Archive for the ‘Complications from IV drug use’ Category

Update on Jail Death Lawsuits

 

 

 

 

Long-time readers of my blog will remember the story of Eric Stojcevski, a young man who died from withdrawal from prescribed medication while in jail in Macomb County, Michigan, for unpaid traffic tickets in 2014.

I blogged about this case on November 3, 2017, February 5, 2016, and October 20, 2015.

I’ve given readers periodic updates because to me, this case is the most extreme example of how poorly sick inmates are treated by jailers. I feel this is one of our country’s biggest moral failings, because it goes on all the time, usually with little to no publicity.

Someone once said we can judge the quality of a society by how we treat the most vulnerable members of that society. Incarcerated people are among the most vulnerable, since they can’t take themselves to a hospital for medical care if they get sick. They are dependent on the jailers to get them care when ill.

This did not happen in the case of David Stojcevski. In June of 2014, he went to jail for failure to pay parking tickets, and it turn into a death sentence. According to news sources, he was being prescribed methadone, clonazepam, and alprazolam by a physician. He was not given any of these prescribed medications when he was in jail.

According to his autopsy, he died from acute drug withdrawal on the seventeenth day of his thirty-day sentence. Despite intense suffering, his pleas for medical attention were ignored. When he exhibited bizarre (withdrawal) behavior, he was sent to a mental health cell, where his last eleven days on earth were videotaped. His family, livid at the lack of medical care that resulted in his death, released the videotape online, where it went viral. The recording showed him naked, having repeated seizures on the jail floor as he died.

His family filed a civil case against jail personnel, and against Correct Care Solutions, the health organization that was contractually obligated to provide medical care to prisoners in the Macomb County jail.

There was a criminal investigation that went nowhere.

The Department of Justice investigated, and said they found no evidence of criminal intent on the part of jail personnel or personnel of Correct Care Solutions. The FBI had to be forced by the family to release its investigation records, and only released part of them.

These records should be helpful to the family’s civil case, and now depositions for this civil case are underway.

According to news reports, [1] Sheriff Wickersham’s sworn testimony revealed that David lost forty pounds in his last seventeen days, spent in the county jail. Over the last three days of his life, he drank almost no water. Of the thirty-three meals served to him over the last eleven days of his life, he ate perhaps three of them.

According to news reports, jail guards thought the medical staff was responsible for deciding when a patient should go to the hospital. Medical staff thought it was the guards’ responsibility to monitor the amount of food and water inmates are consuming.

Sheriff Wickersham admitted he was responsible for the well-being of the inmates, but also admitted he rarely enters the jail. Even though his office is located a few feet from the jail, he enters the jail perhaps once per month. He said he delegated oversight of medical care to another employee, who had no medical training.

News reports didn’t say whether Correct Care Solutions employees had been contacted about the state of health David was in during his last days.

News reports did say that David’s prescribing physician, Dr. Bernard Shelton, was charged with unlawful delivery of controlled substances. [2] This report says he prescribed four million “addictive pills” to Macomb County residents, though it didn’t specify over what period of time or what type of pills they were. From what he prescribed David Stojcevski, it appears to have been opioids and benzodiazepines.

In 2017, according to the state of Michigan’s medical board documentation, Dr. Shelton lost his medical license for inappropriate prescribing of controlled substances that were outside acceptable practice. His charts were reviewed by other physicians, who have the knowledge to judge such things. They said he didn’t check patients on the Michigan prescription monitoring website, he didn’t keep complete records, and lacked essential documentation.

The medical board suspended his medical license for fifteen months, fined him $10,000, and said he wouldn’t be considered for license re-instatement unless he could prove, with clear and convincing evidence, that he had good moral character, the ability to practice medicine with reasonable skill and safety, the ability to follow the guidelines of re-instatement, and for it to be in the public interest that he be licensed again. At present, he does not have a license to practice in Michigan.

Now it appears Dr. Shelton will face criminal charges as well as losing his medical license.

But getting back to David Stojcevski’s case…even if his doctor prescribed opioids recklessly and inappropriately, it doesn’t release the sheriff of his obligation to make sure inmates receive medical care. Watching David suffer on the recordings made by the jail, I can’t help but wonder why no one took any action to help a man obviously in serious need of medical attention.

