Archive for the ‘cultural norms’ Category

You Can Find My Office Next to the Restroom

bathroom break

Warning: this is one of those fluffy entries, not much substances, lots of musings…

A few weeks ago, I ushered a new patient to my office for her initial history and physical. Once in my office, she looked around and said, “Wow, they don’t think much of you, do they?” At first I was puzzled, but then figured out she meant that my office is small and undesirably positioned right next to the patients’ restroom. It’s not furnished lavishly, only with the essentials: desk, exam table, and two chairs. I also have a file cabinet containing some species of records.

Perhaps in the business world, one’s value to a company is reflected in the lavishness of one’s office. It is not like that in the doctor world, or at least not in the doctor world I inhabit. I don’t think about the size of my office, the location, or the furnishings. As long as I have everything I need to do my job, I don’t care or even notice other amenities. But some of the patients notice.

I’ve had some patients ask how I can stand the smell. On intake days, with eight or so new patients in varying stages of opioid withdrawal, my office can sometimes take on a certain redolence from the restroom next door.

It doesn’t bother me. I became immune to bad odors in 1985, roughly when I started my clinical rotations in medical school. By the time I got to my residency program, any sense of smell I still had was burnt out during my two-month rotation through the emergency department. I’ve been exposed to massive burdens of every type of stench emitted from the human body. As a result, I reflexively start mouth-breathing in the presence of unpleasant smells. It’s automatic.

I’ve worked for five opioid treatment program companies, in fifteen separate facilities. In many of them, the doctor’s office was next to the restroom, but I’m sure that’s just coincidence.

The worst was in an old building shaped like a “U”, with the pharmacy in the center. My office was at one end of the “u” and directly across from…you guessed it…the patient bathroom. That wasn’t the worst thing, though. Unfortunately my office had an inch and a half gap between the floor and the wall, and it appeared to be a major thoroughfare for bug travel. It was not uncommon for a roach to emerge from the gap, waving antennae like he was a pageant queen.

I usually had my back to this area, so the patients would be the first to see the invader. Almost without exception, the male patients would jump to their feet and stomp the intruder into bug heaven. I would smile and say, “Thank you, my dragon slayer.” We would share a laugh and get back to business.

Why are the physicians’ offices less luxurious in the opioid treatment programs than the rest of the doctor world? I think for the same reason some OTPs are in run-down buildings in the worst part of town. The stigma against medication-assisted treatment makes it more difficult to get regular medical office space. For all I know, maybe only the buggiest places were rentable. It’s also possible that some opioid treatment programs don’t think it’s worth spending money for a nice facility.

Doctors’ offices at OTPs may tend to be shabby because doctors aren’t in the opioid treatment program every day. Obviously, the counselors who are there every day should get the nicest offices because they will be using them more hours per week. Often when the facilities are cramped for space, the program doctor has to share an office with one or more other people. I know where I work now, two or three other people work in my office when they need space. As a result, a variety of detritus comes and goes.

One day a patient asked, “Are those your shoes under the exam table?” I didn’t have to look up. I knew he meant the pair of espadrilles that appeared one day without any explanation. I said “No, I don’t know whose those are.” He looked at me oddly, as if that were a strange answer, so I told him, “That’s nothing; there are other random things. I just don’t ask anymore.” One day my office was filled with balloons, and on another day, with hot dog buns.

The shoes were gone a month or so later, as quietly as they had appeared.

At my other program, my office is so small that literally we have to ask the patient to leave the room so that we can wheel in the EKG machine, then come back in. It is very cramped, but what I really mind is the heat. This OTP is in the mountains, but as cold as it may be outside, it’s always summer in my office.

This office has no vents and no overhead lights. When I complained about the lack of proper lighting, the program manager brought in floor lamps. One gives a puny little light, and the other throws enough heat to keep French fries warm. I have to remember to dress for summer even in the middle of winter.

It would be easy to take shabby offices personally, but I don’t think that’s generally what is behind it. OTPs take a more utilitarian approach towards facilities than other branches of medicine. I think OTPs get so used to being the red-headed stepchild that they forget to take pride in their surroundings.

Having nice facilities may not feel like a high priority, but it should be. We need to provide space as nice as other medical offices. We provide an intensely important service, with literally decades of data to support what we do for patients. Maybe our surroundings should reflect the importance of what we do, and the significance of what we do.

Thank you Nurses!

aaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaanurso

 

This will be the first blog entry about how much I appreciate nurses at the opioid treatment programs I work with.

I’ve been remiss. Some of the best people I’ve ever met have been nurses at opioid treatment programs. Nearly without exception, they have been bright, caring, and compassionate.

