my method, it all goes to benefit the patients.

I love my idea, both for its practicality and for its poetic justice.

What do you think?

 

  1. https://www.nytimes.com/2019/04/01/health/sacklers-oxycontin-lawsuits.html
  2. http://www.nydailynews.com/news/national/ny-news-richard-sackler-opioid-addicts-scum-criminals-emails-20190507-ujfmvpphqjc77icemxafbjhlai-story.html

Please Stop Smoking

 

 

 

 

 

 

Although my blog is dedicated to opioid use disorder and its treatment with medications, this blog is about the importance of stopping smoking.

I was listening to the American Society of Addiction Medicine’s annual review course from 2018, and while I listened to the lecture of nicotine use, became convinced I must do more to promote smoking cessation among my patients and readers of this blog.

In the ASAM lecture I listened to by Dr. Abigail Herron, she remined me of some bleak facts about smoking: it is the leading cause of preventable deaths worldwide, and it accounts for 20% of deaths in the United States. Half of all smokers will die from tobacco-related illness.

Smokers die, on the average, of ten years earlier than they would if they never smoked.

That last bit of data stopped me. If you are a smoker who is reading this, what would you do to be given the gift of ten more years of life? For me, it would also depend on the quality of those years, but then, stopping smoking is likely to increase the quality too.

Rates of cigarette smoking are going down in the U.S., but as smoking is being promoted in the developing world, we will see more problems in these areas. By 2030, it’s expected that 80% of all smoking deaths will be in developing countries.

Deaths from smoking are usually from cardiovascular disease (heart attack or stroke), lung cancer, and chronic obstructive pulmonary disease (COPD) like asthma and emphysema.

Nicotine causes blood vessels to constrict, and smoking also causes blood to clot more easily, causing vascular disease of all types. We usually think of smoking causing lung cancer, but smoking increases the risk of cancers of the esophagus, kidney, pancreas, stomach, liver, urinary bladder, and uterine cervix. Smokers also are more likely to develop Type II diabetes, osteoporosis, erectile dysfunction, cataracts and macular degeneration, and early menopause.

And wrinkles. Lots of wrinkles, because nicotine cause blood vessels to constrict, limiting blood flow and depriving skin of oxygen and nutrients. I dabbled with smoking when I was younger but stopped after a few months when I thought I saw wrinkles developing. Vanity saved me from nicotine use disorder, and I’m happy about this.

It’s not only the nicotine that does the damage with cigarettes; they also contain harmful ingredients like hydrogen cyanide, ammonia, benzene, formaldehyde, and particulate matter like lead, cadmium, and nitrosamines. Cigarettes contain around forty-eight hundred compounds, and eleven are known carcinogens.

The active product, nicotine, is quite physically addicting. It stimulates the release of dopamine in the brain, producing feelings of pleasure, but nicotine also stimulates other neuro transmitters.

In the past, patients entering substance use disorder treatment programs weren’t asked to quit smoking, because we worried quitting both cigarettes and drugs (including alcohol) would be too hard and people needed something to fall back on. We worried patients would do worse in substance use treatment if they were asked to quit smoking too. Now, we have good evidence that shows the opposite may be true.

Most of the studies done in this area show better outcomes in patients who quit smoking early in their recovery from substance use disorders. Smoking cessation may improve the likelihood of longer-term sobriety. (Gulliver et al., Alcohol Research and Health, 2006) Several studies showed that patients entering addiction treatment were 25% more likely to maintain abstinence from alcohol and other drugs if they also stopped smoking (Prochaska et al, 2004, Joseph et al., 2004).

Patients’ brains may recover more quickly if they quit smoking. A study of patients with alcohol use disorders (Durazzo et al., Alcohol Clinical Experience Research, 2014) showed patients recovering from alcohol use disorder who quit smoking at the same time they stopped drinking rapidly improved on measures of learning and mental processing speed during their first month. Patients who continued to smoke had slower recovery of these mental functions.

Smoking during pregnancy has well-known risks. Moms who smoke are more likely to have miscarriages, low birth weight, ectopic pregnancies (pregnancy in the Fallopian tubes instead of in the uterus), placental abruption (when the placenta tears away from the uterine wall), and increased risk of Sudden Infant Death syndrome. Given these known problems, many moms chose this time to quit smoking.