What if Sheriff Wickersham (or one of his deputies) walked down the street of whatever town is in Macomb County, Michigan, and he came to a man lying on the sidewalk, barely conscious, having a seizure. What would he do? I expect he would squat down beside the sick man, check for a pulse, and summon 911 for help. That’s what most citizens would do, out of common decency and concern for a fellow human.

In other words, it did not take any medical knowledge to know David was in serious need of medical help, yet no one in the whole jail called 911.

You can believe I’ll be watching this case unfold. It has the potential to be a multi-million -dollar case. In other similar cases, awards were in the three-million-dollar range. It’s sad that is takes a large financial award to change the way people do things, but in this case, it appears necessary.

It’s too late for David, but a large settlement or award against Macomb County and against Sheriff Wickersham could be another paving stone on the road of appropriate medical care for vulnerable inmates.

  1. https://www.clickondetroit.com/news/defenders/sheriff-answers-questions-under-oath-about-death-of-inmate-at-macomb-county-jail (accessed 7/4/18)
  2. https://www.clickondetroit.com/news/defenders/doctor-charged-with-distributing-opioids-to-inmate-who-died-from-withdrawal-at-macomb-county-jail (accessed 7/4/18)
Advertisements

Not Dying: A Worthy Goal

 

 

A new study about opioid overdose death and treatment of opioid use disorders was published in the Annals of Internal Medicine this month. [1]

It showed that people who experience a non-fatal overdose have a significantly reduced risk of death if they start on medication-assisted treatment with methadone or buprenorphine. Naltrexone was also examined but limited data prevented conclusions about the use of this medication.

This large cohort study, done in Massachusetts on adults age 18 and older, covered the four years from 2011 and 2015. Subjects were identified as people who experienced at least one non-fatal opioid overdose and survived at least for 30 days afterward. Patients were excluded if they had a diagnosis of cancer.

This turned out to be a huge study, with over seventeen thousand study subjects.

In the year prior to the overdose event, 26% had received at least one medication to treat opioid use disorder. Twenty-two percent received opioid detoxification at least once. Forty-one percent had received an opioid prescription in the preceding year, and 28% received a prescription for a benzodiazepine within the previous year.

For these same patient, in the year after their nonfatal overdose, 30% received at least one medication for opioid use disorder (13% got buprenorphine, 8% got methadone, and 4% got naltrexone. The other 5% received more than one medication.)

People younger than 45 were more likely to received treatment with medication, as were people with diagnoses of anxiety or depressive disorders.

In the year after overdose, 4.6 of the people with a prior non-fatal overdose died, and of those, 2.1% died from opioid-related causes.

For patients treated with medication for opioid use disorder, both the all-cause mortality and opioid mortality rates were significantly reduced; they were cut approximately in half.

Patients who started n methadone after their non-fatal overdose had markedly reduced risks for both all-cause mortality and opioid-related mortality, with the adjusted risk at around half what it was for untreated patients. Results for patients on buprenorphine were nearly the same; they had not quite the degree of risk reduction as with methadone, but still significantly lower risk of death than patients on no medications.

There were no associations between risk of death for patients started on naltrexone, but the authors noted this was a smaller group, so any differences weren’t statistically significant. Of note, most of those patients were only treated for a month or two.

So what does this study tell us?

We have another study that shows medication-assisted treatment with methadone or buprenorphine reduces the risk of death, this time in people with at least one prior non-fatal opioid overdose. In this study, being methadone or buprenorphine reduced deaths from all-cause mortality, as well as opioid-related mortality.

We also see, again, that only a minority of people, 30%, with nonfatal overdose were started on life-saving medication.

I was surprised the percent of people referred for medication-assisted treatment was that high. This study was done in Massachusetts, a state that’s probably at the forefront of opioid use disorder treatment. They have some excellent providers and physician leaders, and better methods to pay for treatment in that state.

I don’t think rural areas in North Carolina come close to a 30% referral rate. I’d be amazed if 2-3% were referred for evidence-based treatment with medication. I suspect most people here who survive near-fatal opioid overdoses aren’t directed, referred, or even informed about medication-assisted treatments. People get referred to OTPs around here by concerned friends and family members, but rarely by physicians.

It has started to change. In our area, of the three OB/GYN groups, we have one practice that refers patients to us. The LME (local management entity, which contracts with the state to see people on Medicaid and those with no insurance) has referred less than a handful of people for treatment. That’s a dramatic improvement from seven years ago when the LME told patients to get off methadone.

