Archive for the ‘Complications from IV drug use’ Category

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

aaaaaaaaaaaaaathegoodbadugly

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.

People with Addiction Need Support, Not Judgement

aaaaaaaaaaaaletter

So I was reading my local newspaper this morning, and was dismayed to read a letter to the editor that criticized our county for paying for transportation for Medicaid patients to get to and from methadone clinics. The author of the letter said, and I am paraphrasing, that we should stop spending money on drug addicts.

I probably started growling without realizing it, because my fiancé asked me, “What?” I told him that I was feeling a desire to write a letter to the editor coming over me.

So I did. I wrote a letter, brief as I could make it while still containing all the facts, outlining my view of the importance of providing addiction treatment. I will send it to the newspaper, but here it is in a slightly edited version for my blog:

“I’m writing in response to an angry letter to the editor in the September 11, 2015 issue of the paper. The author expressed shock and anger that her tax dollars were going to support “drug addicts.”

First of all, who does this person think these “drug addicts” are? I can tell you – They are our friends and neighbors and fellow residents of our county. For some people, the phrase “drug addicts” may still conjure images of depraved street bums, but that’s not accurate. As the medical director of an opioid addiction treatment center, I can tell you that my patients are good people. They didn’t plan to become addicted, and they certainly don’t want the addiction to continue. Anyone can develop addiction, and that’s particularly true with opioids. If the author of that letter to the editor isn’t afflicted by addiction, she should be grateful, and feel compassion towards her neighbors who do have this potentially fatal disease.

Second, all sorts of media outlets tell us repeatedly that this country is in the middle of an opioid addiction epidemic. In the past, our area has been identified as having one of the highest rates of opioid overdose deaths in the country. Due to hard work by many key people, the opioid overdose death rate has fallen. Programs like Project Lazarus in North Carolina have played key roles. Organizations like this realized opioid addiction must be tackled on many fronts: prevention, education, better prescribing, overdose prevention kits, drug take-back days…and treatment. Is the author of the letter suggesting we should ignore patients with this disease, and not use taxpayers’ money to pay for treatment?

My third point is that treatment is essential. Once an addiction has developed, the person has lost control over drug use. Telling the person “just stop,” won’t work. It didn’t work in the 1980’s and it doesn’t work now.

Medication-assisted treatment with methadone or buprenorphine (better known under the brand name Suboxone or Subutex) has the most evidence for success. In fact, this form of treatment has more evidence to support its use than most anything else in medical practice. We now have fifty years of studies that show a patient on medication-assisted treatment is more likely to stop using opioids, have better physical health, better mental health, more likely to become employed, less likely to commit crimes to support drug use, and less likely to die of a drug overdose.

Is it the right treatment for everyone? No, of course not…there are other means of treatment and no one addiction treatment is right for everyone. But many patients get tremendous benefits from methadone treatment (and buprenorphine).

People never hear about methadone patients who are doing well. They aren’t sedated when on a proper dose, and they look like everyone else. Due to stigma against methadone, these patients quietly go about their business, telling no one about their medication. They go to work and do their jobs, they sit behind you at church, and they shop with you at the grocery store. Many of them pay taxes too. They are nice people and good neighbors.

Should taxpayers’ dollars support addiction treatment? I sure hope so! According to studies, every dollar spent on addiction treatment saves taxpayers anywhere from $4 to $8. That’s for drug addiction treatment in general, and methadone treatment saves even more than that. Most of the savings is due to lower costs for incarceration and lower costs of hospitalization. [1]

Think about it: what if one of these patients being transported for methadone treatment stops going to her treatment program? Relapse rates are very high, so it’s likely she’ll return to active addiction. If she contracts endocarditis (an infection of the heart valve seen in IV drug users), she could be in the hospital for six weeks. What’s Medicaid’s cost then? It’s not unrealistic to say the costs could run into the millions, particularly if she needed heart surgery. True, that money may come out of a different budget, but I say we can’t afford NOT to pay for transportation and treatment.”

