Archive for the ‘Complications from IV drug use’ Category

Fentanyl is the New Heroin

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Big drug labs in China and Mexico have found it’s cheaper to manufacture the potent synthetic opioid fentanyl than it is to harvest and process opium into heroin. Therefore, much of what is sold as heroin is now mixed with fentanyl and its more potent analogues, sufentanil and carfentanil.

This is causing heroin overdose deaths in the U.S.  The National Institute on Drug Abuse issued a recent report saying that heroin overdose deaths increased over six-fold from 2002 to 2015. This is shown in the graphic at the beginning of this blog.

This problem is worse in some regions of our country than others; the Northeast has traditionally been plagued with heroin deaths at a high rates, but other areas of the country have higher rates of increase in heroin deaths.

There’s no way to know the potency of drugs sold as heroin, making it much easier to overdose and die.

There are some basic precautions that drug users can take to prevent overdose deaths. This is data all comes from the Harm Reduction Coalition:

  • Don’t use alone. Use with a friend, and stagger your injection times so that one person is alert enough to summon help if needed.
  • Have a naloxone kit available and know how to use it. You can get a free kit from many places, including harm reduction organizations. http://harmreduction.org/issues/overdose-prevention/tools-best-practices/od-kit-materials/
  • Do a test dose. This means instead of injecting your usual amount, try a tiny bit of the drug first, to help assess how strong it is.
  • Use new equipment, if possible. Some pharmacies are willing to sell new needles and syringes with no questions asked. Other drug users in your community may be able to tell you which pharmacies are willing to do this.
  • Remember that if you’ve had a period of time where you’ve been unable to use any drugs, your tolerance may be much lower. Highest overdose risk is seen in patients who have just been released from jail, from detox units, or from the hospital. Do NOT go back to the same amount you were using in the past.
  • Don’t mix drugs. Opioid overdose risk increases when other drugs are used too.
  • Consider getting into addiction treatment. https://findtreatment.samhsa.gov/

 

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Treatment Implications for Intravenous Buprenorphine Use

Hokey Pokey

 

 

During the admission of new patients for opioid use disorder treatment, I ask about prior use of all drugs. I include the medications we use for treatment. I’ve done this since I started working at opioid treatment programs (OTPs) fifteen years ago.

Over the last few years, more patients say they’ve used illicit buprenorphine in the past. At first, I saw patients who were using it sublingually (under the tongue), as recommended, though still illicitly. Most of them wanted to see if this medication would work for them before they committed to the time and expense of entering a treatment program.

Over the past six months, I’m seeing more and more new patients who say they’re using buprenorphine intravenously. This past month, I’d estimate that a fourth of the patients who use buprenorphine illicitly are injecting it. Only a few said they snort buprenorphine.

This presents a big wrinkle to the treatment process.

I see why people use intravenous buprenorphine. It has low sublingual bioavailability, at around thirty percent. That means injecting two or three milligrams gives the same blood level as eight milligrams sublingually. In the short term, people injecting buprenorphine feel like it saves them money. In the long term, I’m certain it will cost more than they can imagine.

Buprenorphine tablets and films were not designed to be injected. Pills and films have fillers in them, and they aren’t sterile. Heating a mixture prior to injection will kill off some of the bacteria, so that’s a harm reduction practice. Using a filter can remove some of the particulate matter, also reducing the potential for harm. However, heat and filters can’t remove all the risk of injecting.

People on the internet insist the bioavailability of snorted buprenorphine is higher than sublingual use, but I doubt that. Either way, you bypass the liver because it crosses to the bloodstream via the veins of the nose or tongue. Plus, alkaline environments increase absorption and bioavailability for this drug, and the mouth is more alkaline than the nose.

Of course there is another reason people with opioid use disorder inject or snort their medication. Their brains associate the act of injecting or snorting with pleasure and euphoria, and can become addicted to the process and feeling of both means of ingestion.

Due to the ceiling on buprenorphine’s opioid effect, it is… arguably… one of the safest opioids a person could inject. But intravenous use is never safe.

Here’s only a partial list of complications from intravenous drug use:

  1. Overdose resulting in death, brain damage from low oxygen, stroke or heart attack from prolonged low oxygen
  2. Pulmonary edema (lungs fill with fluid)
  3. Skin abscesses and cellulitis
  4. Endocarditis (infection of heart valve that is life-threatening)
  5. Deep vein thrombosis (blood clot)
  6. Septic thrombophlebitis (infected blood clot)
  7. Contracting infections: HIV, Hep C or B
  8. Bacterial infections and abscesses in weird places like the spine, brain, joints, spleen, muscles, or eye
  9. Necrotizing fasciitis – rapid, “flesh- eating” infection, also botulism
  10. Pneumonia
  11. Septic emboli – when infected clots break off and go to the lungs, brain from infected heart valves
  12. Fungal blood/eye infections – (seen frequently when pills mixed with saliva are injected)

I have seen patients with every one of these complications. Most of them were in the distant past, when I was an Internal Medicine resident during the late 1980’s, but not all of them. Over the past six months, I’ve seen two patients with spinal abscesses from injecting drugs, though not necessarily buprenorphine.

