Archive for the ‘American Society of Addiction Medicine’ Category

A Bridge to Treatment

 

 

 

 

 

In my last blog, I lamented the lack of communication and cooperation between medical professionals involved in the care of patients with opioid use disorders.

Opinion about medication-assisted treatment has split the field in half. Most old-school, 12-step-based, abstinence-only programs discourage patients with opioid use disorder from seeking treatment with medication like methadone and buprenorphine. Some providers at opioid treatment programs rail against the lack of knowledge and open-mindedness of these programs, yet don’t inform stable patients on buprenorphine about their office-based options, which may be more appropriate and less restrictive (an option usually not available to methadone patients). Office-based providers accept patients from opioid treatment programs without bothering to get records that could give essential information that could make treatment safer.

Hospitals lack information about appropriate referral sources to treat opioid use disorders, and emergency departments let patients leave after a near-fatal overdose with only a list of phone numbers to call for help.

It’s time to break down barriers and put the welfare of patients first.

At the American Society of Addiction Medicine (ASAM) conference this year, I heard a possible solution.

Dr. Sarah Wakeman and Dr. Laura Kehoe, both associated with Harvard Medical School, talked about their Bridge Clinic. This program is set up to be a bridge between acute hospital or emergency department care and long-term primary care for patients with substance use disorders.

This model is “low barrier” or “low threshold” care, which means eliminating obstacles between the patient and appropriate care. The clinic’s mission is to provide on-demand, compassionate care to patients in all stages of addiction.

Most of their patients have opioid use disorder, and around 77% are treated with buprenorphine products. Around 11% are treated with naltrexone. I assume the others are treated for alcohol use disorder or other substance use disorders.

The Bridge Clinic serves as an immediate access clinic for Massachusetts General Hospital patients with substance use disorders who don’t have a primary care provider. This clinic provides both drop- in and scheduled appointments for patients. It’s been in operation for the past several years and has grown quickly, indicating a need for their services. In some cases, patients elect to remain in treatment at this Bridge Clinic rather than go on to primary care, office-based medication-assisted treatment.

This clinic is opened seven days per week, from 9am to 5pm. The physicians who staff this clinic are very aggressive with starting same day pharmacotherapy for substance use disorders, not only MAT for opioid use disorder. They refer to opioid treatment programs when that level of care is most appropriate, or if the patient needs methadone rather than buprenorphine.

They also work with families, and connect patients with other needed services.

The clinic staff includes an addictionologist, family practice physician waivered to prescribe buprenorphine, recovery coach for peer support services, resource specialist who finds other programs to help patients with their needs (food, housing, etc), and administrative assistant and a patient service coordinator. Extended care in the overnight hours can be provided by the colleagues at the emergency department.

Patients are referred from Massachusetts General Hospital, where patients with substance use disorders are offered induction onto medication-assisted treatment while hospitalized.

That’s right. I said that. Patients with opioid use disorder are started on methadone and buprenorphine during hospitalizations for other medical ailments. For example, a patient with endocarditis from IV opioid use disorder can be started on treatment with methadone or buprenorphine before ever leaving the hospital, and the Bridge Clinic can take care of the patient during the gap between hospitalization and arrival at an office-based or opioid treatment program.

This is treatment nirvana!

Patients with near-fatal overdoses can be started on buprenorphine before they even leave the emergency department, and use the Bridge Clinic to link them with care.

This wonderful new idea has substantial evidence to show it works. D’Onofrio et al., [2] published results of a randomized study of patients with previously untreated opioid use disorder who presented to the emergency department. In one arm of the study, patients got treatment as usual, which was referral to treatment facilities. In the second arm, patients received brief intervention counseling and referral to care to an outpatient buprenorphine provider. In the third arm, patients were started on buprenorphine and linked directly with outpatient buprenorphine treatment, with no gap in treatment. In this last group, nearly 80% of patients followed up with buprenorphine treatment and had significantly less opioid use than patients in the other two arms.