At my OTP, we are temporarily short-staffed with nurses, so the stress they deal with is even more evident than usual. New nurses are being hired, so help is on the horizon, but right now, things are tense. Our nurses try to dose patients as quickly as possible without making any dosing errors.

Being a nurse at an opioid treatment program isn’t an easy job. I’ve overheard one imprudent program manager, several years ago, make an unfortunate comment that being a nurse at an OTP was easy, and that “anyone” could do it. He had no medical background, so he can be forgiven for his lack of knowledge.

Not every RN or LPN can manage to do this job well; it takes a special heart.

First of all, the state of North Carolina disagrees that “anyone” can do the job of a nurse at an OTP. They insist you have a nursing degree, so there’s that.

Secondly, medical professionals of all types have jobs where mistakes can be deadly. The ordinary human errors that cause problems in other work environments can kill in our line of work. That’s a special kind of stress. We accept that stress as part of the price of working as a medical professional, and we also accept that other people can never understand what that feels like.

Over a decade ago, I knew a nurse who made a dosing error by mis-reading the physician’s induction order for a patient on methadone. She gave a somewhat higher dose than was ordered by the physician on day two and day three. The patient died on day three. Of course the family was devastated, and a lawsuit ensued, settling for an undisclosed amount. But that nurse will never be the same. She left the OTP and I don’t know if she’s still working as a nurse or not. But that illustrates what a nursing error at an opioid treatment program can mean.

Out of all we do at OTPs, the most critical moment of care happens when the nurse hands over the patient’s daily dose of medication. The patient must be quickly assessed for impairment by the nurse, and the correct dose of medication given. This must be done perfectly, day after day, patient after patient. Any mistakes made at this point can undo the rest of treatment.

Any time perfection is expected of you at your job…that’s stress. And just like nurses in all medical settings, they are also being asked to work faster and faster, to be ever more efficient.

I’m not saying the counselors don’t also have high-stress jobs. Lord knows they do. But their errors don’t have the same ability to kill someone.

Thirdly, the amount of documentation and record-keeping demanded from nurses at the opioid treatment program is mind-blowing. These documents are intermittently inspected by the state’s department of health and human services, by the DEA, by the state opioid treatment authority, by CARF, etc. Someone is always looking over their shoulder, because they are working with strong opioid medications.

I’ve seen many nurses who couldn’t cut it in the OTP. It’s fast-paced and exacting, and often they deal with difficult people. Sometimes patients get angry at the restrictions of the opioid treatment program, many of which are mandated by state and federal organizations. Patients often direct their anger at the nurses. I’m often amazed at their ability not to take these outbursts personally. I’m afraid I might harbor resentment, but they seem to start over every day.

This is not a glamorous field of nursing. On the totem pole of medical specialties, addiction medicine and especially opioid treatment programs are the part of the pole that’s underground. When these dedicated professionals tell their friends and families about the work they are doing, they are sometimes chided for not doing something more mainstream. Or their family thinks their job consists of “shooting up them addicts with methamphetamine,” as one nurse told me.

Of course, we in the addiction treatment field know these nursing professionals are likely helping more people at the opioid treatment program than they would at any office or hospital setting.

It takes strong character to do a difficult job well, especially when you don’t get a lot of praise from nurse peers who know little about this niche area of medicine

So today I am honoring the nurses who work at opioid treatment programs. Thank you for the work you do. You are appreciated.

 

 

Non-drug Ways to Help Insomnia

aaaaaaaaaa

Insomnia is defined as a sleep disorder which makes it difficult to get to sleep or stay asleep. Insomnia can come & go for periods of time, or can be a chronic problem. Not sleeping well can make us less able to handle the stresses of the next day, and can severely affect the quality of our lives.

Insomnia afflicts many patients in recovery, including those on medication assisted treatment with buprenorphine and methadone. Insomnia can occur for many reasons: the brain may be adjusting to life without the chemical ups & downs of addicted life, or because the patient had insomnia even before the addiction started. Physical health problems (chronic pain, thyroid disease, and menopause to name but a few) can cause insomnia or make it worse, as can mental illnesses like anxiety and mood disorders.

Active addiction can destroy normal sleep-wake cycles. Addictive chemicals disrupt the structure and function of the brain, and often people in active addiction become accustomed to passing out rather than falling asleep. It can be difficult to re-learn how to get to sleep naturally.

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

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

1. Go to bed at the same time and wake at the same time every day, even on weekends.
If it’s at all possible, don’t go to bed later or sleep later on weekend days. Get your body into the habit of keeping a regular sleep/wake cycle. You will fall asleep more easily with a fixed bed time.
Besides making your feel better because you’ll get more regular sleep, this practice has other benefits. For example, people with migraine and tension headaches have fewer pain episodes with regular sleep/wake times. Keeping regular sleeping hours is also highly recommended for patients with bipolar disorder, as it can help with mood swings.