The last time I posted about intravenous use of buprenorphine (November 2015), Dr. Wartenberg M.D. (pioneer in the addiction treatment field) wrote about the mitochondrial disease, which has caused liver failure, in European IV buprenorphine drug users. This disorder is specific to buprenorphine

So what are the treatment implications for a new patient who has injected buprenorphine?

First of all, these patients aren’t appropriate for office-based practices, even if the physician plans to prescribe the combination product with buprenorphine/naloxone. Clearly there are some patients who inject combination products and monoproducts. Granted, it’s less common, but it still occurs. There’s usually not enough oversight available at office-based practices to treat more complicated patients. I think they should be referred to opioid treatment programs, where they can be offered treatment with methadone.

What if the patient refuses methadone for some reason, or their risk with methadone is at too high from a medical view? Should patients with a history of injecting buprenorphine ever be treated with buprenorphine?

I think they can be – with great caution and daily dosing, on-site at the opioid treatment program.

At our OTP, we ask all buprenorphine patients to sit in a designated area while their dose dissolves. It usually takes around ten minutes, and they are watched by program personnel. Before they leave, each buprenorphine patient shows one of the staff their mouth, to show the medication is completely dissolved. It does feel a little “police-y” but we had a high incidence of diversion until we started this close observation.

If a patient tries to spit out their medication, they meet with me. I’m rarely willing to continue to prescribe buprenorphine if it appears they are trying to divert their medication. I meet with the patient and we discuss the option of methadone. If they refuse methadone, we try to refer them to another form of treatment.

If a patient with a history of injecting buprenorphine wants treatment with buprenorphine, I tell him I’m willing to give it a try, but that he can’t expect take home doses for a very long time, after months of observed dosing and stability. So far, this approach seems to be working. These patients are getting counseling, and haven’t attempted to divert their medication, so far as we can see. I’ve checked these patients for track marks, which in all cases appear to be healing, with no new marks.

When/if to grant these patients take homes remains a huge question. I don’t want to unduly burden a patient by insisting he must come every day forever, but I also don’t want to give the patient take home doses that could lead to a relapse back to intravenous use.

Harm Reduction: Use Precautions

aaaaaainjecting

 

 

I’m worried about the people in my community who have opioid use disorders. The rate of opioid overdoses appears to have risen, according to my local newspaper, along with the number of overdose deaths. I think it’s at least partly due to the arrival of heroin in our county. I think it’s time I re-posted some harm reduction suggestions for people who are using opioids.

The ultimate harm reduction measure is to get treatment and get into recovery, but if you aren’t ready for that, please be careful when you use drugs.

You can access all the following information, and more, at: http://harmreduction.org/drugs-and-drug-users/drug-tools/getting-off-right/

This is a link to a booklet about how to inject drugs more safely, downloadable for free, or available in hard copy for a small fee. It contains excellent information which could be life-saving.

  1. Don’t use alone. Use a buddy system, to have someone who can call 911 in case you stop breathing. Do the same for another addict. Obviously you shouldn’t inject at the same time. Stagger your injection times.

Many states now have Good Samaritan laws that protect the overdose victim and the person calling 911 for help, so that police don’t give criminal charges to people who do the right thing by calling for help for an overdose.
Take a class on how to give CPR so that you can revive a friend or acquaintance with an overdose while you wait on EMS to arrive.

  1. Get a naloxone kit. I’ve blogged these kits before, and they are becoming more available. So far, about seven or eight of my opioid treatment program patients have used their kits to save other people. The kits are easy to use and very effective. You can read more about these kits at the Project Lazarus website: http://projectlazarus.org/

Evzio is a commercially available kit, very easy to use, that gives verbal instructions about how to use the kit.

Some states, like North Carolina, now have third party prescribing, meaning if you have a loved one with opioid use disorder, you can request a naloxone kit prescription from your own doctor, to have on hand for your loved one with addiction.

  1. Use new equipment. Many pharmacies sell needles and syringes without asking questions. Other people with opioid use disorder probably can tell you which pharmacies are the most understanding.

    Don’t use a needle and syringe more than once. Repeated use dulls the needle’s point and causes more damage to the vein and surrounding tissue. Don’t try to re-sharpen on a matchbook – frequently this can cause burrs on the needle point which can cause even more tissue damage.