For this reason, the Bridge Clinic wanted physicians who worked in the emergency department to get their waivers to prescribe buprenorphine, and accomplished this. When they see patients with opioid use disorder, they either do the induction onto buprenorphine in the ER, or send the patients home to do a home induction by providing a two-day pack of buprenorphine. Since the Bridge Clinic is open seven days a week, such patients can be seen quickly.

This is wonderful, since we know from studies that patients who are started on MAT while in the hospital or emergency department have much higher rates of treatment retention. We also know that higher treatment retention means fewer opioid overdose deaths.

Around half of the patients referred to the Bridge Clinic from the hospital or emergency department are seen within 24 hours of being referred.

The clinic endorses a harm-reduction model, and does not discharge patients for continued drug use. They staff attempt to build trust by offering services without attempting to control the patients’ intake of drugs. The patients are included in the plan of care. They have low no-show rates, and are aggressive at getting patients back in to treatment if they miss appointments.

The Bridge Clinic’s goal is to eventually transition care, after acute stabilization, to somewhere closer to where the patient lives. Sometimes this can be worked out easily, and sometimes there may be problems. Bridge Clinic staff attempt to work out these difficulties.

Some patients need the Bridge Clinic short-term, and others for longer. Their average length of stay is around three months. This program provides help to patients with ongoing drug use, homelessness, pregnancy with substance use disorders, chronic pain patients, and to patients leaving incarceration, eager to find help prior to a relapse.

I was so inspired by the description of this program. It was obvious that these women excelled at gaining the cooperation of their colleagues at their hospital and in the primary care practices. It really sounds like the ideal situation, with everyone working for the good of the patient, no matter what their needs are. There are no waiting lists, and no senseless obstacles for patients to surmount.

Every community needs a bridge clinic, I think. How wonderful that would be, with a warm and friendly place to send patients in crisis, open every day of the week. Patients could be assessed, stabilized, then referred to the best treatment program nearest to where they live.

However, North Carolina isn’t Massachusetts. We have a higher percentage of people with no health insurance, while Massachusetts has expanded Medicaid, which helps pay for this sort of treatment.

But at least we have a model for quick-access, low-barrier care for people in crisis with substance use disorders. If we can ever muster the cooperation and will for such a program, these people can teach us how to do it.

  1. Sordo et al., 2017, British Medical Journal
  2. D’Onofrio et al., Journal of the American Medical Association, 2015, Apr 28; 313(16): 1636-1644.
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Buprenorphine Prescribed in Two Settings

 

It’s very confusing. Even medical professionals get confused, so imagine how it is for patients.

I’m referring to the different setting where buprenorphine can be prescribed for the treatment of opioid use disorder.

Opioid treatment programs deliver care for patients with opioid use disorder in a much more structured setting. OTPs are regulated by sets of federal, state, and sometimes even local agencies. This limits flexibility when responding to changing patient needs, but provides a much more structured – some would say rigid – treatment setting.

OTPs must do observed, on-site dosing, with established protocols. Take home doses can be given, but patients must first meet a set of eight criteria. Some states, along with the federal agency, dropped the time-in-treatment requirement for buprenorphine, since it’s a safer medication than methadone.

Substance use disorder counseling is built in this system with stricter monitoring. OTPs must do a minimum set number of observed drug screens on patients. Opioid treatment centers offer a more intense, controlled, and hopefully more supportive setting for patients new to buprenorphine treatment, or who are struggling in treatment.

Office-based settings for treatment with buprenorphine aren’t nearly as regulated. Providers in office-based settings have more freedom to customize the treatment to the needs of the patient. The prescriber can decide how often the patient needs to be seen for follow up appointments and for substance use disorder counseling. Drug screen frequency and counseling intensity are left up to the prescriber. Some practices do observed urine drug screening, and some practices do not.

Opioid treatment programs are inspected by a number of state and federal agencies. Office based practices are not inspected at all, in most states. Other states, like Tennessee and Virginia, have more regulation around office-based practices, but overall, office-based practices vary more widely in quality and intensity than opioid treatment programs do.

So which setting is best? It depends on the needs of the patient.