I already talk to patients about smoking cessation, but after I listened to Dr. Herron’s lecture, I vowed to redouble my efforts, and talk to everyone about quitting.

Here’s what we know about quitting smoking: though not easy, it can be done. If you have a failed attempt, don’t give up. As with other substance use disorders, learn what you can from each relapse. Learn what does work for you and what doesn’t. Pay attention your triggers.

Medications can help, and double quit rates. The three first-line medications are bupropion (brand names Wellbutrin and Zyban), varenicline (Chantix) and all the nicotine replacement therapies (NRT). NRT comes in patches, gum, lozenges, inhalers, and nasal sprays.

Each of these products have some drawbacks; the gum can stick to dentures, making it less desirable for some patients. The patches can cause a skin rash, and the inhalers can potentially cause breathing problems, so patients may want the advice of their primary care provider.

I’d like to educate readers about e-cigarettes and vaping, but that’s difficult, due to the many products on the market. One product may have significant carcinogenic particulate matter in what is being vaped, and another product may not. Overall, vaped products have fewer cancer-causing substances, but still contain things other than nicotine. At a minimum, e-cigs and vapes contain flavoring and humectants. Since people tend to puff longer with a vape or e-cig, these substances may still be harmful to the heart and lungs.

Though smoking rates in the U.S. have dropped significantly over the past decades, down to around 15% of the population, adolescents use of e-cigs and vapes has increased rapidly. Manufacturers make products targeted towards adolescents, for example, with cotton-candy flavored products.

Thus far, no electronic nicotine delivery systems are FDA approved for smoking cessation. These products might be helpful if they are used as a complete substitute for tobacco. However, people who both smoke cigarettes and use vape products, called dual users, are no more likely to quit smoking than people who aren’t trying. That’s discouraging data about using e-cigs and vapes to quit.

There’s good news for people who want to quit smoking. Circulation improves after only a few weeks of smoking cessation, and lung function can increase up to 30% within the first three months. After one year of stopping smoking, the cardiovascular risk drops to half that of someone who continues to smoke. Ten years after quitting smoking, the risk of developing lung cancer drops to half that of a smoker.

Talk to your doctor to form a plan to help you quit. Consider accessing the free North Carolina quit line for help: https://www.quitlinenc.com/

They have a 24-hour hotline, and even have coaches available to help you.

I’m writing this because I have many friends in recovery from substance use disorders, and some of them still smoke. I like these people, and don’t want them to die early. I want them to quit and be around for many more years, sharing their experience, strength, and hope with the rest of us.

Insomnia

 

 

 

 

 

I planned to regale my readers with news from the big annual American Society of Addiction Medicine conference, held earlier this month. But it was not to be. The day before I was to depart, I woke up with pink eye.

I woke up with the kind of pink eye that caused fluid to sprout from my eye like an overfull bathtub. Of course, this material in highly infectious, and very messy. I dabbed my eye and face with a tissue, discarded it and washed my hands, only to have to repeat the whole process a minute later. In good conscience I couldn’t get on a plane and go to a meeting of hundreds of people and risk infecting them, so I stayed home, feeling grumpy.

I’ll still go to the sessions, online. ASAM has a wonderful online program, where you can hear sessions at conferences you’ve registered for. So as soon as they are posted, I’ll listen to them at home, and then pass new information on to my readers.

In the meantime, here’s a re-run on insomnia. I get so many patients with insomnia. It’s a common problem for people in recovery, who are waiting for their brain chemistries to calm down. Nearly every week, I recite the main points of good sleep hygiene to patients in need of a good night’s sleep.

For someone who has grown accustomed to taking some sort of substance to fix every problem, hearing that the solution isn’t another pill can be hard to accept, but I’m convinced most sleep issues can be cured or improved with the following principles of sleep hygiene:

Many U.S. citizens, and not only addicts, have become “chemical copers.” We have the idea that every problem can and should be fixed with medication. But with insomnia, sleep hygiene is the best first option, and medication can be used if sleep hygiene doesn’t work.