  2. Don’t share any equipment. Many people who wouldn’t think of sharing a needle still share cottons, cookers, or spoons, but hepatitis C and HIV can be transmitted by sharing any of this other equipment. If you have to share or re-use equipment, wash needle and syringe with cold water several times, then do the same again with bleach. Finally, wash out the bleach with cold water. This reduces the risk of transmitting HIV and Hepatitis C, but isn’t foolproof.
  3. Use a tester shot. Since heroin varies widely in its potency, use small amount of the drug to assess its potency. You can always use more, but once it’s been injected you can’t use less. The overdoses on heroin are thought to be due to fentanyl added to the heroin, making it more powerful and more dangerous.
  4. Use clean cotton to filter the drug. Use cotton from a Q-tip or cotton ball; cigarette filters are not as safe because they contain glass particles.
  5. Wash your hands thoroughly before preparing your shot, and clean the injection site with an alcohol wipe if possible. Don’t use lemon juice to help dissolve heroin, as it carries a contaminant that can cause a serous fungal infection.
  6. Opioid overdoses are much more likely to occur in a person who hasn’t used recently or has used less than usual for a few days, weeks, or longer. Overdose risks are much higher in people just getting out of jail and just getting out of a detox. Patients who have recently stopped using Suboxone or Subutex may be more likely to overdose if they resume their usual amount of IV opioids.
  7. Don’t mix drugs. Many opioid overdoses occur with combinations of opioids and alcohol or benzodiazepines, though overdose can certainly occur with opioids alone.
  8. Don’t inject an overdosed person with salt water, ice water, or a stimulant such as cocaine or crystal methamphetamine – these don’t work and may cause harm. Don’t put the person in an ice bath and don’t leave them alone. Call for help, and give mouth-to-mouth resuscitation if you can. And use naloxone if you have it.

To people who believe I’m giving addicts permission to use, I’d like to remind them that people using opioids don’t care if someone gives them permission or not. If they want to use, what other people think matters little. But giving people information about how to inject more safely may help keep them alive.

The Harm Reduction Coalition has excellent information on its website: http://harmreduction.org

In North Carolina, we are fortunate to have a robust Harm Reduction Coalition chapter. You can read more about their remarkable work at:   http://www.nchrc.org/

If you are a person who uses drugs and never plan to quit, your life has purpose and meaning. Use these safety tips to stay around for it.

The Good, the Bad, and the Ugly

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The Good

 Probuphine

Probuphine was approved by the FDA. I’ve written about this medication in several other blog posts. Probuphine is an implantable form of buprenorphine that lasts for six months. It will be suitable for buprenorphine patients who are stable at 8mg per day or less.

I think logistical problems will prevent this medication from becoming mainstream. I hear it must be implanted in a surgical suite, which makes little sense. Maybe it’s more involved than I realize, but I had been under the impression it could be done in an office setting, like Norplant.

I’ve also read that the physician must purchase and store the Probuphine implant, which adds financial risk and DEA scrutiny to a buprenorphine physician’s already crowded schedule.

As I’ve said before, I predict Probuphine will be administered at a few specialty centers, but isn’t likely to be done by most mainstream addiction medicine doctors. Still, it’s another option that hopefully will work well for patients on less than 8mg per day.

Watch your language

The field of Addiction Medicine is pushing for non-stigmatizing language to be used by treatment professionals. Words are important, and some words carry hidden and pejorative meaning in the general public.

For example, I’ve always cringed when I hear the term “dirty” or “clean” urine drug screen. I have to quash my desire to be sarcastic towards the speaker. The proper terms are “positive,” meaning a substance was found in the urine, or “negative,” meaning a given substance wasn’t found in the urine. Addiction Medicine gurus continue to emphasize the importance of using proper clinical terms. I enthusiastically agree with their efforts.

Now experts in the field want to get rid of the term “addict” and “opioid addiction.” They want to replace those words with terms such as “person with opioid use disorder,” and “opioid use disorder,” respectively.

I understand the reason behind these recommendations, and I agree with them, but it’s going to be tough to replace a two-syllable word with a ten-syllable phrase.

Besides, when I say the word “addict,” I suspect I mean something very different than the average person using the word. In my mind, the word “addict” has come to mean “person with the disease of addiction who is probably more likeable and interesting than an average person.”  But then, I chose to spend my career treating these people, so of course I think that way.

Contrast that to an average person in the community, to whom the word “addict” means a bum in the gutter with a needle hanging out of his arm. Most of the time, people are surprised when then encounter real addicts, or to use the new term, people with an opioid use disorder. Because since anyone can develop opioid use disorder, these people usually don’t look different from the rest of us.

Government Support for Addiction Treatment

When the President of the United States endorses medication-assisted therapies, we have arrived. That’s old news now, since he has been discussing MAT in some of his addresses since last year, as a way of addressing the opioid overdose epidemic. But now the promised money is starting to become available.