As I said above, opioid treatment programs may be best for new patients, or those patients who use other substances besides opioids. Office-based programs may be better for stable patients because their treatment can be customized, allowing more freedom.

Ideally, office-based programs and opioid treatment programs should work together, collaboratively, to provide the best care to meet the needs of the patients. This idea of continuity of care happens with other chronic illnesses; patients with asthma may see a pulmonologist during a bad flare of illness, then resume care with a primary care provider after the expert has done everything an expert can do.

But with opioid use disorder, we aren’t there yet. I still sense a spirit of competition rather than cooperation between OTPs and OBOTs (office-based opioid treatment). It’s as if providers think to themselves, “There are only so many patients to go around, and if my patient transfers to that other practice, I will lose money.”

Believe me…there are plenty of patients to go around, unfortunately.

Providers who work at OTPs sometimes make unkind statements, saying OBOT providers are careless, poorly educated about opioid use disorder, and make bad decisions that lead to diversion of buprenorphine products into the black market. Then OBOT providers talk badly about OTPs, saying they are nothing but for-profit juice bars.

I’m as guilty as any – in my blog from last December, I made fun of an OBOT provider who used the cut and paste option of producing notes for office visits, leading to a statement about the patient being 8 months pregnant at each monthly visit for more than a year. (but that was a funny example, no?)

Somehow, we’ve got to start cooperating.

In my next blog, I’ll describe a type of treatment program that was set up to be a bridge between acute care in the hospital or emergency department, and treatment at both settings, OBOT and OTP. It’s inspiring me to be more collaborative and cooperative.

 

When the DEA Raids Buprenorphine Doctors

 

 

I had another blog post ready to go this week, but I’m postponing it to blog about another situation.

So far this year, two well-known and respected Addiction Medicine physicians have had their offices raided by the DEA.

The first one occurred in March of this year. Dr. Stuart Gitlow, the past president of ASAM (American Society of Addiction Medicine), who has a small buprenorphine (Suboxone and other name brands) practice in Woonsocket, Massachusetts, was raided by the DEA.

According to news reports, [1] the DEA raided his home and office, looking at patient records for evidence of wrongdoing. They wouldn’t tell him what they were looking for, and wouldn’t comment to reporters later because, they say, the raid was part of an ongoing investigation.

I searched the internet for some sort of follow up story, but found none.

Dr. Gitlow is an unlikely target for a DEA raid. He is so famous for his work in the field of Addiction Medicine that he has a Wikipedia page. According to that page, he is a psychiatrist specializing in the treatment of addiction. He earned an MBA from University of Rhode Island, and went to Mt. Sinai School of Medicine where he earned his M.D. degree. He did a psychiatry residency at University of Pittsburgh, along with a Master’s degree in Public Health. Then he went to Harvard University for a forensic fellowship.

I’ve heard him give lectures at ASAM meetings and he’s as good as lecturers get. He teaches at the University of Florida, and he’s on the editorial board of the Journal of Addictive Diseases.

Dr. Gitlow confirmed in an interview that the DEA looked at patient records, but he had no idea what they were looking for.

Then in early May of this year, the offices of Dr. Tom Reach were raided by the DEA. Dr. Reach, like Dr. Gitlow, is an outspoken advocate of medication-assisted treatment.

A news article [2] described how Dr. Reach’s nine treatment centers were closed for the DEA inspection, disrupting patient care. Dr. Reach’s home was also raided. In the interview, he said he heard the DEA thought he was doing something wrong, but he had no idea what it could be.

They also looked for controlled substances, but Dr. Reach, like most buprenorphine physicians, has never stored these drugs on-site. The record keeping that is necessary for storing controlled substances is considerable. He doesn’t contract with public insurance, so it couldn’t be problem with that.

Dr. Reach said the DEA took hard drives and cell phones, making it harder to continue with patient care.

Dr. Reach was the past president of the Tennessee chapter of ASAM. Dr. Reach was one of several physicians who were on the expert panel convened last year to draft Tennessee’s new guidelines around physician prescribing of buprenorphine. He’s spent his own time at the Tennessee statehouse, advocating for patients with opioid use disorder and their physicians.