Sleep hygiene, which sounds it means washing behind your ears at bedtime, really refers to habits that help us get satisfactory sleep. Most are common sense ideas, and they can really make a big difference. Here are some of these ideas:

Go to bed at the same time and wake at the same time every day, even on weekends.

If it’s at all possible, don’t go to bed later or sleep later on weekend days. Get your body into the habit of keeping a regular sleep/wake cycle. You will fall asleep more easily with a fixed bed time.

Besides making your feel better because you’ll get more regular sleep, this practice has other benefits. For example, people with migraine and tension headaches have fewer pain episodes with regular sleep/wake times. Keeping regular sleeping hours is also highly recommended for patients with bipolar disorder, as it can help with mood swings.

Avoid caffeine late in the day. For some people, drinking caffeine in the late afternoon can affect them up to six hours later. To be sure, cut off caffeine at least eight hours before you want to sleep. Caffeine doesn’t affect everyone to this degree, but unless you know for sure, try to limit late-day caffeine. If you consume energy drinks, consider cutting back or stopping them.

Make sure your bed is comfortable and your room as free from distractions as possible. Pets and rowdy bed partners may need to sleep in other areas. Make sure the room temperature is conducive to sleep and there’s no noise or light that may interrupt sleep. Keeping the television on for background noise isn’t a good idea and can prevent you from getting to the deeper levels of sleep.

Don’t set your alarm for earlier than you need to. Many of us like to do this so we can hit snooze a few times. However, the most beneficial sleep, REM sleep, comes at the end of the night, and we are depriving ourselves of REM sleep by hitting the snooze button a few times before getting out of bed for good.

Have a bedtime ritual. Have things you do each night before going to bed that relax you and put you in a mindset to sleep. This could be a series of ablutions like brushing your teeth, flossing, or taking a warm bath. Other people may prefer doing prayer or meditation to quiet the mind, or reading.

Don’t nap during the day to catch up on sleep. More than anything else, napping will keep you from sleeping at night.

This is a tough one for me, since napping has long been one of my hobbies. Because I think of a good nap as one of life’s great joys, on some days I’m willing to risk not being able to get to sleep at night and take the nap anyway.

Don’t use alcohol to help you sleep. While alcohol does cause faster sleep onset, it also shortens the sleep cycle, causing us to wake earlier, and robs us of the important REM sleep. Over long term, alcohol can greatly interfere with your sleep cycle.

Only use your bed for sleep. OK, for sex too. But don’t live in your bed so that you become accustomed to eating, watching television, and working on the computer in bed. Your mind should associate bed with sleep, and not these waking activities.

Exercise each day. More than most other suggestions, this one can help you more than you expect. Even a small amount of exercise can have surprisingly good benefits. Don’t exercise too close to bedtime, since exercise can have a stimulating effect.

Sometimes people in early recovery find they want to sleep more than usual. This can be part of your physical recovery, and I think it’s best to listen to your body and allow yourself extra sleep time without feeling guilty. However, some mood disorders also make people want to “take to the bed” during times of stress and negative emotion. This latter situation may need medication if it continues or interferes with your life.

If you try all these sleep hygiene measures and you still can’t sleep, talk to your doctor about a safe medication for sleep. I’ll write more about medications in a later blog.

 

The Tenth Annual NC Addiction Medicine Conference: A Success

 

I just got back from Asheville, the location of the yearly spring conference on Addiction Medicine. This meeting is sponsored by the NC Governor’s Institute on Drug Abuse and the North Carolina chapter of the Society of Addiction Medicine, among others.

I’m glad I took an extra day off work to go to the pre-conference. Last year the preconference was one of the best parts of the whole meeting, and this year was the same. I went to the Motivational Interviewing (MI) preconference, and got a nice refresher on the basic principles of MI. I also got a chance to practice my skills during the session, which can be daunting while being watched by other people.

MI is like that. When done by someone extremely skilled at this counseling technique, it looks so easy. I tell myself, “I can do that, no problem.” Then when given an opportunity, I get brain freeze and it’s not so easy. Like any skill, the only way to get better is to do it and keep doing it, and maybe have a person who is skilled at MI give feedback from recorded sessions (with patient permission, of course). I know the counselors at my OTP submitted recordings to their clinical supervisor for feedback on how well they adhere to MI technique. This feedback can be key.