Available grant money fueled plans for new, collaborative opioid use disorder treatment programs in our state…

One primary care low-cost clinic just started working with their local opioid treatment center to provide needed primary care to patients in that OTP. Referrals should flow both ways, with the OTP sending patients to the medical clinic for needed healthcare, and the medical clinic will detect opioid use disorders in their patients, and refer them for treatment at the OTP.

An exciting initiative to connect people involved with the criminal justice system with appropriate medication-assisted treatment is in the planning phase. With this program, prisoners being released and people under parole and probation will be evaluated by addiction medicine doctors. Where appropriate, they will be offered methadone, buprenorphine, or naltrexone, to better treat their illness, and they will get increased counseling.

Prescription Monitoring Programs Work!

I had a few spare hours last week, and was able to look at around 125 of my 450 OTP patients. I discovered only one patient with some questionable findings, and she’s scheduled to talk with me this week.

What a change from 2007, when over 20% of all my OTP patients had serious prescriptions for opioids, benzodiazepines, and/or stimulants. These were prescriptions about which I knew nothing. Patients had filled prescriptions and there was no way for me to know about it, until our prescription monitoring program came online in mid-2007.By the time I got access late in the year, I found data indicating over a fifth of our patients were filling prescriptions that could harm them with the methadone I was prescribing.

Over the last nine years, our system has improved, making it ever easier and more accurate.

The Bad

All Use of Methadone is Toxic?

Perhaps in response to my blog post that was critical of the medical examiners in North Carolina, a medical examiner called me.

My complaint in the June 5, 2016 blog is that any patient who dies while on methadone maintenance is said to have died from methadone toxicity, regardless of clinical information.

This doctor and I had a cordial yet frustrating conversation. The physician introduced himself and said he was calling me because he had promised to do so after I spoke with him last year about a patient of mine who had died. When we last spoke, the toxicology results had just been sent off. He called yesterday to tell me that the level of methadone in this patient was toxic, and that along with the cocaine found in her system, he was reporting cause of death as “Methadone toxicity, cocaine toxicity.” I already knew this from reading incident report data, but I didn’t interrupt him. I was hoping he would give me additional information, but he didn’t.

When he was done, I informed him, again, that she had dosed at 130mg of methadone for months in the several years prior to her death. At her request, we started a slow taper. She came down on her dose by 5mg every couple of weeks, and she had been dosing at 60mg for several weeks prior to her death. I asked him how, with that information, could he still say she died from methadone toxicity?

He didn’t have an answer, and just repeatedly said her methadone level was “toxic.” He read the level to me, and I told him that I have patients with trough levels  higher than that.  I told him toxic for an opioid-naïve patient may be just what one of my patients needs for stabilization.

I don’t think he ever heard what I was saying. He never got off the topic of drug levels, and implied perhaps she could have obtained methadone from another source.

I suppose this is possible, but unlikely. For this patient to have overdosed on methadone, she would have had to gotten a supply of the medication from another source. I know she didn’t get a prescription for it, since I checked the state prescription monitoring database. And why would she buy illicit methadone off the street when she could just ask to go back up on her dose if she were in withdrawal?

I appreciate that this doctor took the time to call me. He didn’t have to do that, and it probably wasn’t an easy conversation for him. I don’t doubt he’s conscientious at his job.

I only wish he could have heard what I was saying.

What I heard him was saying was more of the same: the medical examiners will base their decision about cause of death on the methadone level, and will not consider any clinical information from me, or presumably from any another other opioid treatment program physician, if a patient dies under my care.

This increases the risk of being a doctor at an opioid treatment program. Because no matter how cautious we are, we treat a group of people who die at higher rates than age-matched controls. Nearly all of our patients smoke cigarettes. Of course they can die from methadone overdose, but they also die at higher rates from cancer, heart disease, liver failure, and other medical problems created from a life time of drug use, including nicotine.

But we now know in advance that methadone will be blamed no matter what. And that’s bad news

The Ugly

Heroin Comes to Town

Last week, several people who should know and have no reason to lie told me heroin can be bought in Wilkes County. I am really sad to hear this.

Heroin has already invaded many small communities. It crept in after black market prescription opioids pain pills became scarce. Indeed, at my state’s yearly Addiction Medicine conference, most OTP doctors said they’ve been treating heroin use disorder for several years.

For some reason, the people I admitted to our opioid treatment program have thus far been around 98% pain pill addicts. Last week, more than half of the new patients were using heroin. One patient came to treatment because the first time he used heroin, he overdosed, nearly died, and woke up in the ambulance. That scared him enough to propel him into substance use disorder treatment.

You may question if heroin addiction is that much worse than pain pill addiction. I think it is, though I could be wrong about this. With pharmaceutical grade pain pills, the user has an idea, usually, of how strong the product is. There’s not much variation from one pill to another. But with heroin, the batch one day could have only a few percent of pure heroin, or 100% pure heroin. There’s no way to know. There’s no way to gauge how strong it is, unless the user dose a “tester shot.” This is when the user uses a small amount of the purchased heroin to see how strong it is. This tester shot is recommended by Harm Reduction Coalition as a way to reduce overdose risk.