Thus far, no charges have been filed against either physician.

Both physicians are politically active. Dr. Gitlow ran unsuccessfully, twice, for state representative in Massachusetts, as a Democrat. Dr. Reach contributes money – some would say a large amount of money – to political candidates he supports. [3]

These two leaders in addiction medicine are far from the only doctors being raided. Dr. Larry Ley, who had several treatment programs in Carmel, a suburb of Indianapolis, was ultimately acquitted of felony drug charges that he faced. Law enforcement personnel, posing as patients, lied about their need for opioid use disorder treatment. Dr. Ley was then charged when he issued prescriptions for Suboxone. [4]

I thought it was a felony to obtain a prescription for a controlled substance under false pretenses. How can a DEA agent pose as a patient and lie about their substance use history to obtain a prescription? Wouldn’t that be an illegal act? Maybe that’s why Dr. Ley was acquitted.

In this case, it seems the county’s head of drug task force didn’t agree with the idea of medication-assisted treatment, saying, ““This type of ruse of a clinic perpetuates the problem because people are still addicted to the drug, and this is what is happening,” said the head of the drug task force, in a press conference held after Ley’s arrest. “This is not fixing the problem.” [4]

Dr. Ley had to close his treatment centers, was left penniless due to legal fees, and is now suing both the city of Carmel and the DEA for conspiring to force him out of business.

Meanwhile, the opioid overdose death rate in Indiana has risen by double digits.

The DEA is authorized to inspect buprenorphine practices at any time. If you are a long-time reader of my blog, you’ll recall my office was inspected in late 2012. I wrote about the experience in a blog post on 12/16/12. The agents were pleasant and cordial. They were willing to meet with me when patients were not scheduled, so it didn’t interrupt my practice at all. They asked about how many patients I had, asked to see copies of patient prescriptions, and asked if I stored any controlled substances on site (of course not). The two agents were polite and cordial.

What happened to Drs. Reach and Gitlow was very different. They were both raided by the DEA, with a warrant that says material can be seized. In a raid, the DEA is so convinced that there’s criminal activity that they take computers, cell phone, and records. Inevitably this disrupts the medical treatment of patients. For both Dr. Reach and Dr. Gitlow, patients had to be turned away from scheduled appointments because of the raids. As Dr. Reach pointed out in a newspaper interview, this can have very real and possibly fatal outcomes for patients depending on buprenorphine to provide stability and keep them from using illicit opioids like heroin.

For a DEA raid to take place, investigators have expectations of finding criminal activities. They would not raid for issues like overprescribing, substandard care and the like. These types of problems would be handled by the state’s medical board.

Of course, I don’t know the circumstances that lead to these DEA raids. It’s remotely possible that a Harvard-educated physician leader of ASAM is slinging dope on some corner of Woonsocket, Massachusetts, in his free time…but I doubt it.

The trouble with these DEA raids is that while they make the papers when they happen, no news releases state what was found. If no wrongdoing was discovered in the masses of material seized by the DEA, the public won’t hear about this. All that remains is the taint of criminal investigation.

I’ve been working with some organizations to try to get more office-based physicians interested in treating patients with opioid use disorder with buprenorphine, a potentially life-saving medication. I’ve reassured worried doctors that they won’t become DEA targets just because they prescribe buprenorphine. I told them that unless they store medication on premises, the chances of getting raided are very small.

I hope I haven’t erred in telling new doctors this. I legitimately thought the nation’s leading health experts are pushing treatment for opioid use disorders, to stem the tide of opioid overdose deaths we’ve been having oer the past twenty years.

Now, with raids on well-respected practitioners, I don’t know what to think.