But back to the study. So even in one of the most progressive states, only 30% of people got life-saving treatment.

Let’s picture a patient who has a near-fatal episode of a different chronic disorder. Thankfully, the patient survives this episode. There’s a treatment medication for this disorder that will reduce the patient’s risk of dying by half over the next year. What do you think would happen if this patient wasn’t given or referred for that life-saving treatment?

There would be an outcry. There would be wringing of hands and rending of garments, and possibly gnashing of teeth. There would be lawyers…malpractice lawyers, swarms of them.

Yet this exact situation happens over and over, again and again, in emergency departments across this nation.

To be fair, this article doesn’t say why the patients who survived a near-fatal overdose weren’t started on medication. Maybe emergency department personnel offered this medication but the patients refused.

Realistically, there are significant barriers to starting medication-assisted treatment of opioid use disorder. Methadone can only lawfully be prescribed from a properly-licensed opioid treatment program. Maybe emergency department physicians gave referrals to OTPs, but the patients didn’t show up. Maybe they referred to office-based buprenorphine prescribers.

Every time I do an intake on a patient entering treatment with MAT, I ask if there’s been an overdose in their history. Much of the time, the answer if “Yes.” I then ask what kind of recommendation for treatment they got. Most times the patient looks at me blankly. They can’t think of any kind of treatment recommendation or referral. One patients said, “They told me to quit using drugs.”

Telling people to quit using drugs IS NOT treatment for opioid use disorder. It’s sad that I even have to write this, as it should be well-known by all medical personnel.

All of us working in this field need to keep chugging along. We need to put this article in our mental back pocket, ready to talk about if/when the time comes when we hear stale old beliefs about medication-assisted treatments.

This study points to the bottom line: “We are using medications that reduce the risk of dying by half, for people who have had a prior nonfatal overdose.” Not dying is a huge benefit of treatment, perhaps the ultimate benefit.

It is long past time for medical professionals to set aside their personal opinions and what they think they know, in favor of hard data. Methadone and buprenorphine reduce the risk of dying, and patients with opioid use disorder must be informed & encouraged about these treatments. To do otherwise is malpractice.

  1. Larochelle et al., “Medication for Opioid Use Disorder after Nonfatal Opioid Overdose and Association with Mortality: A Cohort Study,” Annals of Internal Medicine, June 19, 2018

Avoiding Overdoses

August 31: Overdose Awareness Day

 

 

 

“I’m not gonna overdose. I know my limits.”

I really hate hearing these words. Usually patients say this in response to my concerns about their pattern of drug use while I’m prescribing methadone or buprenorphine. But many patients feel like they are the experts. They can’t imagine making a deadly mistake with their drug use. But I’ve heard this phrase, or something close to it, from at least five people who are now dead from overdoses.

I was reminded of this situation after reading an article in the latest issue of Journal of Addiction Medicine. Najman et al. wrote an article titled “When Knowledge and Experience Do Not Help: A Study of Nonfatal Drug Overdoses.”

The author of the study looked at nonfatal overdoses in Australia in 2013, where overdose deaths have risen steadily since 2007. In that country, unlike the U.S., heroin use is declining while pharmaceutical opioid misuse is rising.

This study looked at nonfatal overdoses in people who inject drugs. These people, identified by the needle and syringe exchange programs in Australia, were interviewed about the circumstances surrounding these overdoses, in order to get a better understanding of the risks. A total of 50 people were interviewed for this study.

Most of these people were male, middle-aged, single, and unemployed. Nearly all were smokers. Half had a diagnosis of liver disease and almost all reported a mental health diagnosis. Most injected pharmaceutical opioids, though some also injected heroin and methamphetamine. These were very experienced drug users, with an average of 21 years of intravenous drug use.

Surprisingly, more than half of the study subjects were in some form of treatment for substance use disorder. This finding is contrary to other studies, which have found being in treatment lowered the risk for overdose. Around 46% were in medication-assisted treatment with either methadone or buprenorphine. However, some of the overdoses happened on days that the person missed dosing for some reason, and substituted another opioid such as heroin or fentanyl. Thirty-two percent of study subjects dosed with either methadone or buprenorphine in the twenty-four hours prior to experiencing their overdose.

Most of these overdoses happened in private homes, and around half received some sort of folk remedy for overdose such as being slapped, put into cold water, or being shaken. Naloxone kits weren’t routinely being distributed at the time of this study.