Heroin manufacturers usually don’t care about quality control. The heroin could be cut with God knows what else. Some of these substances cause special problems, since they weren’t meant to be injected into the human body.

Quinine, for example, has been found as a contaminant. I’m not sure why it’s used to dilute heroin, but it is. Quinine can cause kidney damage, bleeding disorders, and severe allergic reactions. Some experts believe many heroin overdoses are really fatal allergic reactions to products used to cut the heroin. In the street parlance, adding substances to a drug is called “stepping on it,” meaning diluting it so it can go farther and make the seller more money.

Other regular heroin contaminants include caffeine, talcum powder, powdered milk, chalk, or flour.

Recently there’s been a tendency to include fentanyl in the heroin product, making it an even stronger opioid. This has caused many overdose deaths, particularly in the Northeast. I strongly suspect that’s what my patient with the near-fatal overdose injected.

 

 

 

 

 

 

 

 

 

Buprenorphine: Current Practices

NCSAM

I just got back from the NC Society of Addiction Medicine annual conference. (Yes, I’ve been to several conferences lately.) One of the sessions I attended was a lively discussion of the current practices in office-based prescribing of buprenorphine, for opioid addiction.

The session was run by two experienced, knowledgeable addictionologists, who mediated topics and shepherded the dialogue. One physician works in North Carolina and the other in Tennessee. The room was packed with at least fifty people, most of us doctors who prescribe buprenorphine for addiction.

Deliberations were collegial but we didn’t agree on all issues, of course. Dissenting opinions were respected and debated.

The first topic I can recall was about how often buprenorphine patients need to be seen. Most practitioners agreed that new patients needed to be seen at least weekly initially. As stability develops, we gradually extend the time between visits to one month. One doctor opined that no patient should be allowed to go any more than one month between physician visits. When the moderator asked if anyone disagreed, I raised my hand, and the moderator asked me to explain.

With some trepidation, I told the audience that I had a super-stable group of patients in my practice. I inherited most of them from another physician who was one of the first in the area to prescribe buprenorphine. This group of patients all have over five years of stable and relapse-free recovery. A few have been in stable recovery for nearly ten years. These people work, and have happy and productive lives.

So yes, I do allow these patients to go two months between visits.

No one booed or hissed me, but I got the feeling I’m doing something with my patients outside the realm of normal for most doctors prescribing buprenorphine. Thankfully, the moderator made the point that we should use our clinical judgment and adjust treatment to best fit each situation, which made me feel better.

I was mulling this over later, and maybe I do have an unusual group of patients, who have been stable on MAT for so long. Some of these patients elected to stay on sublingual buprenorphine because they are doing so well on it, and they fear relapse if they taper off of it. Others plan to stay on buprenorphine because they developed addiction as a complication of chronic pain treatment. Happily, the buprenorphine works as well for their pain as it does for their addiction, so we get the two birds with the one stone.

There’s another unusual thing about these super-stable patients: almost all of them are deeply involved in 12-step recovery. Many were in Alcoholics Anonymous prior to their opioid addiction. They developed addiction to opioid pain pills after receiving prescription opioids for an acute or chronic pain condition. Once they started on buprenorphine to treat the opioid addiction, they continued going to Alcoholics Anonymous (a few go to Narcotics Anonymous).. Other patients didn’t start going to AA until after they entered MAT on buprenorphine.

I’ve had many people write comments to my blog, furious when I even mention 12-step recovery and MAT in the same sentence. But I have living proof in my practice of multiple patients on medication-assisted treatment of opioid addiction who have been able to make 12-step programs work for them.

Getting back to the conference…we spent much time discussing the monoproduct buprenorphine versus the combination product buprenorphine/naloxone. All of us agreed there’s a need for caution with prospective patients who insist they can take only the monoproduct (this is the equivalent of the brand name Subutex), because it does have a higher street value than the combination product.

Of course, there are people who inject the combination product (Suboxone film, Zubsolv, etc.), but overall, people seeking to inject buprenorphine are much more likely to prefer plain buprenorphine. Black market prices are higher for the monoproduct than the combination product, underscoring the preference for monoproduct.

One outspoken doctor said the monoproduct should rarely if ever be prescribed. Another doctor echoed my feelings on the matter when he said something to the effect that some patients really do have a bad reaction to the naloxone in the combination products, and if we are cautious, we can prescribe the monoproduct. However, the general opinion was that financial reasons weren’t sufficient to take the risk of prescribing the monoproduct.

I disagree with that, but kept quiet, already feeling like maybe I’m a bit too liberal.