The first day of the conference proper kicked off with an address by Dr. Elinore McCance-Katz, MD, PhD, who is the Assistant Secretary for Mental Health and Substance Use, SAMHSA. She talked about the federal response to the opioid use disorder epidemic, which includes strengthening the public health surveillance, supporting research, providing Narcan, advancing the practice of pain management and improving treatment access, among other things.

Then she talked about SAMHSA’s response to the opioid epidemic, including the STR grants authorized under the CURES Act, then about the State Opioid Response act, which has a budget of $1.5 billion. She also discussed four or five other important SAMHSA measures.

I appreciate her passion. I wanted to stomp my feet and say “Amen,” when she endorsed using only evidence-based treatments to treat opioid use disorders. She said we should stop doing detox only, unless patients were provided with depot naltrexone injections before leaving detox. Then she said of lab testing in medication assisted treatment that cost thousands of dollars: “This is nonsense.” Yes. Thank you, Dr. McCance-Katz.

Next to speak was Kody Kinsley who gave the NC update on the state of addiction. He described how we have spent our grant dollars so far, and about how Medicaid will change in the future. He talked specifically about how Medicaid expansion could help our state. I don’t think he had to convince this audience. Most of us have seen how dismal medical care (not only substance use disorder treatment) can be for people with no insurance and no Medicaid.

He lost me when he started talking about SPAs. I didn’t know what he was talking about, but I quickly learned he wasn’t talking about places to go for massages and facials. I got so bogged down trying to decide what a SPA was that I missed much of the last part of his message.

A talk from Sandra Bishop-Freeman from the NC Department of Epidemiology and Public Health was scary as hell.

This isn’t a good time in history to be someone with substance use disorder in general, and opioid use disorder in particular. Fentanyl and its analogues are potent, and small packages of these products contain a great deal of opioid firepower. This means it’s easier to smuggle into the country. These fentanyl analogues are sometimes made into counterfeit pills, to fool authorities, but these counterfeits often end up on the street. A buyer may think he’s getting a Vicodin pill when it’s really fentanyl.

And now cocaine is being laced with fentanyl, fueling a twin epidemic. This is scary because cocaine has made a resurgence in my county, or maybe never left in the first place. But this fentanyl-laced cocaine could cause quick overdoses for people not intending to use fentanyl.

Then there’s news about a 1000% increase in deaths from methamphetamines, designer benzodiazepines, and combinations of Imodium and Kratom that are causing deaths.

It was a great and informative talk, but a bit depressing.

The last of the plenary speakers was Dr. Corey Waller, an entertaining and informative speaker. He talked about integrating substance use disorder treatment into hospital systems with specific and practical ideas about making this happen. In this talk and another later in the day, he inspired me to want to try again to work with my local hospital.

I love hearing new ideas and learning about current trends, and I also love seeing old friends and meeting new people working in the field. I was able to talk with four or five other doctors I’ve known for years, and catch up with what happening in their lives. That’s always fun.

I was one of three presenters at a morning workshop about updates and challenges of prescribing buprenorphine (and methadone) for patients with opioid use disorder. It went very well.

I can’t say I enjoy doing presentations, but there’s nothing like a presentation to force me to thoroughly investigate a topic, so I learn even if no one else does. And I feel good about doing the occasional presentation, because I’m doing my part to help educate new prescribers.

I had some material to cover toward the end of the session, and I thought the other two physicians would use up the bulk of our time. In other words, I didn’t think I would have to talk for very long. But the two other physicians were gracious and wanted to allow me enough time to talk, so they left me with a half hour.

That worked out well, because after my fifteen minutes talking about how opioid treatment programs and office-based buprenorphine providers could work together, we still had fifteen minutes for audience questions. And this audience asked some great questions, covering our most difficult issues: misuse of monoproduct versus combo product; co-occurring use of benzodiazepines either by prescription or illicit; law enforcement investigations of buprenorphine prescribers; when – if ever – to terminate treatment for noncompliance; maximum dose for buprenorphine products; the cost of treatment and grant funds, to name but a few.