  1. http://www.woonsocketcall.com/news/city-doctor-s-home-office-raided-by-fbi/article_1e4270a0-2bb5-11e8-be84-b7f0c2501d63.html
  2. http://www.wjhl.com/local/dea-agents-raid-watauga-recovery-centers-in-tn-va-and-nc/1156361147
  3. http://doctorsofcourage.org/ralph-thomas-reach-md/
  4. https://www.thedailybeast.com/addiction-doctor-dea-shut-me-down-so-mayor-could-clean-up-town?ref=scroll

North Carolina’s Addiction Medicine Conference

I had a great weekend.

I went to the annual NC Addiction Medicine Conference, held in April each year, in Asheville. This year, I took an extra day off work and went to the pre-conference workshops, which I haven’t done in the past, because of poor planning on my part.

I went to the workshop titled “Treating Women for Substance Use Disorder During the Perinatal Periods: Integrated Medical and Behavioral Health.” It was fantastic. Hendree Jones, PhD., lead author or the MOTHER study, was one of the main speakers. I’ve heard her talk before, and not only does she present information in a straightforward way, she epitomizes the empathy that providers should have towards their patients. Dr. Mishka Terplan, MD, was the other presenter, and was equally eloquent and gifted lecturer. During the workshop, we broke into small groups to interact with other participants about topics.

Here are the latest ideas I heard: it’s ok – really, it is ok – to treat pregnant women with buprenorphine/naloxone combination products. We don’t have to switch them to the monoproduct. I already knew a pregnant woman shouldn’t be switched from methadone to buprenorphine, but I learned a pregnant woman shouldn’t be switched from buprenorphine to methadone, either.

I learned the depressing news that screening and brief intervention for substance use disorders are less likely to be done in women than men, and when their screen is positive, women are less likely to receive any intervention. Also, physicians aren’t good at diagnosing substance use disorders in women who are on either end of the age spectrum.

I learned about the social determinants of health that influence the outcome of pregnancies and substance use disorders the same as they influence all of health.

I learned that split dosing in pregnancy can be helpful with buprenorphine, same as it is with methadone. I have been splitting the dose of pregnant patients on buprenorphine nearing the end of their pregnancies, but wasn’t sure there was data or expert opinion that supported doing this. There is.

These lecturers talked specifically about the Bell study – that pesky study out of Tennessee that concluded taper of medication-assisted treatment during pregnancy was a reasonable idea. Even Bell’s own data didn’t support that conclusion, since the incidence of neonatal abstinence wasn’t decreased with a taper (or cold turkey withdrawal in jail). Reduction of NAS is the main reason Tennessee physicians in TN and elsewhere taper the dose of buprenorphine/methadone during pregnancy.

I already knew these facts, but since I deal with some obstetricians who don’t approve of the use of buprenorphine/methadone for the treatment of pregnant women with opioid use disorder, it was nice to confirm my approach is based in facts and data. After so much resistance from local OBs, I start doubting myself, wondering if I’ve got it wrong because after all, I’m not an obstetrician. It’s a great feeling to have what I’ve been recommending confirmed by the experts.

The whole conference was great. On the day of the main conference, I gave a thirty-minute presentation about the state laws passed around opioid and buprenorphine prescribing. I think it went well. I was well-prepared, since I’d spent hours researching, then hours rehearsing my presentation. I hate speaking in public, and have jitters about it. The more I practice, the more confident I feel. I felt a flood of relief when it was over, and pleased I’d gathered the courage to do this.

Then I went to an outstanding presentation on LGBTQ patients. I learned a lot, and feel more confident that I can treat this population in a culturally competent way. That presentation was followed by one on peer support specialists. This is not necessarily a completely new idea, but now there’s funding available for such personnel. I know how valuable peer support specialists can be, since we have several who work with our patients. They can be a godsend.

It went on like this for the rest of the day and the next too. All the speakers I heard were outstanding.

At this (and similar) conferences, it’s not just the information I get, or the credit hours that I need to remain licensed. There’s also a delight in being around people with the same passion to help people with substance use disorders. Sometimes we argue. I don’t think a group of three hundred doctors will ever agree on everything. But we remember we have more in common than the few points about which we have disagreements.

It’s nice, being among providers who understand the joys and tribulations of caring for our patients.