I have had patients, stable on a buprenorphine combination product (usually brand name Suboxone films), who suddenly lost their health insurance. If such patients had negative drug screens for years, and no history of intravenous use, I switched them to the generic monoproduct because it’s the cheapest buprenorphine product on the market. These patients could not have stayed in treatment if I’d made them stay on the much more expensive brand names. Most of those patients prefer the films, and when they got new insurance, asked to switch back to the films.

I did not suspect these patients would sell their medication for profit. You have to know them, but these patients had stable jobs and no leanings toward criminality. And I am by no means a gullible person.

Since then, a generic combination product came onto the market. Still more expensive than the monoproduct, it’s less expensive than all the name brands.

Next we discussed how to deal with patients who say they are allergic to naloxone, and thus can’t take the combination product (Suboxone, Zubsolv) but only the monoproduct (Subutex).. Patients usually don’t mean an actual allergy, but rather intolerance to naloxone. These patients report headache, nausea, etc. when they ask their physician to prescribe the monoproduct. Of course, this raises suspicion with physicians that such patients plan to misuse the medication by injecting or snorting.

Should physicians just accept what patients say at face value, or should we say sorry, I only prescribe buprenorphine in combination with naloxone? After all, there’s no way to “prove” a headache or nausea. There’s no test we can order that will give any useful information. One doctor said he sent such patients to a neurologist for evaluation of the headache, or to a gastroenterologist to decide the cause of nausea. He says most patients fail to follow through, and so he weeds such prospective patients out of his practice that way.

An audience member suitably questioned this habit, asking how could a specialist be expected to determine if a medication caused headache or nausea? I think it’s kind of a sneaky way to get rid of patients who want buprenorphine monoproduct.

I have the same fears when fielding new calls from prospective patients. I’ve instructed my patient contact representative (who is also my office’s licensed professional counselor, after-hours contact person, pharmacy liaison, licensed clinical addiction specialist, prior approval wrangler, and fiancé) to tell these people that I do not prescribe the monoproduct to new patients. I have no problems saying “no” upfront to these patients, and try to explain why I’ve made this decision for my private practice (even though, as above, I have prescribed it for patients I know very well).

I use the monoproduct in the opioid treatment program where I work, because those patients dose with us every day until they have a period of stability. The dosing nurses roughly chop the tablets, to minimize diversion, and patients stay on-premises until the medication has dissolved, also to make diversion more difficult. These patients don’t get any take home doses until we feel they have stabilized.

We also discussed how long to keep patients on buprenorphine. The bottom line is that no one knows. Best outcomes are seen in patients who stay on buprenorphine, since there’s still a high relapse rate back to opioids in patients who stop buprenorphine. I ask my patients periodically if they wish to start a slow taper, if they’ve been stable for over a year. I don’t push them to taper if they’re not ready, but if they are, I recommend they taper slowly. From the discussion at this meeting, it sounds like most of my colleagues do the same.

We discussed the maximum daily dose of buprenorphine. According to studies, a daily dose of 16mg saturates most of a patient’s opioid receptors, and increasing the dose to 24mg only gives about a 4% increase in the number of covered opioid receptors. Some doctors say this shows buprenorphine should never be dosed more than 16mg per day.

However, about a third of the doctors in the room raised their hands when the moderator asked if they had any patients who seemed to require 24mg per day to stabilize.

I didn’t interject anything into the discussion, but I just went to a session at the national ASAM meeting where this same topic was discussed. While it’s true that basic pharmacology would indicate 16mg is probably the just as effective as 24mg in most patients, several studies have shown better patient retention in treatment when higher doses (24-32mg per day) are used.

It’s possible this isn’t a physiologic effect, but more of a mental process. We can’t be sure. But for whatever reason, if my patient does best at 24mg, I’ll allow her to stay on that dose.

For patients on higher doses, we need to make sure they aren’t diverting some of their medication. Patients sometimes ask for a higher dose than they need, in order to get enough medication to treat a friend, family member, or significant other. Some doctors call this “piggy-backing.” Even though it means a suffering addict is getting treatment, the piggy-backer won’t get any counseling. Also, law enforcement types use examples of diversion to demonstrate that buprenorphine is a bad street drug, contributing to the stigma against patients doing well in their treatment. Diversion threatens the whole concept of office-based treatment program.

All in all, we had two hours of lively interaction on the finer points of office-based prescribing of buprenorphine. I don’t think all doctors will agree about everything, but it’s nice to hear what other physicians are doing, to make sure I am not too far out of line with the standard of care.

Injecting Buprenorphine (Suboxone, Subutex)

aaaaaainjecting

I know why addicts inject buprenorphine (Subutex): they think it saves them money. Over the long run, however, I doubt that’s true, given the hidden costs of addiction.