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

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

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

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

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

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

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

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

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

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

The State of Denial (Tennessee) gets Another Chance

aaaprejudice and ignorance

If you read my blog, you know Tennessee is a frequent target of my ire. I’ve been aghast and distressed at Tennessee’s refusal to allow an opioid treatment program to open in the Eastern part of that state. Hopefully, that’s about to change.

Now a new opioid treatment program has applied for a certificate of need with Tennessee’s Department of Mental Health and Substance Abuse Services, asking for permission to locate a methadone clinic in Eastern Tennessee. Sources say this is the eleventh attempt to locate an opioid treatment program that prescribes methadone in that part of Tennessee. In 2002, approval was given but then withdrawn due to a technicality.

Even if the certificate of need is approved, this company faces stiff opposition from the modern-day equivalent of villagers with pitchforks, demanding that no treatment center be located near them. This is the ugly face of modern day NIMBYism, and it violates the American with Disabilities Act, a topic of a past blog. (See November 14, 2012) It’s illegal, and past federal court rulings have sent a clear message to towns that violated the ADA in this way, with high six-figure fines.

I’m surprised anyone wants to put a new clinic in Tennessee, given its recently passed anti-evidence-based regulations on methadone clinics, but I’m pleased. Eastern Tennessee probably has more untreated opioids addicts per acre than anywhere else in the nation. Tennessee has the 13th highest opioid overdose deaths per capita, compared to all other states, and is ranked number two in the kilogram of opioids prescribed per capita. [1]

Yet it has only a small number of opioid treatment programs. The nearest methadone clinic to Eastern Tennessee is located in Knoxville, and in bordering states. These states treat the opioid addicts Tennessee is neglecting. The certificate of need submitted by the petitioning opioid treatment program says that around one thousand opioid addicts are now traveling one or two hundred miles round trip each day for treatment. You know there are thousands more getting no treatment at all.

The state will make a decision about the certificate of need request this summer. Of course, any educated interpretation of data would conclude that the certificate of need should be approved forthwith. As I said, you can’t throw a rock in Eastern Tennessee without hitting an opioid addict. But so many people don’t know anything about the benefits of methadone.

Lack of knowledge about methadone does not prevent people in positions of authority from taking a strong stance against it. For example, this is a quote in the Johnson City Press from Roger Nave, committee chairman of the public safety committee of the county where Johnson City is located: “We have top-class medical facilities in this area to deal with any problem that our citizens have. The addicts do need help and support, but methadone is not the answer to their problems.”

Does Mr. Nave actually know any facts about methadone?? Does Mr. Nave know that the treatment of opioid addiction with methadone is one of the most strongly evidence-based medical treatments in all of medicine? Does he know that we have over forty years’ of studies that show the treatment of opioid addiction with methadone reduces overdose death rates and suicide rates? Does he know it improves employment rates and dramatically reduces crime rates? Does he know addicts treated with methadone have better physical and mental health? Does he know that for each dollar spent on methadone treatment, taxpayers save four dollars, mostly in reduced incarceration costs? Does he know that methadone treatment of opioid addiction significantly reduces the incidence of HIV in intravenous opioid addicts? [2,3,4]

Eastern Tennessee now has Suboxone providers, and these doctors have likely saved hundreds of lives. Buprenorphine is a great medication, and I prefer prescribing it rather than methadone because of its better safety record. It works on the same principle as methadone: both are long-acting opioids that can be dosed once daily to keep opioid addicts from having withdrawal or craving, thus freeing them to focus on changing their lives.

But buprenorphine is not strong enough for all opioid addicts. It doesn’t work for all opioid addicts. In fact, no treatment works for all opioid addicts, even medication-assisted treatment with buprenorphine and methadone. Some are too sick for these medications, and some aren’t sick enough.

Suboxone programs are too expensive for many addicts. Yesterday I called three programs in Tennessee to get an idea of their prices. A month’s worth of treatment is around $400, including doctors’ visits, group and individual counseling, and drug tests. The medication is not included in this cost, and can cost an additional $240 to $900 per month, depending on the dose of medication. Opioid addicts without health insurance can’t afford that kind of treatment. Methadone programs usually cost $9-$11 per day, and addicts can pay as they go.

At least one big Suboxone program in Johnson City doesn’t do maintenance treatment, but only a few months of detox, despite more studies showing greater benefit with longer treatment. Some addicts are forced to come off Suboxone before they are ready, a recipe for relapse.

Suboxone is a valuable option for opioid addicts, but let’s make all forms of evidence-based treatment available for opioid addicts. Why not let addiction specialist doctors decide which treatment is appropriate, rather than government officials without any medical training?