During lunch, Dr. Frederick Altice gave an informative and concise presentations on Hepatitis C. He made me wish I had enough time to treat our patients at the opioid treatment program who have Hep C, instead of needing to refer them to the nearest FQHC (federally-qualified health center). It’s getting very easy to treat these patients, with liver biopsies and interferon being a thing of the past.

Late in the afternoon, I facilitated our closed opioid treatment program session. This session is meant only for providers working at OTPs, and we usually talk about topics specific to treatment at OTPs. This year, the topic was advocacy.

This topic was based on a case that I blogged about September 16, 2018. They provider involved in the case, Lisa Wheeler, PA, gave an excellent and passionate presentation about the specific case, but went farther into the issue. She explained how and why stigma exists, and the negative consequences we see when provider-based stigma cuts into patient care.

She presented the full case, explaining how a patient of hers, brand new to treatment, was diagnosed with endocarditis and told that per hospital policy, she couldn’t get a second surgery on an infected artificial heart valve. She was also denied visitors and was forced to give up all electronics in order to be admitted for treatment, leaving her with no cell phone or internet access and very lonely indeed.

Lisa Wheeler also gave us the glorious follow up of the case: she – eventually, after long hours of advocacy by Lisa and other people – was transferred to UNC Chapel Hill where she underwent life-saving cardiac surgery. She now is doing very well, healthy, with seven months of recovery.

Then we had a general discussion about other cases we’ve seen where healthcare providers denied care to patients on medications to treat opioid use disorder. Of the twenty or so providers in the room, many had similar cases.

We talked about what we can do to combat stigma, and came up with some general ideas. Sometimes just calling our colleagues, to try to educate them in a friendly way, can be the best approach. We can be informal and friendly, and educate in a gentle way. We need to remember that many providers didn’t get much education about substance use disorders and their treatment during medical school or residency. Those of us working in this field can be a source of information for other providers, who often change their approach when they have more facts.

When bias is egregious and causes harm to patients, sometimes it’s necessary to get more outspoken with advocacy. We identified the Legal Action Center, located in New York City, as a group with some materials that can be useful. They have a MAT “toolkit” with sample letters, to be adapted to specific situations, such as if a patient is charged with driving while impaired while on a stable dose of methadone or buprenorphine. There’s a sample letter to send to a patient’s lawyer, to help explain MAT with its benefits. ( https://lac.org/mat-advocacy/ )

In the end, a handful of providers agreed to form a committee to try to form better advocacy ideas. I’ll keep you informed how that goes.

The entire conference was great, and I’ve only described part of the first day. I could go on & on, but in the interest of keeping this blog post to a readable length, I’ll end with an exhortation to my readers: if you provide treatment to people with substance use disorders, you need to go to this yearly conference. Now there’s also an “Essentials” conference in Raleigh in the fall, which presents a second opportunity to learn.

You can go to this website for more details: https://addictionmedicineconference.org/

Advice for New Prescribers

 

 

 

The medical care providers of this nation are being encouraged get training necessary to prescribe buprenorphine products (brand names Suboxone, Zubsolv, Bunavail, Sublocade, and the generics) for the treatment of opioid use disorder in their patients. We need more good prescribers, because even after twenty years into this opioid situation, only about twenty percent of patients who need treatment can get it.

I’ve written on this topic a few times in the past, but this blog entry will contain some advice directed to new prescribers of buprenorphine products. Hopefully it will help them have good experiences prescribing medication-assisted treatment.

Here are some ideas that work for me at my office:

Treat the patient with opioid use disorder with the same attitude and compassion that you would for any other patient with a potentially fatal chronic illness. If you can’t do that, then don’t treat patients with substance use disorders. Patients detect negative attitudes such as distain and dislike even when those attitudes are communicated non-verbally. For whatever reason, if you can’t put judgment aside, then work on your own issues before you attempt to treat suffering people trying to get well.

Patients will resent a physician with a bad attitude. That will contaminate the relationship with predictable results.

