Archive for the ‘drug diversion’ Category

Pain Clinics Behaving Badly

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I worry about pain clinics. More specifically, I worry about what happens to patients enrolled in opioid treatment programs who transfer to pain clinics.

Weirdly, now there are pain clinics that also claim to treat opioid addiction. I’m not saying that the same doctor couldn’t do a great job of treating both problems, but I worry a great deal when that doctor seems to approach these two distinct medical issues as if they were the same medical issue.

Medication-assisted treatment (MAT) of opioid addiction with methadone or buprenorphine is NOT the equivalent of treating chronic pain. When I call my MAT patients’ other doctors to coordinate their care, quite often these doctors ask me if it would violate the patient’s pain contract with my facility if they were to prescribe opioids for a few weeks. When I tell them I don’t treat pain, but addiction, they are puzzled. I elaborate, and use the opportunity to educate the doctor about opioid addiction and its treatment with methadone and buprenorphine.

To be sure, there’s overlap between the two disorders. Studies estimate that anywhere from a third to a half of opioid addicts also have chronic pain issues. And we know that the treatment of chronic pain (an arbitrary definition is more than three months) with opioids can cause the patient to develop a second medical problem, addiction.

Not all opioid addicts have pain. And not all chronic pain patients develop addiction. Many people who live with chronic pain don’t use opioids. In fact, we don’t have evidence that shows long-term opioids help people with chronic pain all that much, due to the tolerance that builds quickly to short-acting opioids and their anti-pain effect. The human body makes changes to compensate for the presence of opioids, and becomes less sensitive to those opioids. Typically, the dose has to be repeatedly increased to get the same anti-pain effect, a phenomenon known as tolerance. Many of these patients may actually have worsening of their pain, called hyperalgesia, due to the changes the body makes in how pain messages are processed.

Some patients can be treated with opioids long-term (longer than three months) and continue to benefit from them without developing any addiction to them. I don’t usually see these patients, since they are doing well in their treatment at pain clinics. Possibly for genetic reasons, they never develop addiction. By addiction, I mean the obsession with and craving for opioids, and inability to control the use of opioids. They will certainly become opioid dependent, and experience physical withdrawal if opioids are stopped suddenly, but that’s physiologic. The mental obsession, a hallmark of the disease of addiction, is not present.

To illustrate further, let’s look at the new guidelines from the fifth and latest edition of the Diagnostical and Statistical Manual of Mental Disorders, more commonly known as the DSM. In the latest version, eleven criteria are used to decide if the patient has mild, moderate, or severe substance use disorder:
1. Taking the substance in larger amounts or for longer than the you meant to
2. Wanting to cut down or stop using the substance but not managing to
3. Spending a lot of time getting, using, or recovering from use of the substance
4. Cravings and urges to use the substance
5. Not managing to do what you should at work, home or school, because of substance use
6. Continuing to use, even when it causes problems in relationships
7. Giving up important social, occupational or recreational activities because of substance use
8. Using substances again and again, even when it puts the you in danger
9. Continuing to use, even when the you know you have a physical or psychological problem that could have been caused or made worse by the substance
10. Needing more of the substance to get the effect you want (tolerance)
11. Development of withdrawal symptoms, which can be relieved by taking more of the substance.
Only the last two criteria are physical; the rest of the criteria have to do with psychological indicators. In order to diagnose mild substance use disorder the patient has to fulfill two or three of the eleven criteria; if four or five criteria are met, the patient has moderate substance use disorder, and if six or more are met, the patient has severe substance use disorder
Addiction interferes with the patient’s ability to control the use of prescribed opioids. All sorts of bad things can happen, up to and including opioid overdose death, when a person with opioid addiction is given a month’s worth of opioids by a pain clinic.

This is my beef with pain clinic physicians. I’ve seen several examples of them prescribing opioids for a month at a time to chronic pain patients who also have been diagnosed with opioid addiction. These doctors set patients up for failure when they prescribe a month’s worth of heavy-duty opioids like Opana or fentanyl. The patient takes too many pain pills too soon, ends up in withdrawal, and gets kicked out of the pain clinic for misusing the prescription.

Is this unexpected? Is this the patient’s fault? Did the patient bring it on herself because she didn’t follow doctor’s instructions? I say an emphatic NO! Given what we know about addiction, it’s completely predictable, even expected. I’d argue it’s a failure on the physician’s part to understand the nature of addiction.