With so many untreated opioid addicts in Eastern Tennessee, all forms of evidence-based treatments need to be available. At present, health officials in Tennessee push patients into medication –free treatments. These can work, if patients are given long enough treatment and if they can afford it. In my experience, inpatient programs in Eastern Tennessee seem to keep patients for two or three weeks, instead of two or three months. This is understandable, since Medicaid isn’t known for generous reimbursement, and private insurance rarely pays for longer treatments. Patients with no insurance at all are often asked to bring money up front to pay for treatment. Asking an addict to bring a few thousand dollars with them to start inpatient treatment doesn’t work, for obvious reasons. Even treated patients are sent back home to the same living situation, and relapse quickly. Using inpatient detox alone for five to seven days has always given relapse rates of 92%, with most relapsing within the first week.

Tennessee state officials have a chance to save lives, if only they can put aside their personal biases and look at the science supporting medication-assisted treatments. It’s the right thing to do. It’s a bargain, too. Patients are mostly self-pay, so it doesn’t cost taxpayers anything. Even from a purely economic view, methadone treatment would save taxpayers money.

If you support medical treatment of opioid addiction with evidence-based therapies, please write to the state and let them know. If you are an addict who has been helped by methadone, send a letter to the below address. If you are a family member who has seen the benefits of methadone treatment in your loved one, tell the people in government. This is the time to act. Don’t let this opportunity to slip by. Send your letter to:

Tennessee Health Services and Development Agency
Melanie M. Hill, Executive Director
Frost Building, 3rd Floor
161 Rosa L. Parks Boulevard
Nashville, TN 37243

1.http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6043a4.htm?s_cid=mm6043a4_w
2.http://international.drugabuse.gov/sites/default/files/pdf/methadoneresearchwebguide.pdf
3.California Department of Drug and Alcohol Programs, 2004, California drug and alcohol treatment assessment (CALDATA) California Department of Alcohol and Drug Programs. California Drug and Alcohol Treatment Assessment (CALDATA), 1991-1993 [Computer File]. ICPSR02295-v2. Ann Arbor, MI: Inter-university Consortium for Political and Social Research [distributor], 2008-10-07. doi:10.3886/ICPSR02295
4.http://www.asam.org/docs/publicy-policy-statements/1methadone-rev-10-061.pdf?sfvrsn=0#search=”methadone

Officially an Epidemic

 

It’s official. Prescription drug abuse in the U.S. is now called an epidemic by the Centers for Disease Control and Prevention. In November, CDC officials released a new report of prescription drug addiction. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6043a4.htm?s_cid=mm6043a4_w

It’s really interesting reading.

The CDC points out that prescription opioid overdose deaths now outnumber heroin and cocaine overdose deaths combined and prescription opioids were involved in 74% of all prescription drug overdose deaths.

The breakdown of their data by state is particularly interesting. The states with the highest rates of opioid overdose deaths are, in descending order: New Mexico, with a rate of 27 deaths per 100,000 people, then West Virginia, Nevada, Utah, Alaska, Kentucky, Rhode Island, Florida, Oklahoma, and Ohio. Tennessee missed the top ten, but was still 13th highest in overdose deaths, with a rate of 14.8. North Carolina’s rate was 12.9 per 100,000 people, which put North Carolina 24th out of 50 for prescription overdose deaths. That’s too high, but much improved since 2005, when North Carolina was in the top five states for prescription opioid overdose deaths. The lowest opioid overdose death rate was seen in Nebraska, with 5.5 deaths per 100,000 people.

The CDC also analyzed information about the amount of opioids prescribed in each state. They measured kilograms of opioid pain relievers prescribed per 10,000 people in each state. The state with the highest rate had over three times the rate of the state with the lowest rate. It’s no surprise that Florida had the highest amount, at 12.6 kilograms per every 10,000. Illinois had the lowest amount, at 3.7 kilograms per 10,000 people.

The big surprise: Tennessee has the second highest amount of opioids prescribed, adjusted by population. (OK, they tied for second place with Oregon). Yep. Tennessee, the state that refuses to allow more opioid treatment centers to be built within its borders, has 11.8 kilograms of opioids prescribed per every 10,000 people.  But since I want to devote an entire blog entry to Tennessee’s backward outlook on addiction and its treatment, I’ll defer further comments about that state.

Sales of prescription opioid quadrupled from 1999 to 2010. According to the CDC, enough opioids were sold last year to provide a month of hydrocodone, dosed 5mg every four hours, for each adult in the U.S.