For example, I talked to one physician who had his waiver to prescribe buprenorphine from an office setting. I asked him why he wasn’t using his waiver to treat patients, since there were so many in our community that needed help.

He told me the visits with the first two patients went poorly. He said both these patients threatened his life and the lives of his family members. After that, he decided not to risk treating anyone with opioid use disorder.

I was shocked. I’ve never, in the thirteen years I’ve been prescribing from an office practice, had any patient threaten my life, though I’ve made some angry at me. I had to wonder what kind of bedside manner this doctor had, for his first two patients to want to kill him. That sounds like I’m blaming the doctor, and maybe I am, but his experience was so contrary to my own that I had to wonder what was going on. I suspect his patients didn’t feel respected by him.

I’ve had one patient threaten me with bodily harm, but that was at an opioid treatment program in Gastonia, NC, more than a decade ago. The patient was an avowed KKK member, tall and large, with tattoos of hate groups on his muscular arms. I might have been worried, except at the time he threatened me, he was so impaired on benzos that I could have pushed him over with a finger. I’d just told him he couldn’t dose with methadone that day, due to impairment. The next week, he greeted when we passed in the hall. I assume he had been in a blackout from his benzodiazepine ingestion the week before and didn’t remember our previous interaction.

Be clear with your patients about your expectations. At the first visit, I sit with the patient and go over a patient agreement form. I adapted it from a SAMHSA website where you can find helpful forms, tools, and ideas.

https://pcssnow.org/resources/clinical-tools/

https://www.samhsa.gov/medication-assisted-treatment/training-resources/publications

In that agreement, I outline my expectations. I have paragraphs indicating that disruptive or violent behavior won’t be tolerated and are grounds for immediate dismissal from my practice. In thirteen years, I’ve never had one patient become rowdy or disruptive. Having said that, I do realize other prescribers have had different experiences.

I ask patients to keep and be on time for appointments, and if they don’t show up and don’t call, they will be charged for the missed visit. I tell patients I won’t call in prescriptions if they miss a visit. Having said that, I’m also flexible enough to know that things do come up – cars break down, traffic jams occur, etc. In the winter, travel can be treacherous, so that’s another factor to be dealt with. All I ask is that the patients communicate problems early so we can find a reasonable solution.

Patients who miss appointments, don’t call, and won’t answer our calls to find out what’s going on will have problems at my practice. It may or may not be their fault, but if it doesn’t work out they will need to find a new provider.

My agreement also says I won’t “fire” a patient before I talk to them face-to-face. Patients tell me they’ve been dismissed by a practice by letter, for some issue or another. I think that’s cowardly, and disrespectful to the patient. If there’s a reason I feel I can no longer to continue treatment as we are, I owe it to the patient to tell them exactly what the problem is. Sometimes we can find solutions short of termination and sometimes we can’t. At least the patient will know I respect them enough to talk to them, and they will know the basis of my decision. They will also get a referral to a new provider, or at least a recommendation.

Be careful with patient selection and try to match the patient with the best level of care.

Not every patient will do well in an office-based setting. For example, if a patient has been using buprenorphine products illicitly by insufflation or injection, that patient probably is best treated in an opioid treatment program, where observed dosing is done.

Most patients need to be on the combination products buprenorphine/naloxone. Adverse reactions do occur with the monoproduct, but they are rare, and drug diversion is not. If a new patient needs the monoproduct, I refer them to an opioid treatment program where they can be properly observed.

If that patient has been treated in another office-based setting with medical records that support their progress and compliance on the monoproduct, my recommendation would be different. Many factors influence my treatment decisions, so I need all the information I can get to make the best decisions.

This leads me to my next recommendation: get old records. Make the effort to get records from a previous practice. Sometimes patients, to curry favor with a new prescriber, will tell tales about how awful their last prescriber was. That may be true…or there may be more to the story, so get records to get a better idea of what happened at the last practice.

Don’t falsify your own records. It’s unethical and probably illegal to bill for services you document but don’t provide. To get higher insurance reimbursements, physicians sometimes chart long review of systems and/or physical exams than were performed. This is called “up-billing.” I suspect up-billing when I see records with four pages of single-spaced type for each visit, but then notice the same four pages for each monthly visit, with no changes.