When asked about the cause of their overdose, many the subjects said they were impaired by alcohol or benzodiazepines. Over half said they used benzodiazepines within twenty-four hours of their overdose. Of the 50 subjects, 64% said they had been prescribed anti-anxiety medications sometime in the year prior to overdose, and 38% said they’d been prescribed sleeping pills. Another 36% said they’d been prescribed some sort of tranquilizer in the year prior to overdose. I’m assuming many of the subjects were prescribed more than one of these groups of medications.

Alcohol was not as prominent as sedative medications as contributory cause of overdose; only 34% of subjects said they had some amount of alcohol in the twenty-four hours prior to their overdose.

Over a third of subjects had used fentanyl, a very powerful opioid, leading up to the overdose.

The authors of the study concluded that these experienced drug users were aware of common risks for overdose, yet drug intoxication from sedatives such as alcohol or benzodiazepines may have clouded the user’s thinking when injecting opioids. They also found that unexpected availability of drugs contributed to overdoses.

It’s an interesting study, and a little disturbing to me, particularly the data about overdoses in people who were enrolled in medication-assisted treatments. It does underline the importance of daily dosing of MAT, and the importance of avoiding alcohol and benzodiazepines in patients on MAT.

And if you didn’t know…August 31 is International Overdose Awareness Day.

News You Can Use

 

 

 

 

 

 

 

 

New ACOG Recommendations:

The American College of Obstetrics and Gynecology (ACOG) just released an updated recommendation about the treatment of opioid use disorder in pregnant women: https://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Opioid-Use-and-Opioid-Use-Disorder-in-Pregnancy

Their last statement was issued in 2012, in cooperation with the American Society of Addiction Medicine (ASAM). This newer statement was released earlier this month, also in cooperation with ASAM.

By my reading, this update is more direct about recommending medication-assisted treatment for pregnant women with opioid use disorder, and specifically discouraged medically supervised withdrawal from opioids during pregnancy.

This statement was in the update’s conclusions: “For pregnant women with an opioid use disorder, opioid agonist pharmacotherapy is the recommended therapy and is preferable to medically supervised withdrawal because withdrawal is associated with high relapse rates, which lead to worse outcomes. More research is needed to assess the safety (particularly regarding maternal relapse), efficacy, and long-term outcomes of medically supervised withdrawal.”

I suspect this released update may have been prompted by the actions of obstetricians in certain locations (Tennessee, for example), where medically supervised withdrawal is routinely recommended by obstetricians. As you recall in a blog earlier this summer, I showed you a letter written by OBs from TN, recommending “medically supervised withdrawal” for patients on medication-assisted treatment of opioid use disorders.

As the ACOG update emphasizes, there’s scant evidence to show medically supervised withdrawal provides any better outcomes for the baby, but certainly places the mother at risk for relapse.

I am pleased to see this update, and plan to mail it to a few obstetrics practices in my own area. Some OBs may be giving patients recommendations not supported by their own professional organization out of ignorance, in which case more information can help. Other OBs do it for ideological reasons, in which case I doubt any amount of information can help, but at least I’ll know I’ve tried to do something.

Screening for substance use disorders was also strongly emphasized in the new document, with specific recommendations about how this should be done. In other words, asking a pregnant patient, “You don’t take any drugs, do you?” is not considered to be adequate or recommended screening.

Increased Risk for Death in Patients with Opioid Use Disorder who Leave Buprenorphine Treatment

We have multiple studies, dating back decades, showing patients with opioid use disorder who leave treatment with methadone have higher risks of overdose deaths. We believe the same thing is true with buprenorphine treatment, but now we have more data to support that assumption.

A French study of 713 buprenorphine patients showed that being out of buprenorphine treatment was associated with a 30-fold increase in death, compared with patients who stay on buprenorphine treatment.

Now that’s impressive.

This was a study done in France, where most patients with opioid use disorder are treated by general practitioners in private practice. This would be roughly equivalent to what physicians do now in the U.S. in their office-based buprenorphine practices, often called OBOT treatment.

The study was published in the July/August 2017 issue of the Annals of Family Medicine, by Dupouy et al. It looked at new patients admitted onto buprenorphine treatment from early 2007 until the end of 2011, and covered over 3,000 person -years of treatment.

The authors say that the data showed, “…being out of treatment was associated with sharply elevated mortality risk.”