The CDC estimates that for every prescription overdose death, there are at least 130 more people who are addicted or abuse these medications, and 825 who are “nonmedical users” of opioids. (I’m still not sure how nonmedical users differ from abusers. To me, if it’s nonmedical, that’s abuse.) Not all of the 825 are addicted or will become addicted – but they are certainly at risk.

Just like what was found in other studies, people who abuse opioids are most likely to get them for free from a friend or relative. So if you are giving pain pills to your friends or family members, you are part of this large problem.

In 2008, 36,450 people died from prescription overdose deaths. That was nearly equal to the number of people who died in auto accidents, at 39,973. In fact, in seventeen states, the number of overdose deaths did exceed auto accident deaths.

The CDC authors conclude that the prescription opioid addiction isn’t getting any better, and in measurable ways, it’s worsened, with some states worse than others. The worst areas, not surprisingly, have higher rates of opioid prescribing that can’t be explained by differences in the population. To me, this means doctors in some states are overprescribing, or at least aren’t taking proper precautions when they do prescribe opioids.

In my next blog entry, I’ll explain how people and organizations in North Carolina have been working hard to deal with the prescription pain pill addiction problem. Based on information from the CDC, it appears my state has made some major progress, at least compared to one of our neighboring states.

Cotton Fever

An addict still using heroin recently asked me what “cotton fever” was, and how he could tell if he was sick with it.

 Cotton fever is caused by bacteria commonly found on cotton plants, initially named Enterobacter agglomerans, later changed to Pantoea agglomerans. Most intravenous drug addicts filter heroin through cotton filters, to remove particles that could clog both their injection needle and their veins. Sometimes fibers of cotton break off from the filter, carrying the bacteria with it. These bacteria in the bloodstream cause fever and chills, but in a healthy person, this usually resolves on its own. It’s rare to see it cause serious infection. However, doctors still recommend addicts with cotton fever seek medical care and receive appropriate antibiotics. (1)

At least one study isolated an endotoxin produced by this bacteria, so it’s possible that the fever is actually caused by this toxin, released from the bacteria, and not from an actual infection.

 Enterobacter species, while found in feces of both animals and humans, are also found in the plant world. Usually, these bacteria aren’t a particularly vicious, which is why they rarely cause sepsis (overwhelming infection) unless the individual has an impaired ability to fight infection. In the 1970’s, some medical products (blood, IV fluids) were found to be infected with this species, and caused significant infections, but this was probably due to a large amount of the bacteria infused into patients.

 Cotton filters become more fragile with use, so addicts using new filters probably have a lower risk of cotton fever. After cotton filters are used, they remain moist and can become colonized with all sorts of bacteria, especially if they are kept warm, as happens when they are stored in a pocket, close to the body. This bacteria can cause infection when injected. Cotton filters can transmit hepatitis C and possibly other infections, if they are shared with other drug users. (2)

 Filters also retain some of the injected drug, making them of some value in the world of intravenous addicts. It’s considered a gesture of generosity to offer another addict your “cottons” because the addict will get some small amount of the drug. (3)

 Even in view of all of the above, it’s still better to use a filter than to use unfiltered heroin. A new cotton cigarette filter has been shown to remove up to 80% of particulates in heroin, and reduces the risk of thrombosis of the vein from particles. Other makeshift filters are made from clothing, cotton balls, and even tissue paper.

 Syringe filters are manufactured for medical and laboratory use. They can be designed to filter particles down to 5 micrometers. Besides being more expensive and difficult to obtain, studies show these filters retain more of the drug than other makeshift filters, making them less desirable to some addicts. (2)

 Cotton fever itself usually isn’t fatal. The biggest challenge is knowing if the addict has cotton fever or something worse, like sepsis. Sepsis is an infection of the blood stream, and even heart valves can become infected, causing serious and life-threatening problems. 

I asked a former IV drug addict about his experience with cotton fever.

 Me: What does cotton fever feel like?

 Former Addict: You get a fever that kind of feels like withdrawal. You know there’s something bad wrong, and you don’t know what to do about it. I’ve laid on the floor and thought I was going to die. A lot of times people get it when they’re rinsing, and that means they’re coming down anyway. When the dope got short and I was rinsing cottons, that’s when I got it.

 Me: How long does it last?

 FA: It seems like it lasts a long time, but the intensity is bad maybe an hour or two. You shake, you sweat; it feels just like the flu.

 Me: Ever go to the hospital with cotton fever?

 FA: No, no! (said emphatically) I was usually wanted by the police. Only time I went to the hospital is with severe trauma.

Me: I don’t understand what you mean by rinsing.

 FA: Rinsing’s when you squeeze that last little bit of drug out of the cotton [filter]. You rinse the spoon and cotton with a little water. I would save all my cottons. That was my rathole for when the dope ran out. I would actually load the cottons into the barrel of a syringe then draw water in to the barrel of syringe, then squeeze until they were bone dry. I squirted that on to a spoon, and used a new cotton to draw that into a syringe.