I blogged before about a patient whose records recorded an exam saying “consistent with eight-month pregnancy” for every monthly visit for over a year. Yeah…kind of suspicious…using that cut-and-paste feature, I think.

If you do telemedicine, make sure you have some sort of medical personnel on site with the patient to look for physical finding you may miss with telecommunications. I just admitted a patient to our opioid treatment program who had been on Suboxone for six months from a provider he only saw online. This patient was injecting his medication, but his prescriber couldn’t see it. His most prominent tracks were on the side of his neck, which could be hidden with a high collar. Obviously, this could have ended in disaster had the patient not realized he needed a higher level of care.

Be careful about lab schemes. If a laboratory diagnostic service is charging patients $500 for one drug screen, it’s probably a scam. In past years, these organization popped up like mushrooms in manure, saying they could do extensive lab testing for all patients, but only charge those with insurance. Uninsured would get free testing.

As it turns out, some of those companies charged outrageous fees to the insurance companies, including Medicaid and Medicare, for expensive and unnecessary testing, in get-rich-quick schemes. Here’s a link to an article that explains how this works:

https://www.healthcarefinancenews.com/news/report-urine-based-drug-tests-helping-some-doctors-soak-profits

Good providers don’t want to sully their name by associating with shady laboratory service providers. Physicians can do good point-of-care testing on site for $10 or less. Sometimes patients need more extensive testing, and this can be decided on a case-by-case basis rather than testing every patient for dozens of drugs that aren’t commonly used in the community where you practice.

Be aware of what drugs are trending in your area and make sure they are included in your drug testing protocol. In the past, heroin was rare in rural areas, but that’s changed. As I’ve discussed on this blog, heroin frequently contains fentanyl, a much more powerful opioid that’s responsible for many overdose deaths.

Ask your new patients what drugs are being used in your community. They can be great sources of information, as can local addiction medicine educational conferences, and your local law enforcement officials.

Make friends with the medical director at your local opioid treatment program. Most physician medical directors at opioid treatment programs are happy to work collaboratively with office-based providers. We share patients all the time and need to do what’s best for the patient. We don’t need to look at each other as competitors, because there are more than enough patients for everyone, unfortunately. Let’s work together to get people into treatment, and to match the patient with the right level of care.

It can be a relief for an office-based provider to know they have a facility willing to deliver a higher level of care when necessary. Sometimes the patient may need inpatient treatment, but at other times it might be an opioid treatment program, where the patient may come daily for dosing and oversight.

Again, some patients, in an effort to curry favor with a new prescriber, may talk disparagingly about another treatment facility, so don’t take a patient’s word that an opioid treatment program does an awful job.

Decades ago in my previous life as a primary care physician, I learned that the new patient who tells me how wonderful I am compared to their last terrible doctor will soon be saying the same thing to another new doctor, about how terrible I am. I know there are terrible doctors, but there are also some patients that can’t be pleased no matter how good the physician.

Finally, get involved with organizations that can help you. You don’t need to re-invent the wheel; as I mentioned above, help is available from several sources.

Go to the SAMHSA website mentioned above and you will find helpful resources. Or you can go to the American Society of Addiction Medicine website for information: https://www.asam.org/  You may decide to go to one of their excellent conferences.

Go to the Providers’ Clinical Support System (PCSS) website and search their educational offerings at https://pcssnow.org/ They have archived webinars, mentoring programs, and other great things available.

If you work in North Carolina, there is the UNC ECHO program, which offers live teleconferences three days per week on issues surrounding medication-assisted treatment of patients in the office setting. You can hear cases presented and listen to input from experts and other prescribers, while getting free (yes I said free) CME hours. Once involved, you can present your own difficult cases to get help with difficult patient situations. You can go to their website at: https://echo.unc.edu/ or leave me a comment with your email and I can connect you to the organization.

It can be difficult to persuade new prescribers that treating patients with opioid use disorder is rewarding and fun. I became a physician because I wanted to help people, sappy as that sounds. I didn’t feel the sense of satisfaction during the decade I worked in primary care, for whatever reason, that I now feel working in the field of Addiction Medicine.