Maybe the doctor didn’t know the patient had addiction, you may argue. Maybe – but if these patients are transferring from an opioid treatment center, they would have methadone or buprenorphine in their urine drug screen. If either of those drugs were present, wouldn’t it be prudent to ask the patient for permission to call the local opioid treatment program, to see if there are records available? Wouldn’t it be prudent to see if your new patient is STILL an active patient at the local opioid treatment program?

Sometimes opioid-addicted people must take opioids for acute pain disorders, but there are ways to minimize risk, like having a dependable non-addict hold the pill bottle, only prescribing a few days at a time, and doing pill counts. Since acute pain is a short-term problem, it doesn’t carry the same risk as month after month of opioid prescribing.

I do have specific advice for the pain clinics of the world, particularly in my part of the world:
1. Get old records. If the patient is transferring from my opioid addiction treatment program to your office-based opioid treatment program, we have essential information that can help you give the best and safest treatment. More likely, you’ll get information that will keep you from harming the patient.
For example, if you want to start the patient on buprenorphine, it would be essential to know the date of the last dose of methadone, and the amount. Otherwise, you could put your new patient into precipitated withdrawal, and unpleasant experience all around.
As another example, if you’re treating a pain patient with fentanyl, you may have second thoughts – hopefully – if we have old records describing the patient’s past near-fatal overdose from fentanyl.
2. Don’t be an asshole when I call you to get information about a patient who transferred from my program to yours, then back to mine after having a relapse back to active addiction. It’s not my fault, and certainly not the patient’s fault. You should have known that a person with opioid addiction, doing well on methadone maintenance, would decompensate when you switched her to fentanyl patches and a hundred and twenty oxycodone for breakthrough pain.
I’m not trying to rub it in your face, but I am trying to educate you, in the nicest way possible, that you made a mistake. I’m hoping if I can explain to you why the patient’s decompensation was predictable, you won’t continue making the same mistake. I’m also making sure you won’t keep prescribing opioids for this particular patient.
3. Don’t let your physician assistant prescribe buprenorphine for “pain” but then also list opioid addiction on the patient’s problem list. It’s disingenuous. We all know that under DATA 2000, physician assistants and nurse practitioners can’t prescribe buprenorphine for addiction. You say it’s for pain, so that a physician extender can see this patient, but then have to tell the patient’s insurance it IS for addiction to get them to pay for it. Besides being bad medical practice, isn’t that insurance fraud?
4. When the family member of one of your patients tells you that patient is misusing her medications, please check it out. Yes, sometimes people do call prescribers trying to interrupt a patient’s treatment for malicious reasons. We have the same problem at our opioid treatment program. However, we do all we can to check on patient safety. If the third party says your patient is injecting your prescribed medication, it’s easy to call the patient into the office to look for track marks. (You do know what those look like, right?)

Doctors at pain clinics could say I’m just mad because they sometimes “steal” our patients. While I’m not happy when patients leave our treatment program, no one can “steal” patients because no one owns patients.

The biggest part of my disgruntlement all centers on the four behaviors I’ve described above. If new pain clinics/addiction treatment programs were accepting our patients who were doing well, and were appropriate for an office-based addiction treatment program…I’d be fine with that. If it worked out for the patient, and saved them time and money with no increased risk of relapse, great. I love to see patients doing well.

But I don’t think all pain clinics give good care, and I’m disturbed when patients suffer set-backs due to mismanagement.

Opioids and Benzodiazepines Prescribed More Frequently in the South

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Last month, the CDC released information comparing rates of opioid and benzodiazepine prescriptions by state and by region. It did not surprise me to learn the South had the highest rates of benzodiazepine and opioid prescribing of the entire nation.

U.S. citizens already receive twice the number of pain pills per capita than our Canadian neighbors. But in addition to that difference, there’s a 2.7-fold difference between the state with the lowest opioid prescribing rate per capita (Hawaii) and the states with the highest rate per capita (Tennessee and Alabama tied for first place). [1]

The same held true for benzodiazepines, with even more difference in prescribing rates. In Hawaii, doctors prescribed benzodiazepines 19.3 times for every 100 people. But in Tennessee, doctors prescribed benzodiazepines 61.4 times for every 100 people. That’s over a three-fold difference between these states.

Alabama, Tennessee, and West Virginia were the top three prescribers for both opioid and benzodiazepines. We already know that higher prescribing rates are associated with higher overdose deaths rates from these medications. Incredibly, these three states were more than two standard deviations away from mean prescribing rates for the entire country.