 Me: Why do you use cotton filters? Do you use it with every drug you injected?

 FA: I used cotton to strain any dirt that may be in the product, that might get up in the syringe. I didn’t want no dirt. Didn’t have to be cotton. [If you don’t use a filter, you] shoot a bunch of trash up in yourself, and get trash fever.

 I used an itty bitty cotton. Some people would use a quarter of cigarette butt. That was wasteful to me. It got too saturated, could hold too much residue, or dope.

 I didn’t have to use cotton with quarter gram morphine or Dilaudid. Not enough trash to stop it up. If there’s trash in the syringe, I used a cotton.

 Thankfully, this person has been in recovery from addiction for more than thirteen years. When I asked him how he was able to stop, he said Narcotics Anonymous meetings.

 Recovery is the best way to avoid cotton fever. You never have to go through that again.

  1. Rollinton, F; Feeney, C; Chirurgi, V; Enterobacter agglomerans-Associated Cotton Fever,  Annals of Internal Medicine 1993; 153(20): 2381-2382.
  2. Pates, R; McBride, A; Arnold, K; Injecting Illicit Drugs, (Oxford, UK, Blackwell Publishing, 2005) pp. 41-43.
  3. 3.       Bourgois, Phillippe; Schonberg, Jeff; Righteous Dopefiend,(Berkeley, California, University of California Press, 2009) pp8-9, 83-84.

The Story of a Recovering Addict

Following is an interview with a successfully recovering opioid addict. He received treatment at methadone clinics off and on for years, and finally achieved medication-free recovery after going to an inpatient treatment program for 42 days. Later, he began to work in the field of addiction treatment as a methadone counselor. He was promoted multiple times over the years to his present position as director of the narcotic treatment program at his clinic. This is his perspective about his own experience and what he’s seen with methadone treatment.

JB: Can you tell me your title at the opioid treatment clinic where you work?

KS: Director of Narcotic Treatment, which is our opioid treatment program. [He supervises counselors working at multiple clinic sites, with a total census of around thirty-four hundred methadone patients]

JB: Can you please tell me about your own opioid addiction, and how you got into recovery, including what kind of substances you may have used, what kind of treatments, and your experiences with them?

KS: I started out using pain killers, mostly Percodan tablets, back in the late 70’s, which lead me to using heroin. Heroin wasn’t easy to get [where I lived], so I started using Dilaudids [a name brand of the drug oxymorphone]. I started using Dilaudid on a regular basis in the county I lived in. That was the primary drug I used for quite a few years.

[My] first experience with methadone treatment started in 1978, with a brief episode of treatment, a matter of a month or so, with no success. Pretty much during the 1980’s, I was on and off methadone programs with little or no success, because I refused to participate in group or individual sessions. At the time, there was very limited counseling going on [at methadone clinics]. If there was a problem, you saw your counselor, and that didn’t happen a whole lot. Patients were simply trying to get more methadone. At that point, the methadone dosages were very low. I think the average dose back then was somewhere between forty and fifty milligrams. And we [patients on methadone] didn’t know that. We didn’t know that. We just found out through….

JB: You didn’t know what dose you were taking?

KS: Oh, no. We didn’t know what dose we were taking, for a number of years. As a matter of fact, that didn’t change until right before 2001.

JB: Wow

KS: Yeah.

JB: Could the patient find out if they wanted to? [the dose they were taking]

KS: We were blind dosed then. That didn’t change until just before 2001.

JB: Was that unusual for methadone clinics to do?

KS: To my knowledge, I think we [the clinic where he now works, and previously was a patient] were one of the last ones to keep doing that. It was just something we had done over the years and never changed it. [The patients] didn’t know what their dose was.

Through the 1980’s, I was on and off methadone programs, sometimes for a few years at a time, and sometimes had some success. The biggest benefit I had from taking methadone and being on the program was that I was able to work. I held a job the entire time, and I wasn’t doing anything criminal.  It served the purpose it was supposed to serve there, because I had to work, and I was able to function fairly normally. But I never moved into actual recovery, and still used some opiates from time to time. So that was pretty much the 80’s. Two good things happened in the 80’s. In 1981 my son was born, and in 1989, I got clean.

JB: Big things.

KS: Two monumental things in my life. So, I went through that period of time I had talked about, when I started using opiates, in about 1974. Then I started getting on the methadone programs, on and off, [starting] from ’78, but I continued to use. I was using Dilaudids on a daily basis for a number of years. When I got on the methadone program, I would curtail that, but always wanted to go back to Dilaudid. That [Dilaudid] became my drug of choice.