We already knew that people with opioid use disorder have an increased risk of death. Early in this article, the authors state that the accepted mortality rate of untreated heroin use disorder is around 2 people per 100 patient years. This means that if you follow 100 heroin users for a year, it is likely that 2 will be dead at the end of the year. An older study, by Hser et al., followed people with opioid use disorder over time, and found that around 50% were dead at 30 years.

We’ve had other studies that show being in treatment with buprenorphine or methadone decreases risk of death, but this may be the first study showing that getting help in a primary care setting reduces the risk of death so remarkably.

This was a very large study, so the data is more impressive to me All this data supports the conclusion that opioid use disorder is a serious and potentially fatal disease, and that being in medication-assisted treatment markedly reduces the risk of death.

 

Mismanagement of Opioid Use Disorder

aaaaaa

 

 

 

 

I’m going to give an overview of what happened to one patient with opioid use disorder, changing enough details to keep people from recognizing the person. I’ve changed non-essential data, but not the medical facts as I learned them from the patient. The facts were confirmed by medical records that I obtained from two local hospitals, a local cardiologist, and a teaching hospital. I could not get records from the mental health clinic that is mentioned because none were made. All of this happened a few years ago.

This 31 year-old man had years of opioid use disorder which progressed to intravenous use for a little over a year before he started feeling ill. He went to his local hospital and was correctly diagnosed with endocarditis, which is a serious and life-threatening infection of the delicate valves of the heart. He was transferred to a teaching hospital, had a surgical repair of a heart alve, given six weeks of antibiotics, and sent home.

He says no one mentioned any sort of addiction treatment, but he admits he probably would not have agreed to treatment anyway. He also admits it’s possible he just doesn’t remember and treatment was discussed. His records contain no mention of substance use treatment referral upon his discharge from the hospital.

About a year later, he was re-admitted to our local hospital with fever and suspected endocarditis. His attending physician in the hospital started treatment with appropriate antibiotics but correctly identified he needed to be seen by a specialist too. As his medical record reveals, two teaching hospitals refused to accept this patient in transfer because he had no insurance, no money, and because he didn’t quit using drugs after the first illness. The physicians that could have accepted the patient in transfer said they don’t want to waste resources treating him again.

His admitting physician explained all of this to the patient. Since it appeared he would die without surgery, Hospice care was arranged to ease his remaining days. He was sent home to die. Somehow, qualifying for Hospice care also got him approved for Medicaid.

After his Medicaid came through and he’d been on antibiotics waiting to die for some weeks, he started wondering what would happen if he arranged an appointment with a cardiologist on his own. Since he now had Medicaid, he was able to make an appointment with a local cardiologist. Though he hadn’t died yet, he was very sick, with fluid building in his lungs and backing up into his feet and legs.

I got the cardiologists’ records, and between the lines I could sense he had been as puzzled as I was now– why was this man turned down for medical care? The cardiologist correctly suspected the patient didn’t have a severe endocarditis, since he probably wouldn’t still be alive at that point. He arranged a referral to a cardiologist friend of his at the local teaching hospital, and a more sophisticated evaluation was done. It showed a hole in the patient’s heart. Blood was flowing in the wrong direction, causing heart failure and severe shortness of breath.

The patient was admitted to the hospital and had a procedure to patch this hole. As it turned out, this procedure could be done without open-heart surgery.

All is well, right? Nope. The original problem, opioid use disorder, has still not been comprehensively treated, although this teaching hospital did at least give this patient a few days of buprenorphine during his short hospitalization. He was told to follow up with a Suboxone doctor in his area.

He tried. He called several office-based buprenorphine physicians in his area. But he had Medicaid, and couldn’t find a doctor to accept this form of payment, or else the few that did accept Medicaid didn’t have appointments for many weeks.

He relapsed to intravenous opioid use, and became sick with fever, had trouble breathing, and went to his local hospital’s emergency department. He was given some fluids, some antibiotics for “pneumonia,” and told to go home.

Before he left, he asked if he could be referred for treatment of his addiction, and was told he would have to go to the local mental health provider that contracts with Medicaid in his county.

He went in person to that facility the next day, and asked the receptionist if he could be referred to the local methadone clinic. He was told they didn’t make referrals to the methadone clinic, so he left, discouraged. He never imagined it could be so hard to get treatment for his addiction.