Even more disturbing, Tennessee doctors prescribed oxymorphone (Opana) at an amount 22 times that of doctors in Minnesota.

That’s just bizarre. It could also explain why so many of the patients I admit to OTPs in the mountains of North Carolina mention Opana as their drug of choice.

The CDC authors of this report admit it’s unlikely there’s much difference in rates of disorders needing treatment with opioids or benzodiazepines. My interpretation of this statement is that it’s an indirect way of saying doctors in the South are overprescribing opioids and benzodiazepines. The authors allude to the problem of overprescribing in the South, mentioning that the South also has higher rates of prescribing for antibiotics, stimulants in children, and medications known to be high risk for the elderly.

How did my state of North Carolina compare to the rest of the nation? Our data isn’t as embarrassing as that for Tennessee, but there’s certainly room for improvement. In NC, doctors prescribed around 97 opioid prescriptions per 100 people, and 45 benzo prescriptions per 100 people.

Benzodiazepine co-addiction complicates induction onto methadone and buprenorphine done by opioid treatment programs for the treatment of opioid addiction, and this co-addiction also predicts poorer treatment outcomes. [2, 3]

This supports what I’ve long suspected: the treatment of opioid addicts with MAT is different in the South than in the West. My colleagues in California, inferring from the CDC’s report, don’t have to deal with benzodiazepine co-addiction as often as I do in the mountains of North Carolina. That co-occurring addiction changes the clinical picture, and makes induction onto methadone particularly more risky.

This is not the South’s finest hour. We must do more to educate doctors about appropriate prescribing, starting in medical school and continuing throughout the physicians’ professional careers. If doctors don’t start this change, someone else will surely do it for us.

1. http://www.cdc.gov/vitalsigns/opioid-prescribing/index.html
2. Brands et al, 2008, Journal of Addictive Disease
3. Eiroa-orosa et al, 2010, Drug and Alcohol Dependence

Addiction

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Sometimes it’s frustrating to hear repeatedly on the news that opioid addiction is such a problem. It’s easy to feel helpless about the situation, and doubtful about how you can help. In this blog entry, I’m going to describe some very specific things you can do to reduce the impact of addiction on our society.

 If you are an addict, get help immediately. Many people have so much shame about becoming addicted that they’re mortified to seek help, fearing the stigma attached to addiction and to an admitted addict, so it takes tremendous courage to admit you have this problem. If you are getting medications from your doctor, tell her the truth. Tell her you are misusing the medicine and need help. She should be able to guide you to an appropriate addiction treatment center, to get an evaluation. At a good treatment center, you should be informed of all of your treatment options. This should include information on both medication-free treatment and medication-assisted treatment.

 If you are doctor shopping for prescriptions, stop it now. As more and more doctors use their states’ prescription monitoring database, sooner or later you will be discovered by one of your doctors. In my state of North Carolina, doctor shopping is a felony, because it’s considered using false pretenses to get a controlled substance. Instead, get treatment. If you’re selling these medications, stop it before you go to jail or kill someone.

 Get rid of all old medication in your cabinets, especially if they are controlled substances like opioid pain pills, sedatives, sleeping pills, or stimulants. According to a recent survey, most young people got their first opioid drug from friends or family. Many times, they took what they found in their parents’ medicine cabinets, or in their friends’ parents’ medicine cabinets. Some communities have regular “drug take back” days, where people bring unused medication for disposal. If you don’t have these in your community, you can wet the pills and mix them with coffee grounds or cat litter, and then throw them in the garbage. The coffee grounds and cat litter will deter addicts looking for medication. Don’t flush pills in the toilet, because there are fears the medication can enter our water supply. (Though I’ve always wondered about drug metabolites that are excreted in urine and feces…don’t they get into the water supply too?)

 Don’t share your medication, with anyone, even family. In this country, sharing medication is so common people don’t realize it’s a crime. Some people feel that if it’s their medicine, and they bought it, they have the right to do with it what they want. This isn’t true. Giving controlled substances to another person is a crime, and dangerous as well. Selling a controlled substance is even worse. Speak up to friends and family, letting them know you don’t think it’s OK for Aunt Bea to give Jimmy one of her Xanax pill because his nerves are bad today. Jimmy needs to see his own doctor.