I was on the methadone program in 1989, and having some problems with alcohol. Prior to getting on the program, I was told, “We’re not going to allow you on the program, unless you go on Antabuse.” So I did that and I was successful at stopping drinking, and had some success with methadone. I decided I wanted off the methadone, started detoxing off, and had a series of positive drug screens for a variety of opiates: morphine, Dilaudid, and several different things I had access to. The methadone center said, “We’re going to make a recommendation that you enter residential treatment.” And I said, “Sounds great to me, I’ll do that in a couple months.” And they said, “No. We’re going to make a recommendation you do that… pretty quickly.”

And that’s what happened. I said, “I don’t think I can do this. I’ve got some things to do.” And I remember it like it was yesterday. The counselor got up and walked out of the room and he left me sitting there by myself. Then he walked back in, said, “We’ve got you a bed.” And that’s what lead me to [inpatient treatment].

So I went to forty-two days of residential treatment, and actually entered that program ready to quit using and get into recovery. And from that point on, recovery has been the most important thing in my life….family, of course…but I’ve pursued recovery since May 3, 1989. I followed all the suggestions. [I’m] still really involved with 12- step meetings, and still really involved with some of the same things I did when I first came in [to recovery]. Obviously, I don’t go to as many meetings, but still go to meetings on a regular basis

JB: Do you have any regrets about either type of treatment? The forty-two day inpatient or the methadone?

KS: I do believe that in my case, I needed to be taken away from my environment, simply because of the people I was associated with. That’s not the case for everyone. In my case, I needed to be away from my environment. So the detoxing from the methadone and going into a residential program, that’s what worked for me. Obviously, people can do that other ways. But I still had people in my life that were negative influences.

JB: If you had an opioid addict who presented for treatment for the first time, what would you recommend? If money were no object?

KS: I’d recommend that individual seek inpatient treatment. Now, if they had an extended history of opiate dependency, then that person’s success rate in residential treatment is obviously going to be limited….and…it would just depend on the individual. Methadone treatment might be the way for them to go. I know that’s kind of teetering on the fence. I’m going to be somewhat….I’m going to hold on to how powerful residential treatment was for me. But I had failed at methadone treatment. And, there again, it was a different time, the methadone doses weren’t enough at the time.

JB: Did you feel normal on your dose of methadone or did you [still] feel withdrawal?

KS: I was feeling normal, however, I could still feel drug use [other opioids].

JB: So it wasn’t a blocking dose?

It was not a blocking dose. You knew if you got medicated at 7:00 am, at 5:00 pm you could fairly well feel somewhat of a rush and feel the effects of [other opioids].

JB: How did you get started working in the field of addiction treatment?

KS: I came out of treatment, worked for a family business for a couple of years, and always, from day one, I thought, “What a fascinating thing….if I could somehow do this…to get into that line of work [meaning addiction counseling].

 I started, after two years, as an evening counselor at a residential treatment program, and saw that I really wanted to do that. There was an avenue for non-degreed people to come in to a counselor position. You didn’t have to have a degree in substance abuse or anything like that, so I pursued that, and followed the certification process. I didn’t work in residential treatment but nine months, and then moved to methadone counseling. From that point on, I had found what I wanted to do. And I’ve been offered a promotion at the treatment center to another department when I was over the methadone program, and turned it down to stay with that population [meaning opioid addicts in treatment on methadone].

JB: So you obviously enjoy it.

KS: Oh yeah.

JB: What did you like about it?

KS: I think my ability to relate to that population, without having any thought or putting any real effort…I don’t have to think about it. I know I can talk to that population, and I know I can make them feel normal, by just holding a conversation with them….it might not be about drug use. It might not be about anything pertaining to the treatment episode, but I feel like…that I know exactly where they’re coming from, and I can give them some hope that they don’t have to keep living that way. Just an identification with that population.

JB: That’s a precious gift.

KS: I agree.

JB: Do you believe that your background in addiction helps you when you talk to patients?

KS: I do. I believe wholeheartedly that you can’t teach that. I’ve had some people work for me who had a graduate degree, have never personally had an incidence of opioid addiction or any addiction in their family, and they’re absolutely fantastic clinicians. And you know they’re in that line of work for a reason. So [personal experience with addiction] does not need to be a criterion; in my case, it helps. I find it fascinating to watch someone work who has no self-history of addiction. They can be very effective.

JB: What are the biggest challenges you face now at your work?