1. http://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/frequently-asked-questions/drug-addiction-treatment-worth-its-cost

Increasing Cases of Hepatitis C in Appalachia

aaaaAAAAnic

The Centers for Disease Control and Prevention (CDC) released information last month about the increased incidence of Hepatitis C in four states: Kentucky, Tennessee, West Virginia, and Virginia. From 2006 until 2013, acute Hep C cases in those states increased by 364%, in people younger than 30 years old. Seventy-three percent of those new cases occurring in people who injected drugs. The incidence in non-urban areas rose more than in urban areas.

Because many new Hep C infections occur in patients who have few symptoms, the incidence reported by the CDC likely underestimated the true number of true cases.

The authors of the study reminded us that HIV is transmitted the same way as Hep C, and increased incidence of HIV could potentially increase as well. The authors emphasized the importance of making effective addiction treatment available for intravenous drug users, as well as preventive efforts to stop the spread of infectious diseases like HIV and Hep C.

These facts are scary. The surge in opioid addiction over the last fifteen years could be followed by a surge in HIV and Hepatitis C infections. In a recent post (May 7, 2015), I described a micro-epidemic of HIV in a small Indiana town, where 140 new HIV cases were diagnosed in a town of only 4200 people. I don’t want to see this happen again and again in small towns in the U.S.

Let’s learn from the 1980’s, when the AIDS epidemic first emerged. The U.S. did not strongly and immediately support measures that could have limited the spread of this disease. Think how many cases could have been prevented with good information, condoms, needle exchange, and addiction treatment.

Let’s not wait until the situation worsens to do something. We must get serious about harm reduction measures and increased access to addiction treatment.

Needle exchange, where intravenous drug users are provided with clean needle in exchange for used needles, reduces the risk of infectious diseases like HIV and Hep C. Naloxone kits can reverse otherwise fatal opioid overdose deaths. Of course, the ultimate harm reduction measure readily available addiction treatment for addicts who want it.

I know many people at federal and state levels are aware of this problem and have been working on it. Let’s help change happen by giving harm reduction measures our support. For more reading on harm reduction, check out this website: http://www.nchrc.org
This is our excellent harm reduction organization here in North Carolina. Click on the “Advocacy” tab to find out what you can do to help.

Even if you don’t care about what happens to drug addicts, it is in your personal best interest to keep other people in our population from contracting infectious diseases that can affect us all.

Opioid Addicts in Indiana Contract HIV

aaaaaaaaaaaaindianaThe New York Times ran an article 5/5/15 about a small town in rural Indiana that is facing a relative epidemic of new cases of HIV.

Austin, Indiana, a town of only 4200, has more than 140 people just diagnosed with HIV. The town is struggling to understand what to do about this epidemic, since the area has had a low HIV rate in the past.

The new cases of HIV were intravenous opioid addicts, and Opana was specifically mentioned by the opioid addicts in the article.

As in many small towns, needle exchange has been met with resistance from citizens who feel giving free needles to addicts only serves to encourage them to use more drugs.

Fortunately, the Indiana governor has authorized a needle exchange program for the area where addicts were sometimes using the same needle as many as three hundred times. Unfortunately, the needle exchange is not being run according to best practices. People must sign up for the service. Obviously, many opioid addicts who could benefit from free new needles are hesitant to register with anyone, due to the shame and stigma associated with addiction in this country.

To add to the difficulty, local police still arrest any addict found with needles, unless they are enrolled with the needle exchange. In other words, if one addict signs up for needle exchange and distributes these new needles to other drug users, those users could still get arrested if the police find their needles. Police say they are doing this to force addicts to register with the needle exchange.

We already know, from decades of studies, that actions like these by the police erode trust in the whole needle exchange program. Studies show needle exchange works best when people aren’t asked to register, and are allowed to procure free needles for other people who won’t come to a needle exchange. These type programs are very effective at halting the spread of HIV

The article only tangentially mentions treatment; it says some intravenous drug users have gone to a residential treatment center about 30 miles away, and others remain on a waiting list.

Sadly, no mention is made of medication-assisted treatment of opioid addiction with buprenorphine and methadone.