 Give your children clear and consistent anti-drug messages. Don’t glamorize your own past drug use, including alcohol, by telling war stories. It should go without saying, though I’m going to say it: don’t use drugs with your kids, including alcohol and marijuana. Also, don’t err in the opposite direction, and exaggerate the harms of drug use, because you’ll lose credibility with your kids. Some may remember how the film “Reefer Madness” was mocked. Talk to your kids in an age-appropriate way about drugs and alcohol, even if they don’t appear to be listening.

 If you have a family member addicted to prescription medication, call their doctor to describe what you see. The doctor probably can’t discuss your relative’s treatment, unless given permission, but your doctor can accept information. Write a letter, and be specific with what you’ve witnessed. If your loved one runs out of medication early and then buys off the street, let the doctor know.

 If you feel your addicted loved one is seeing an unscrupulous doctor, report what you know to your state’s medical board. These professional organizations are the best equipped to review a doctor’s pattern of care, to decide if the doctor is prescribing inappropriately. Charts are often reviewed by other doctors who decide if the standard of care is being met.

 Underage drinking is serious. For each year you can postpone your child’s first experimental drug use, including alcohol, you reduce his risk of addiction by around five percent. (1) Don’t involve your kids in your own alcohol consumption; for example, don’t send you kids to the refrigerator to get you a beer. Don’t allow adolescents to drink in your house, fooling yourself with the idea of, “At least I know where they are.” Not only is it illegal, but it’s harmful.

 Don’t use drugs or alcohol to treat minor emotional discomfort, unless you have discussed it with your doctor. For example, don’t use pain pills to help you sleep. Don’t use the Xanax your doctor prescribed for your fear of flying to treat the sadness you feel from breaking up with a boyfriend. Try to get out of the mindset that there’s a pill for every bad feeling, and try to help your friends and family see this, too.

 See a doctor for the treatment of serious mental illness. Some mental disorders are so severe that they require medication. There are many non-addicting medications that treat depression, anxiety, and other mental disorders. Getting the appropriate treatment has been shown to decrease your risk of developing an addiction to alcohol and other drugs.

 Monitor your adolescent’s friends. Youngsters with friends who use drugs are more likely to begin using drugs. Of course, most youngsters who experiment with drugs and alcohol won’t develop addiction, but the younger experimentation begins, the more likely it is that addiction will develop. Older siblings can be a good or harmful influence.

1. Richard K. Ries, David A. Fiellin, Shannon C. Miller, and Richard Saitz, Principles of Addiction Medicine, 4th ed. (Philadelphia, Lippincott, Williams, and Wilkins, 2009) ch.99, pp1383-1389.

Safe Storage of Medication

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Please please PLEASE, patients on opioid treatment programs, store your medication safely.

Of course, the vast majority of patients in opioid treatment programs, dosing with methadone or buprenorphine, store their medication safely and never have any medication storage issues.
The public never hears about these people, who calmly go about their daily lives as productive members of society.

But one incident of a pediatric overdose on medication prescribed for a patient in an opioid treatment program threatens the reputations of treatment programs and their patients. Each time a pediatric overdose occurs due to improper storage of medication, people who oppose opioid treatment programs get new ammunition to say patients should never be allowed any take home doses.

By the way, this information about safe storage of medication applies to opioids prescribed for pain and other controlled substances. Anyone prescribed any medication should store it safely.