Any provider interested in joining North Carolina’s Society of Addiction Medicine should go to these websites:

http://www.ncsam-asam.org/

https://governorsinstitute.org/

The advantages of joining the state chapter of Society of Addiction Medicine (and also the national organization, called American Society of Addiction Medicine, or ASAM) include reduced rates on conferences, access to other physicians interested in treating patients with substance use disorders, and access to online CME hours (ASAM).

And support. Lots and lots of support, because we have a job that can be challenging.

Additional resources for physicians include the Provider Clinical Support System (PCSS)

https://pcssnow.org/

Providers in North Carolina who want more data about providing office-based treatment of opioid use disorder using buprenorphine can join ECHO UNC, a program of weekly teleconferences that can be accessed by computer or by phone. This is free, and participants can get CME hours. The format is a case presentation, followed by questions and commentary about management options, then a short didactic session. Then the session wraps up with a second case presentation. It lasts 2 hours, and participants can join for all or part of the weekly conference. It’s held each Wednesday from 12:30-2:15 or so.

Interested providers can go to: https://echo.unc.edu/ to learn more and to sign up to participate.

Buprenorphine Regulations

Map is from vox.com

In response to the rise of opioid use disorders in this country, lawmakers in heavily affected states are passing laws they hope will help. But well-intentioned laws may have unintended consequences, requiring re-evaluation of those laws.

Nearly one year ago, The Virginia legislature asked the Virginia Board of Medicine to regulate prescribing of buprenorphine. Legislators were worried about the diversion of prescribed monoproduct buprenorphine to the streets. You can read about this in more detail in my blog entry dated February 24, 2017.

It’s been a year since that blog entry, and I have a little bit of data regarding some of the consequences of Virginia’s new rules.

Initially, the new Virginia Board of Medicine (VBOM) regulations said the buprenorphine monoproduct could only be prescribed for pregnant ladies and nursing mothers. They did this because the monoproduct, containing only buprenorphine and no naloxone, has a higher street value and is more likely to be injected and misused than the combination product.

The VBOM received so many complaint letters that they finally changed the regulations to say that each buprenorphine physician could prescribe buprenorphine monoproduct to up to three percent of their patients. Each of these patients must have documentation of their intolerance in their chart.

It was hoped that this compromise would limit the amount of buprenorphine monoproduct being prescribed, while still making allowances for some patents with intolerance to naloxone in the combination product.

The VBOM didn’t stop there. They passed regulations about care at opioid treatment programs (OTPs), which are already the most heavily regulated medical providers in the nation. The VBOM said if buprenorphine monoproduct was used, the patient had to consume it on site, with observed dosing, and that no take home doses could be allowed for the monoproduct.

To clarify, this meant that OTP patients dosing with buprenorphine monoproduct had to either switch to the combination product, buprenorphine/naloxone, to get their usual take homes, or dose daily at the OTP on the monoproduct and forfeit all the take homes they had earned.

Or they could switch to methadone, where take homes are still allowed, following standard guidelines.

This is the irony – methadone is a heavier and stronger opioid than buprenorphine, and more likely to cause overdose death if taken illicitly or diverted. Virginia patients can get methadone take home doses, after they have a period of stability and meet the guidelines which have been in place for decades.

OTPs must follow both state and federal guidelines, and must obey the stricter of the two. The federal guidelines dropped the time in treatment requirement for buprenorphine, meaning the federal agency decided to allow the admitting physician to decide how many take home doses were appropriate, from day one, for a buprenorphine patient.

Essentially, Virginia went the opposite direction, and eliminated take homes, at least for the monoproduct.

At the time the new regulations were implemented, there were 600 Virginia patients on buprenorphine at OTPs. Monoproduct was used because was about half the price of the combination product, and kept treatment more affordable for patients. Also, because OTPs already followed stricter regulations than office-based programs, the risk of diversion was felt to be lower than at office-based programs.

Of those 600 patients, 384 patients attended one of the four OTPs owned by Acadia Healthcare in Virginia. They collected data on what happened to their Virginia patients after these new regulations were implemented. Since I work for Acadia, that data was released to me for an upcoming presentation, but I’ll give my readers an early view.