I did my own research: residents of Austin can drive to an opioid addiction treatment center less than a half hour away, in Charlestown, Indiana Also, there are at least two OTPs in Louisville,, only a few minutes farther, in Kentucky.

I hope someone is telling all the opioid addicts about this option. We know that after an opioid-addicted person enters medication-assisted treatment, the risk of contracting HIV drops at least three-fold. Thankfully HIV can now be treated, and is more like a chronic disease than the death sentence it was twenty-five years ago, but wouldn’t it be better to prevent HIV in the first place?

I fear Austin, Indiana is a harbinger of things to come in other small towns in our nation. Let’s stop with the politics, and get patients into medication-assisted treatment. Let’s do unrestricted needle exchange, and let’s hand out naloxone kits!

Is Heroin the New Opana?

aaaarateif drygoiusibubgdeaths ukvikvubgheriub

From CDC data released 3/15

From CDC data released 3/15

The Center for Disease Control and Prevention (CDC) released new data last month showing a rapid rise in heroin overdose deaths. While total overdose deaths from opioids remained level for the past few years, deaths involving heroin escalated sharply.

The rate has tripled since 2010, and nearly quadrupled since 2000. Males have a four times higher rate than females with the highest rate seen in white males aged 18 to 44. All areas of the country had increased heroin overdose death rates, but the highest were seen in the Midwest, with the Northeast right behind them. The South, for a change, had the lowest rate of heroin deaths, after the West.

Those of us treating patients at OTPs knew heroin was moving into areas where pain pills once dominated, but I had no idea deaths had tripled in three years. That is appalling even to me, and I see appalling things all of the time. I can’t stress enough how bad this is.

Why is this happening? I’ve read and heard various opinions:

 Some people speculate that since marijuana became legal, that crop is less profitable to Mexican farmers, who switched to growing opium poppies. This is just a theory, though the timing supports the premise. I don’t know how it can be proved, short of taking surveys of Mexican farmers, which seems problematic and unlikely to happen.

 As we implemented measures to reduce the availability of prescription opioids, the price increased. Heroin is now cheaper than pain pills in many areas, and heroin’s purity has increased. Many addicts who can’t afford pain pills switch to heroin to prevent withdrawal. NIDA (National Institute for Drug Addiction) estimates one in fifteen people who use prescription opioids for non-medical reasons will try heroin at some point in their addiction.

Maybe that’s why the South still has the lowest heroin overdose death rates: we still have plenty of prescription opioid pain pills on the black market.

 With the increased purity, heroin can be snorted instead of injected. Many people start using heroin by snorting, feeling that’s safer than injection. It probably is safer, but addiction being what it is, many of these people end up injecting heroin at some point.

 Heroin has become more socially acceptable. In the past, heroin was considered a hard-core drug that was used by inner city minorities. Now that rural and suburban young adults are using heroin, it may have lost some of its reputation as a hazardous drug.

Most experts in the field agree that much of the increase in heroin use is an unintended consequence of decreasing the amount of illicit prescription opioids on the street. But we are doing the right thing by making prescription opioids less available. Physicians are less likely to overprescribe and that’s essential to the health of our nation.

Now it’s critical that we provide all opioid addicts with quick access to effective treatment, no matter where they live.

The face of heroin addiction has changed. It is no longer only inner-city minorities who are using and dying from heroin; now Midwestern young men from the suburbs and rural areas are the most likely to be using and dying from heroin.

In the past, when drug addiction was seen as a problem of the poor and down-trodden (in other words, inner-city minorities), the general public didn’t get too excited. But when addiction affected people in the middle classes, there was a public outcry. The Harrison Act of 1914 was passed due to public demand for stronger drug laws.

I think the same thing will happen now. Suburban parents will organize and demand solutions from elected officials for this wave of heroin addiction. Indeed, I think that’s already started to happen.

Let’s make sure a big part of the solution is effective treatment.

Let’s make treatment as easy to get as heroin.