So let’s review what should be done to keep medication safe and out of the hands of people for whom it isn’t prescribed, including children.
1. Store your medication in a lock box that is locked. It does no good to have a lock box if you leave the key in the lock. The key must be stored in another place. Otherwise, it’s just a box.
2. Unless you’ve been directed to split your dose, take your medication all at one time. The seal on the bottle is there for a reason. Once the seal is broken, all of the medication is meant to be taken at once. This gives less chance for part of your dose to be ingested by accident or on purpose by another person.
I know patients like to take a little bit of their dose at a time, multiple times during the day. That’s a pattern leftover from active addiction with short-acting opioids. Each time an addict takes something, it gives a feeling of benefit.
But the unique pharmacology of both methadone and buprenorphine means patients can take the entire dose once daily and feel the same as if they take multiple doses. In fact, with buprenorphine, some people in the early studies did OK with every other day dosing.
Some patients are fast metabolizers of methadone and have to have split dosing. We can determine who needs split dosing with careful dose titration and peak and trough blood levels when needed. Then the dose can be split precisely, in individual bottles.
3. Plan for the unexpected. People who don’t have children living in the home often get complacent about medication storage. But what about when friends or family visit? You may not remember to remove your medication bottles or unlocked box from plain site. It’s best to stay in the habit of storing your medication, in a locked box, out of sight and reach.
4. Children are driven by curiosity. If medication is stored where kids can get into it, overdose is more likely. Don’t underestimate a child’s capacity to get into things.
5. Be careful with your empty bottles. Patients are instructed to drink their methadone dose, and then put a little water in it to rinse any residual and drink that too. It’s possible a small amount of medication could still be in the bottle. That’s one reason we ask you to store empties in the lock box, too.
6. Don’t let your child be any part of your daily medication administration. Kids naturally like to imitate their parents. Take doses of all medications in private, out of their view. Of course, don’t let your kids play with or handle your empty bottles.
7. Your take home bottles should spend all their time in the lock box. That’s their home. That’s where they live. The only time they leave the lock box is for the few moments it takes to consume your day’s dose, and afterward the bottle goes right back in to the lockbox. It makes me nuts to see patients transporting empty bottles in their coat pockets and purses.
8. Don’t tell other people what medications you are on. Addicts in active addiction can do desperate things like break into your house and steal medication.
9. If your medication does get stolen, call the police right away. That way, if someone overdoses and dies from the medication dispensed to you, you have a record of doing all you can to report that it’s fallen into the wrong hands.
10. If the worse thing happens and a child or other person takes your medication, call 911 right away. You will lose take home medications, but it’s still the right thing to do. Remember that methadone and buprenorphine cause a peak effect anywhere from two to five hours later. Just because you don’t see any problems in the child for the first hour does NOT mean the child is safe. Don’t take any chances.
11. If you or a member of your household takes opioids either by prescription or illicitly, get a naloxone kit. Keep it in your house so that if an overdose happens, it can be reversed quickly. You can read more about naloxone kits on my blog post on April 27, 2013. You still need to call 911, because naloxone’s effects wear off much faster than methadone or buprenorphine.

Lastly, and it’s self-serving for me to say so, but store your take home doses safely for your doctor’s sake. That take home dose with my name on it is a vote of confidence that you will be careful about how you store your medication. It’s always a judgment call, and sometimes I get it wrong. I am affected when bad things happen with diverted or improperly stored take home doses that I’ve prescribed. Plus, I become more cautious when considering patients for take home doses. Medication-assisted patients complain about overly restrictive regulations around take home doses of medication, particularly methadone, but cases of pediatric overdose make those regulations necessary.

However, I try to remember that the vast majority of medication-assisted patients store their medication correctly and never have any incidents of accidental pediatric ingestion or any other misuse of medication. They’re responsible and careful. For every episode of carelessness leading to a pediatric overdose, hundreds of patients never have an episode with improper storage. It’s not fair to paint them with the same brush.

New Opioids

I’ve blogged about states that have passed new laws addressing the prescribing of opioids, but the manufacturers of prescription opioids medications also have made changes to help reduce the potential for medication misuse. Of course, opioids will never be misuse-proof, but at least it’s a little harder to misuse some of the newer ones.

Oxecta is a new immediate-release brand of the drug oxycodone. It’s formulated so that it breaks into chunks when crushed, instead of a powder. When it’s mixed with water, it forms a gel so that it can’t be injected. This pill contains sodium laurel sulfate, a substance that irritates the nose if snorted.

Lazanda is a new delivery form of a very potent opioid, fentanyl. This brand is designed to be used as a nasal spray, which I would expect to be very addictive. The preparation itself has no anti-abuse features, but in order to distribute, dispense, prescribe, or be prescribed this medication, parties have to sign an agreement and be enrolled with the drug company. This extra scrutiny is hoped to deter diversion by distributor, pharmacy, doctor, or patient. Physicians must take a training program specific for this brand, and be enrolled with the drug company as a prescriber, or pharmacies can’t dispense to the patient.

Patients also need to complete a patient-prescriber agreement. Many people (like me) think doctors aren’t likely to jump through these extra hoops to prescribe this particular brand, when other brands of the same medication are already on the market, though not in the form of nasal spray.

Remoxy, another brand of oxycodone, hasn’t yet been FDA approved. Supposedly, it’s resistant to injection or snorting, and also has been formulated to be resistant to alcohol extraction.

Drug companies are now required by the FDA to have plans to evaluate and mitigate the risks associated with the opioid drugs they manufacture, particularly if they make sustained release or long-acting opioid preparations. This cooperation by drug manufacturers is a necessary part of turning the tide of opioid addiction in this country.