KS: That would be…documentation. [The demand for] documentation in this field has really overcome the interpersonal relationship. I can’t help but think as time goes on, that’s going to continue. We don’t have twenty or thirty minutes to sit down with a client, and get into one issue after another, or whatever [the client] may have on their plate. And in opioid treatment, a lot of times it’s brief therapy. They [patients] don’t want to talk to you for twenty or thirty minutes. But you don’t have time to do that, because of the documentation. [The counselor has] three people waiting in the lobby, and you’re kind of selling that person short.

The documentation standards continue to rise, and in methadone treatment, I don’t know how that can go hand in hand with a fifty to one case load. Whereas, someone else might have the same documentation required in the mental health field, but they might have sixteen people they’re seeing.

JB: So you’re saying that the state and federal regulations about documentation actually interfere with the amount of counseling the patients get?

KS: Right. Right.

JB: That’s sad.

The clinic where you work has eight different sites. Can you tell me about what sort of interactions you’ve had with the community leaders, local police, and medical community?

KS: Overall, with any opioid treatment program [methadone clinic], there’s going to be a negative stereotype associated with it in the community, as you well know. Local law enforcement has a bias [against] the [methadone] program. What we’ve found is, any interaction we have with them, and the better understanding that they have [of what we do], the better. And I believe we can make a difference in what law enforcement, and other areas of the community [think about methadone programs].  It’s going to have to happen one person at a time.

An example of that would be when I got a call, a couple of weeks ago, to one of the clinics at ten o’clock at night. An alarm is going off. So I meet the police out there, and we go in, make sure nobody’s in the building. I’m trying to give him some information about it [the methadone program].

He says, “Is it true they come in every day and ya’ll shoot ‘em up?” (laughter) So he thinks that’s what happens.

            So, I educated him on what we do and followed that up with, “Why don’t you stop by and get coffee any time you want to and we’ll give you information.” They were very receptive to that. That’s how you’ve got to approach it. Be willing to talk to people and give them information. [Do the] same thing with community leaders. They’re just not educated in outpatient opioid treatment. Once they get some information, they seem to have a different take on it.

JB: Can you tell me what you’ve seen, particularly over the last seven years, about the types of populations that are coming to the clinics, and if that’s changed any?

KS: I started working in methadone treatment seventeen years ago. We used to have statistics on the methadone program. The average age of a person coming on the program was thirty-four years old, at that time. We had eighty or ninety people on the program and that was it. And they were long term users, primarily heroin as drug of choice. We’ve seen what’s happening over the years.

Heroin has decreased somewhat. Prescription medications went wild. I just read information that forty-four percent of patients entering methadone programs in the nation were on prescription opioids. The age of the person coming on the program has dropped from thirty-four into their late twenties. I don’t have that exact number. But we’ve seen them get younger, and we’ve seen prescription drugs take the place of heroin, in driving people into treatment.

JB: What seems to be the main type of prescription drug, or is there one?

KS: OxyContin changed the landscape in our setting. It’s still a driving force, as far as putting people into treatment. We have an increase in heroin here, but the western part of the state…OxyContin and morphine are on the scene….and any painkiller.

JB: Do you have any opinion about why that happened? Why the incidence of pain pill addiction seemed to rise over the last seven to ten years?

KS: If there’s a reason for it….I think it’s generational. It’s passed down. It’s easy. You’ve got doctors giving the mother and the father painkillers for whatever reason, legitimate or not. It gets passed on…obviously there’s a genetic link for some kinds of addiction or alcoholism. I think you know what you’re getting there [meaning a prescription pill]. People addicted to opioid drugs have very few avenues to get quality heroin in those regions of the country. [Pain pills] are a sure bet. Patients say, “I know what I’m getting when I get that pill.”

JB: If you had the ear of policy makers in Washington D.C., what would you tell them? What would you like to see happen in the treatment field for opioid addiction?

KS: I’m going to refer back to what I said earlier. In methadone treatment, there should be some kind of review, as far as what needs to be documented. Obviously, there needs to be accurate documentation, but not to put methadone or opioid treatment into the same mental health arena for documentation requirements. Because you’re dealing with a different environment, a different population, and a different caseload.

JB: Would you like to see buprenorphine play a role [at the methadone clinic]?

KS: Yes, there’s a need for it. You’ve got such a stereotype against methadone facilities, that’s another avenue for people to be in treatment [meaning buprenorphine]….whether it’s administered in the methadone facility or [community] doctor-based, there’s a need for that.

This interview was with one of the many wonderful people I’ve had the honor of working with at methadone clinics. In my years of work in the medical field, I’ve never been surrounded by as many quality people, who had passion for their work, as I have in addiction medicine. I don’t know if I’ve been extremely lucky, or if all addiction treatment centers draw dedicated individuals to work within their systems. Many of these workers try hard to dispel the stigma and social isolation that addicts feel.

Follow

Get every new post delivered to your Inbox.

Join 757 other followers