He continued to feel very bad, with fevers, cough, and then developed severe back pain. He went to another local hospital’s emergency department, was again told he had pneumonia, and that he needed different antibiotics. He was sent home from the emergency department, but went back a few days later, when his back pain worsened.

He says he got the feeling the hospital personnel felt he was drug seeking for pain medication. He admits he did want pain medication, but mainly because of severe back pain. He was told to be patient, and give the antibiotics time to work.

The day before he came to our opioid treatment center, he went back to the first local hospital with fever, back pain, and trouble breathing. He was told for a fourth time that he had pneumonia, and was sent home with new antibiotics.

He got the address of our opioid treatment program from one of his friends, and came in person to see if we could help him. Since I wasn’t there that day, we set him up with an intake appointment for the next day, and he arrived bright and early to start the intake process.

When I first laid eyes on this patient, my impression was that he was seriously ill and not stable enough to start treatment with us that day. He looked bad. However, I listened with fascination to his entire story, which he told in short bursts of conversation between gasping breaths.

I didn’t want to start treatment. I wanted to get him to a teaching hospital as quickly as possible. He was sweaty, breathless, wincing in pain and clutching his back, and running a low-grade fever. He did have sounds in his lungs consistent with pneumonia, but at this point he’d been on antibiotics for over a week. Clearly something more than pneumonia was going on.

But I knew I could not turn him away without doing something for him. More as a gesture than as a real treatment, I gave him an induction dose of buprenorphine and sent him to the teaching hospital, located about an hour from us.

I got a call back later that day from the resident physician who admitted this patient. The severe back pain that my patient had reported at four hospital emergency department visits turned out to be osteomyelitis, which is a bacterial bone infection needing antibiotic treatment for several months. He also had an abscess on the spine nearby the infected bone. The bacteria they finally cultured was methicillin-resistant Staph aureus, also known as MRSA.

He spent months in several hospitals. He had to undergo a debridement of the bone to get rid of infected and dead material, and had to be on very heavy intravenous antibiotics for a prolonged time.

Because he had been started on buprenorphine at our opioid treatment program, I convince the residents they could continue that medication, and gave some suggestions for increasing it a little bit.

Finally, he was healthy enough to leave the acute care hospital to go to a physical rehabilitation hospital, where he stayed for about six weeks. Thankfully, since he had already been started on buprenorphine, these providers were also willing to continue his medication. He was re-admitted to our opioid treatment program the day after he was discharged from the physical rehab hospital so that we could continue his treatment.

He had to have strong opioids early in his hospitalization but by the time he came back to our OTP, he was only on buprenorphine 8mg sublingually per day. I did have to increase his dose a little for fine-tuning, and he’s been healthy ever since, with no positive UDS, no illicit drug use.

He looks fantastic. He’s healthy, energetic, and works every day. He’s usually smiling, and he makes me smile too. I don’t think he’s using any illicit opioids for many months.

He asked me a difficult question. He wanted to know how his medical treatment could have been better. I told him that I had the luxury of hindsight and the pile of his medical records, but I did see some mismanagement of his care. I told him these were the things that bothered me about his treatment:

  1. He was turned down for medical care when he came to his local hospital for what they thought was endocarditis. It turned out to be something different, but the small hospital didn’t have the technology to diagnose and manage the problem. They did the right thing by attempting to transfer him to another hospital, but were refused. I don’t know what recourse a physician at a small hospital has if teaching hospitals refuse to accept a patient, and I’m sure this patient was refused because he had drug addiction, and judged as a person not worthy of care.
  2. There was an appalling lack of attention to his underlying medical disease that fueled all of his medical problems. He should have been told about buprenorphine and methadone as treatments for his problem, and referrals should have been made. Ideally, he should have been referred after his endocarditis infection, or by any of the half-dozen doctors who saw him after that. Then even when he specifically asked for referral for that sort of treatment, the mental health facility missed an opportunity to help this man, saying they didn’t refer to the methadone clinic.

Believe me, we notified people who supervise this mental health facility about their failure to act, and what we thought of this failure. We have been assured this will never happen again.

3.This patient sensed an attitude of distain in his caregivers, and I also sensed it in the wording of the documents from the hospital. The emergency department records are sketchy, with little documentation of the medical reasoning of the attending physician. I worry that the physician saw the patient as a bad person seeking drugs, rather than a sick person with a treatable illness. I know I’m sensitized to this issue, so it’s possible I’m jumping to the wrong conclusion.