Case Study of an Opioid-addicted Patient: New England Journal of Medicine

aaaaaaaaaaaacase

A doctor friend of mine sent me an article from the New England Journal of Medicine from November 13. 2014. I subscribe to the NEJM, but somehow overlooked this article, so I’m happy he brought it to my attention. My friend reads my blog and knows I have lamented how I was taught in my Internal Medicine residency to treat endocarditis (potentially life-threatening infection of a heart valve), but not the underlying cause, which was addiction (read in my blog post of December 7, 2014).

The journal article he sent me is a case study of a young woman with endocarditis from intravenous drug use. The case study begins in the usual way, describing her history and physical findings. Nothing was uncommon here: the patient told them she was a drug user, and she had track marks, fever, and a heart murmur. The history and physical findings screamed, “Endocarditis! “ A chest x-ray and then chest CT scan showed multiple septic emboli, commonly seen with endocarditis, sealing the diagnosis.

But this case wasn’t only about the diagnosis and standard treatment with antibiotics. To my delight, the first sentence describing the case management was “Methadone was administered orally.”

Huzzah!

But as it turned out, the patient was only put on a methadone taper while hospitalized. She was started on a protracted course of antibiotics and sent to an extended-care facility, where she quickly relapsed. This relapse illustrated the second point of the article: medication-assisted therapy must be continued to be effective.

As the case discussion points out, “As with other medications for chronic diseases, the benefits, at least in the short term, last only while the patient is taking the medication.” In other words, her relapse was predictable, and not due to failure on the part of the patient. The relapse happened because of failure to continue the medication by the doctor.

A little later in the case study I read these wonderful sentences: “Although making a diagnosis of endocarditis is a crucial first step (emphasis mine), understanding the root cause of the endocarditis is a key feature in the diagnosis and management of this patient’s illness. Endocarditis is only a symptom of her primary illness, which is an opioid-use disorder.”

I loved this case presentation for two reasons: it emphasized treating the entire patient, including the underlying disease of addiction, and it pointed out that short-term medication with methadone or buprenorphine doesn’t work, just like temporary treatments for other chronic diseases don’t cure anything.

This patient developed endocarditis again after her relapse, and needed a second hospitalization. This time, she left the hospital on buprenorphine maintenance. She relapsed again after two months, had a third episode of endocarditis, this time due to a fungus, and required a third hospitalization.

After that treatment was over, she was maintained on buprenorphine. At the end of the article, the authors reported that the patient had over a year of abstinence from drug addiction, was taking buprenorphine, and going to AA and NA regularly.

In the discussion of appropriate treatment of both the endocarditis and the opioid addiction, I read this delightful sentence::The opioid agonists methadone and buprenorphine are among the most effective treatments for opioid-use disorder.”

Can I get an “Amen!”?

The same paragraph goes on to describe the benefits seen with MAT, which include decreased opioid use and drug-related hospitalizations, and improved health, quality of life, and social functioning. This article also clearly states MAT will reduce the risk of opioid overdose and death. Many references are cited at the end of the article for non-believers in MAT.

This article also included recommendations about educating patients about overdose risk, and providing them with naloxone.

At the end of the article, the patient who was the subject of this case study discussed her perspectives regarding her treatment. She related how each time in the past, she was treated for whatever medical problem she had, and then sent on her way, with little effort to treat her addiction. She says she’s grateful for the second episode of endocarditis, because she met the doctor who treated the addiction and gave her hope that she had a treatable disease. Prior to that, she doubted she could stop her active addiction, because she saw herself as a bad person, not as a sick person.

This article ends with this patient’s words: “To be honest, I never thought I would be standing here, clean for over a year. I thought that I was going to die.” That effectually describes the hopelessness of patients in active addiction.

I hope such endorsement of medication-assisted treatment of opioid addiction by the prestigious New England Journal of Medicine will help convince more doctors of the legitimacy of MAT.

During my training in the 1980’s, I didn’t learn how to treat the underlying cause of the endocarditis. I am delighted and encouraged to find the New England Journal of Medicine has published an article that does just that. This article clearly and overtly states the importance of treating the real problem, not just symptoms of the problem. Today’s doctors have a valuable opportunity to change the lives of many of their future patients.