Buprenorphine has a relatively low bioavailability, at around 30%, when taken sublingually (under the tongue). This means only 30% of the total dose reaches the blood stream. If the pH of the mouth is lowered, bioavailability is reduced even further. This is why we recommend patients on buprenorphine avoid eating or drinking anything acidic for about twenty minutes prior to taking their dose.

By definition, when a drug in injected, it has 100% bioavailability. Therefore, some people inject their prescribed buprenorphine in order to get the desired blood level with a lower dose of buprenorphine. If they are prescribed 8mg per day, perhaps they use 4mg intravenously and sell the rest of their dose, or stockpile it.

People who misuse buprenorphine in this way may be blinded by their addiction to the multiple dangers of injecting drugs.

Anytime humans inject drugs into their bodies that weren’t meant to be injected, problems will occur. All sorts of medical complications can arise, which can cause exorbitant medical bills for drug users…and tax payers.

Skin: These pills weren’t meant to be injected, so they are not sterile. Buprenorphine does come in a sterile ampule to be used intravenously in healthcare settings, but I doubt that form would be found on the street for sale. The sublingual pills and film have bacteria in them, and we all have bacteria on our skin. Inevitably, some bacteria “go along for the ride” when pill matter is injected. This can cause skin and soft tissue infection of varying severity. Patients who inject can get anything from a mild cellulitis, which is an infection of the skin and soft tissues underneath, to life-threatening sepsis, which is a blood infection from bacteria. Many patients get abscesses, which are localized pockets of pus which must be drained in order to resolve.

The worst skin infection is called necrotizing fasciitis, which is a rapidly progressive infection that kills tissue. It’s also known as “flesh eating” bacteria. Often, surgeons have to remove whole infected areas of this dead tissue in order to save the patient’s life.

Scars and track marks are probably the most common skin manifestation of intravenous drug use. These can be minimized by also using a new needle, and not re-using needles.

As an aside, please don’t try to treat your own skin infections by yourself. I’ve seen horrible complications when patients try to drain abscesses on their own. And that leftover antibiotic you have on the shelf at home may not be a good choice to treat skin infections, particularly not the newer resistant bacteria.

Cardiovascular system: The tablets aren’t pure buprenorphine. The manufacturer’s website lists corn starch as another main ingredient. I don’t know for sure what that does to veins, but I know I use it in the kitchen to thicken a concoction if it’s too liquid. I imagine it does the same thing to blood in the veins. Even if the addict uses something to filter what he is injecting, some particles can still get through to the veins. Risks can be minimized by using a micron filter.

Again, bacteria can cause problems in the cardiovascular system. Sepsis, an overwhelming blood infection, can lead to endocarditis. This is a serious and life-threatening infection of heart valves. If the infection destroys a heart valve, heart surgery with valve replacement may be necessary.

Thrombophlebitis is a condition where the veins become clotting and possibly infected, usually at the injection site but sometimes further “downstream” in the vein. If this occurs in the deep veins pieces can break off and go to the lungs, causing pulmonary emboli.

If a drug is accidently injected into an artery instead of a vein, catastrophic complications can occur, including loss of limb below the level of injection. The artery becomes damaged which causes inflammation and clotting. The patient usually feels intense pain and burning immediately after injecting. Some sources suggest this can be treated with elevation of the limb and blood thinners, so go to your local emergency room if this happens to you.

Pulmonary: Corn starch and other particles like talc can cause clots and inflammation, creating structures called granulomata. As more granulomata are created, oxygen exchange in the lungs becomes more difficult, causing low oxygen levels in the patient.

Pulmonary emboli are clots from the venous blood system that break off and travel to the pulmonary arteries. When these clots are large enough, they can kill rapidly. The patient may have sharp chest pain, feel short of breath, and have a fast heart rate with low blood pressure. Blood can’t travel through the lungs to get oxygen, and the patient dies from lack of oxygenated blood. Even small clots can cause serious problems, particularly if they are also infected with bacteria.

This list isn’t complete – many other medical problems occur with intravenous drug use. Of course the most common may be transmission of the Hepatitis C or B viruses if needle/syringes/injection works are shared, as well as HIV. There are weird things like endophthalmitis, and infection of the internal eye, and other medical problems too numerous to list.

Opioid addicts using intravenously can get addicted to the process of injection. The brain repeatedly associates the ritual of injection with a rush of pleasure, and so the whole act of injecting can be difficult to stop. I’ve had patients on methadone and buprenorphine who continue to inject saline with no drugs just to feel the rush from using a needle. This can be overcome with time and counseling, but some patients have enormous difficulty with this.

So if you are reading this and considering injecting your buprenorphine in order to save money, please don’t do it. You will likely end up paying much more in the long run, and I don’t necessarily mean in a financial sense.