I’ve tried my best to talk to local physicians. In a few enjoyable exceptions, I’ve had great responses and cooperation. In other cases, I’ve had rude responses. Most responses are neutral, neither rude nor friendly, and I sense a disinterest in the topic.

I wish all of the doctors who treated this patient when he was sick with opioid use disorder could see him now. He’s a happy and productive member of society, and yes, he does plan to stay on buprenorphine indefinitely. I support that decision.

This patient, and hundreds like him, are why I love my job.

Karmic Chickens Coming Home to Roost

Rate of Hep C infection among women giving birth in Tennessee per 1,000 live births – 2014

 

 

 

 

 

A recent report in the CDC’s MMWR (Center for Disease Control and Prevention’s Morbidity and Mortality Weekly Report) described the incidence of Hepatitis C virus infection rates among women giving birth in Tennessee, and the U.S., during the time frame 2009-2014.

In essence, the number of pregnant women delivering babies who were infected with Hep C doubled in the U.S. during this time, but in Tennessee, it tripled. The factors that increased the risk of Hep C included having a history of injection drug use, living in a rural county, smoking during pregnancy, and co-occurring Hepatitis B virus infection. The highest incidence was in the Eastern mountainous part of the state.

Obviously, this increase in Hep C incidence coincides with the rise in incidence of opioid use disorders.

Eastern Tennessee has been uniquely vehement in its rejection of evidence-based treatment of opioid use disorders, while maintaining one of the highest opioid prescribing rates of the nation. You do not have to be psychic to foresee the inevitable: increased burden of disease, death, poverty, disability, and crime.

I’ve been blogging about the sorry state of Tennessee’s approach, or lack of approach, to treating opioid use disorder since I started this blog in 2010 – see entries from 11/13/10, 1/26/12, 1/30/12, 11/14/12, 7/7/13, 10/19/13, 10/23/13, 4/12/14, 4/26/14,  8/25/14, and 12/12/14. Since late 2014, I grew tired of blogging about the same issue and moved on to other topics

I started working at opioid treatment programs in 2001. In 2005, I worked for a non-profit opioid treatment program with eight sites scattered across Western North Carolina. Because their OTP in Boone had so many people driving from Tennessee for treatment, this organization tried to open an opioid treatment program in Eastern Tennessee. These patients drove an hour or more, one-way, to get treatment in NC because it wasn’t available in Tennessee.

The state of Tennessee and the officials of Johnson City would not allow an OTP to open there. I’m not sure what reason they gave, but we all know the real reason: stigma against medication-assisted treatment of opioid use disorder.

If we fast forward to 2013, I was working for CRC Health when they attempted to open an opioid treatment program in Johnson City. Despite the open knowledge of a large population of people with untreated opioid use disorder in that area, state officials in Tennessee’s Health and Human Services maintained there was no need for an opioid treatment program, because there was an insignificant number of people who needed treatment. By that time, there were a number of office-based practices prescribing buprenorphine, but those physicians couldn’t legally prescribe methadone. As we know, one drug will never work for all patients.

A few years ago, the Crossroads group, which has opioid treatment programs in North Carolina, sued to get the right to put an OTP in Johnson City. They were also defeated.

People who know these things tell me there have been at least ten attempts to start an opioid treatment program in Tennessee’s Eastern part of the state over the last fifteen years, and all were refused.

The newspaper of that area, the Johnson City Press, reported earlier this year that an opioid treatment program is set to open in Gray, Tennessee, this summer. However, even though it’s going to be operated by the East Tennessee State University and the Mountain States Health Alliance, both reputable health agencies, local citizens are still picketing in an attempt to thwart the opening of this OTP, too.

I really hope science defeats ideology this time.

Also in Tennessee, as I described in several of my blogs, the state legislature passed a law making it illegal for a person with substance use disorder to become pregnant. Once the woman is pregnant, she is breaking their law, and subject to being jailed. Of course, all of the women jailed under this law so far have been poor and/or minorities, unable to afford lawyers to work on their behalf. Some of these jailed women tried to get help, but no treatment facilities would accept them, because they were pregnant.

Knowing this, pregnant women with substance use disorders may avoid pre-natal care.

I suggest this might contribute to this state’s high Hep C rate in women delivering babies, and also to their high rate of neonatal abstinence syndrome.