Of those 384 patients, 260 made the switch to the combination product so that they could continue to get take home doses. In other words, two-thirds of the patients switched, and one-third did not.

The cost of medication doubled, but rather than pass this on to the patients, Acadia Healthcare absorbed all the extra cost. The patients paid the same as if they were getting the cheaper monoproduct. This was fortunate, since an overnight doubling of costs could have caused hundreds of patients to leave treatment.

To some lawmakers, an extra couple of hundred dollars per month might not seem like much. But to many patients, it’s the difference between being able to stay in treatment or having to leave and go back to illicit drug use.

So, what happened to the patients who didn’t make the switch?

  • 15 switched to methadone, and will be able to get take home doses once they meet criteria. It’s takes a while, but at least they can get take homes eventually.
  • 21 transferred to out-of-state opioid treatment programs because they had an intolerance to the combination product.
  • 24 (6%) patients dropped out of treatment.
  • 58 remained on the monoproduct and accepted that they will have to dose every single day that they are in treatment. Since all these clinics are in rural areas of Southwestern Virginia, I suspect some of these people are driving long distances daily, and incurring extra expenses for that travel.
  • 6 patients were lost to follow up, and couldn’t be contacted to see what happened.

Studies show the risk of death increases as much as eight-fold for patients who leave treatment, so those 24 people are at high risk. I suspect the 6 people who couldn’t be found are also in that risk group.

I have a little bit of data about what’s happened on the receiving end with patients on buprenorphine at Virginia OTPs. One OTP located in Boone, NC, received 12 patients in transfer from Virginia. Those patients could have been OTP patients or office-based patients; I don’t have that data.

I have my own office-based buprenorphine practice in the Lake Normal area of North Carolina, which is 73 miles from the North Carolina-Virginia border. My practice got around twenty phone calls last year, just after Virginia’s law changed. These patients were willing to drive from Virginia to my office if I would prescribe buprenorphine monoproduct. I declined to accept any of those patients, both because it is unworkable in the long run to come from such a distance, and because I was concerned about regulatory scrutiny in my own state.

You can draw your own conclusions based on this limited data. It appears that roughly two-thirds of patients, if forced to switch to the combination product, can do so and remain in treatment.

But remember, costs weren’t increased for those patients enrolled at Acadia OTPs.

That would not have been the case for office-based self-pay patients, who would have paid roughly double each month for their prescriptions for combo products at the pharmacy. Community pharmacies would not have absorbed the extra cost.

I combed the internet, trying to discover data on what happened to office-based patients in Virginia on the monoproduct. If data is out there, I haven’t found it. Or perhaps it’s still being collected and analyzed. I also looked to see if overdose death data changed much in 2017, but it’s likely too early for this.

The American Society of Addiction Medicine has written a public policy statement addressing regulations on office-based buprenorphine policy. This document outlines the most reasonable approach to assure appropriate care for patients while limiting onerous regulations for providers. State legislators would do well to read this policy and abide by its specific recommendations.

https://www.asam.org/docs/default-source/public-policy-statements/statement-on-regulation-of-obot.pdf?sfvrsn=df8540c2_2

I’m tempted to give a summary of ASAM’s statement, but ASAM warns against this, at least without their permission. They don’t want people to use just a section of their policy to justify a position; they want their statement to be read in full.

I think that’s smart of ASAM. I encourage interested readers to check it out.

Continuum of Care for Opioid Use Disorder

 

 

 

 

 

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

“Um, so…are you pregnant?”

“No! Why?”

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

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

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

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

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

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

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

I’m doing my part.

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

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

Here are a few wonderful opportunities to interact and learn:

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

 

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

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

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

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

News You Can Use

 

 

 

 

 

 

 

 

 

 

 

 

 

Tidbits From the latest issue of Journal of Addiction Medicine

Don’t Forget the Family

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

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

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

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

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

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

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

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

 

Ondansetron for opioid withdrawal:

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

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

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

That’s disappointing, but important to know.