Overdose Danger In Chicago

aaaagotnaloxone

Apparently heroin mixed with fentanyl is making a new appearance in Chicago, IL. An article in the Chicago Tribune two days ago (http://www.chicagotribune.com/news/local/breaking/ct-heroin-overdoses-met-20151002-story.html ) described how that city has seen 74 overdoses in 72 hours, all from heroin suspected to be laced with fentanyl.

The article says that most of the overdoses were reversed with naloxone, better known as Narcan, but that emergency workers had to use two and three times the amount of Narcan as usual. However, at least one death is suspected to be from the dangerous heroin. Lab tests are still pending, and expected to confirm the presence of fentanyl.

This latest distressing news comes against a backdrop of decreased funding for the treatment of addiction. In fact, the Republican governor of Illinois, Gov. Bruce Rauner, re-wrote a bill that originally required Medicaid to pay for addiction treatment medication and counseling. The Governor took out that portion of the bill, saying the state couldn’t afford the expense. This re-written bill was rejected by the state senate.

Supporters of the original bill pointed out that studies show money paid for addiction treatment saves money in the long run, usually due to lower incarceration costs and lower medical costs.

Today, the Chicago Tribune also ran an article about how some states are requiring school nurses to have access to naloxone in middle schools, junior high, and high schools in some states. The National Association of School Nurses has asked for naloxone to be part of each school’s emergency first-aid kits.

This news about overdoses is appalling. I hope the state will look harder at whether they can afford NOT to fund addiction treatment for Medicaid patients. We know from prior studies that for every one dollar spent on addiction treatment, taxpayers are saved anywhere from $4 to $11.

Consider one heroin addict who contracts endocarditis (life-threatening infection of heart valve). The duration of treatment with intravenous antibiotics is usually six weeks. If the patient requires heart surgery and valve replacement, costs go even higher. A conservative estimate for the cost of hospitalization might be tens of thousands to hundreds of thousands of dollars. But a year’s worth of medication-assisted treatment costs around forty-two hundred dollars for one person. For further perspective, I recently read that the cost of incarcerating one person for one year is around $24,000.

Treatment saves taxpayer money. Even if citizens of Illinois don’t care about the health and well-being of addicts, they should care about the added taxpayer expenses of untreated drug addicts.

Also, I want to remind readers of my blog who may still be using IV drugs of the following safety ideas:
1. Don’t use alone. Use a buddy system, to have someone who can call 911 in case you stop breathing. Do the same for another addict. Obviously you shouldn’t inject at the same time. Stagger your injection times.
Many states now have Good Samaritan laws that protect the overdose victim and the person calling 911 for help, so that police don’t give criminal charges to people who do the right thing by calling for help for an overdose.
Take a class on how to give CPR so that you can revive a friend or acquaintance with an overdose while you wait on EMS to arrive.
2. Get a naloxone kit to reverse an overdose. Contact your local Harm Reduction Coalition via the internet, or Project Lazarus.
3. Use new equipment. Many pharmacies sell needles and syringes without asking questions. Don’t use a needle and syringe more than once. Repeated use dulls the needle’s point and causes more damage to the vein and surrounding tissue. Don’t try to re-sharpen on a matchbook – frequently this can cause burrs on the needle point which can cause even more tissue damage.
4. Don’t share any equipment. Many people who wouldn’t think of sharing a needle still share cottons, cookers, or spoons, but hepatitis C and HIV can be transmitted by sharing any of this other equipment. If you have to share or re-use equipment, wash needle and syringe with cold water several times, then do the same again with bleach. Finally, wash out the bleach with cold water. This reduces the risk of transmitting HIV and Hepatitis C, but isn’t foolproof.
5. Use a tester shot. Since heroin varies widely in its potency, use small amount of the drug to assess its potency. You can always use more, but once it’s been injected you can’t use less. The recent overdoses in Chicago illustrate how change in potency can be fatal.
6. Use clean cotton to filter the drug. Use cotton from a Q-tip or cotton ball; cigarette filters are not as safe because they contain glass particles.
7. Wash your hands thoroughly before preparing your shot, and clean the injection site with an alcohol wipe if possible. Don’t use lemon juice to help dissolve heroin, as it carries a contaminant that can cause a serous fungal infection.
8. Opioid overdoses are much more likely to occur in an addict who hasn’t used or has used less than usual for a few days, weeks, or longer. Overdose risks are much higher in people just getting out of jail and just getting out of a detox. Patients who have recently stopped using Suboxone or Subutex may be more likely to overdose if they resume their usual amount of IV opioids.
9. Don’t mix drugs. Many opioid overdoses occur with combinations of opioids and alcohol or benzodiazepines, though overdose can certainly occur with opioids alone.
10. Don’t inject an overdosed person with salt water, ice water, or a stimulant such as cocaine or crystal methamphetamine – these don’t work and may cause harm. Don’t put the person in an ice bath and don’t leave them alone. Call for help, and give mouth-to-mouth resuscitation if you can. Use a naloxone kit if you have one.