So…if an OTP finally opens – about seventeen years into our opioid epidemic – it will be built on the backs of scandalous numbers of people who suffered due to this backwoods misanthropy.

Ten or twenty years from now, we may look back at this disgraceful behavior of state and local officials of Eastern Tennessee with mortification, and vow never again to allow such a travesty crush ordinary people with a bad but treatable disease.

I think Tennessee will continue to give us information we can use – about how NOT to approach substance use disorders. It’s just a shame affected people have paid – and will continue to pay – the ultimate price for this information.

 

Naloxone in Action


At the recent American Society of Addiction Medicine (ASAM) conference, I read a poster describing a study entitled “Lives Saved with Take-home Naloxone for Patients in Medication Assisted Treatment.” The article, by Katzman et al., from the University of New Mexico School of Medicine, described the outcomes from providing naloxone overdose reversal kits to patients enrolling in medication-assisted treatment of opioid use disorders

The study subjects were admitted to medication-assisted treatment over three months in 2016. The poster didn’t say whether they started buprenorphine, naltrexone, or methadone, but I’m guessing the patients were admitted to methadone maintenance.

In the end, 244 subjects enrolled and had education about opioid overdose and how to use a naloxone auto injector kit.

Twenty-nine subjects were lost to follow up, leaving 215 subjects available for inclusion in the study. Of these 215 subjects, 184 didn’t witness or experience overdose.

That means 31 subjects either experienced or witnessed at least one opioid overdose episode.

The scientists conducting the study interviewed these 31 subjects, and discovered that 39 opioid overdoses had been reversed and all of those lives were saved. Thirty-eight people were saved with the naloxone kits distributed by the opioid treatment program, and one study subject was revived by EMS personnel.

When study authors looked at who was saved by these study subjects, they discovered 11% of people saved were acquaintances of the study subjects, 16% were family members, 58% were friends, 6% were the significant others of study subjects, and 13% were strangers.

The study authors concluded that “a significant number of lives can be saved by using take-home naloxone for patients treated in MAT [medication assisted treatment] programs.” The authors also felt the study showed that naloxone isn’t usually on the patient who entered treatment, but more frequently on friends, relatives, and acquaintances that the MAT patient encounters.

I was intrigued by this study because it mirrors what I’ve heard in the opioid treatment program where I work. We are fortunate to get naloxone kits from Project Lazarus to give to our patients. It’s rare that one of our patients enrolled in treatment needs naloxone for an overdose, but much more frequently, I hear our patients say they used their kit to save another person’s life.

If anyone doubted the abilities of people with opioid use disorders, and felt they couldn’t learn to give naloxone effectively, this study should put that idea to rest. If anyone mistaken thought people with opioid use disorders wouldn’t care enough about other people to put forth an effort to save another person, this study should put that idea to rest, too.

In fact, I’ve seen a real enthusiasm among our patients to make sure they have a kit, in case they get the opportunity to save a life. They are eager to help other people, and I find that to be an admirable attitude that’s nearly universal among the people we treat.

Sometimes I get into discussions with patients about what they think about the naloxone kits, and where they think the kits can do the most good. I’ve heard some good ideas. One patient said every fast food restaurant should have a naloxone kit, since she knew many people with opioid use disorder inject in the bathrooms of these facilities. Actually, I just an online article discussing something similar: http://www.wbur.org/commonhealth/2017/04/03/public-bathrooms-opioids  

This article expresses the problems that injection drug use has become for public restrooms, and makes a case for safe injection centers. This is presently illegal in the U.S.

Even Massachusetts General Hospital armed its security guards with naloxone kits, so they could give this life-saving medication to people they found who had overdosed in the hospital’s public bathrooms.

Another patient suggested giving naloxone kits to people living in trailer parks.

I know that feeds into a kind of stereotype of those who live in trailer parks, but apparently there is some basis for saying such residential areas have high density of people with opioid use disorders. It’s worth looking at.

Several patients said that all people receiving opioid prescriptions for chronic pain should also be prescribed naloxone kits, and I think that’s been recommended by many health organizations too.

Most communities have at least talked about arming law enforcement and first responders with naloxone kits, and hopefully that’s a trend that will continue to spread.

Naloxone isn’t a permanent solution for opioid use disorder, but it can keep the people alive until they can enter opioid use disorder treatment. Because dead addicts don’t recover.