Last year, Purdue Pharma re-formulated OxyContin, making it more difficult to crush to snort or inject.  I noticed a sudden drop-off in patients entering treatment for pain pill addiction who said OxyContin was their drug of choice. During the years 2002 through 2007, nearly all of the opioid addicts I admitted to treatment said OxyContin was their preferred drug. It became obvious that the re-formulation made a big difference.

Addicts can and will still abuse these medications orally to get high, but the new formulations really do reduce abuse by making pills less likely to be snorted or injected.

Misuse of Suboxone: What Should We Do?

I’ve been discouraged by the number of people who write to this blog indicating that they abuse Suboxone by snorting or injecting. I know that’s a small number of people, compared to the thousands that have used Suboxone to get their lives back, and who are in excellent recovery, but it still depresses me.

What should the addiction medicine community do? What should the government do, if anything? What about law enforcement?

In this country, most law enforcement people see abuse of Suboxone the same as any other street drug. For them, it’s usually black and white. If it’s not prescribed for you, or if you’re using it in a way that’s not prescribed, it’s a crime for which you should be prosecuted.

Harm reduction proponents see the situation wholly differently. Since Suboxone is usually safer than other illicit opioids (note I said safer, not safe), even when it’s misused, why not allow the illicit use? In fact, why not hand out Suboxone tablets to anyone proven to be an opioid addict? If the addict snorts or shoots Suboxone, at least he’s not shooting heroin, a much more dangerous drug. True, that person is susceptible to medical complications from injecting and snorting, but this would be true for any other opioid. And some studies indicate that most of the illicit Suboxone is bought by addicts either self-medicating in order to stay out of withdrawal, or giving the medication a try before making the financial commitment to go to a doctor’s office for a legitimate prescription.

In a purely scientific world, I would agree with the harm reductionists. But that’s not the world we live in. We should be sensitive and alert to political forces that would like to annihilate our present freedom to prescribe Suboxone from a doctor’s office. Doctors – and their patients – have to be good stewards of this freedom, by taking whatever measures are appropriate to keep Suboxone out of the hands of illicit users.

 So what can doctors do to reduce Suboxone diversion?

  • Tablet counts and film counts. When I get a new patient, I have in my monitoring agreement that I will occasionally call them to go to their pharmacy (Some patients drive up to forty minutes one way to see me, so it’s more convenient to go to their pharmacy than to my office. Most pharmacists are happy to help.) for medication counts. If the count is short, either the patient is taking more medication than prescribed, or diverting it. Decreased diversion is the drug manufacturer’s big selling point for the films, rather than the tablets. They say that since each box has a lot number, if a patient has sold or given away some of their films, they can’t just buy replacement films to replenish before their count, like can be done with tablets. The lot numbers have to match. I can see where in theory that can be true…but I can also think of some ways to easily get around that, which I won’t post here.
  • Urine drug screens to make sure buprenorphine is present in the urine. Screening should be done anyway, to check for other drug use. Doctors doing urine drug screens should, of course, have buprenorphine on their test panel. In the past this was an expensive test, but not at present. My on-site test kits cost less than $10 when bought in bulk, and test for buprenorphine, methadone, opiates, oxycodone, THC, cocaine, methamphetamine, and benzodiazepines. (I have individual test cassettes for other drugs, when indicated.) Obviously, if there’s no buprenorphine in the urine, we have a problem.
  • Check the prescription monitoring program in your state. If the patient is getting prescriptions for other opioids, like morphine or oxycodone, it’s possible the patient stops Suboxone and uses these opioids between doctor visits. The other possibility is that they sell these other opioids, also not an acceptable situation, since it fuels other addicts’ addictions.

What can patients do to help keep Suboxone away from illicit users?

  • Don’t share your medication. Even if someone you care about is in withdrawal, help him to get care from a legitimate source. Don’t endanger him and yourself by sharing medication. And of course…don’t sell your medication. Duh.
  • Make sure you keep your Suboxone in a lock box, or other safe place. Not only will this keep your medication away from children, but also from addicts looking for opioids. Many patients new to recovery haven’t yet cut off ties with all drug users, and other addict “friends” may be looking for medication.
  • If you know of a Suboxone patient who’s selling medication, tell their doctor. You don’t have to call the police to get them into legal hot water, but you should do all you can to stop the illegal sale of any prescription medication. After all, a patient selling Suboxone is endangering your right to get convenient, office-based treatment.
  • Family members: please call your loved one’s doctor if any part of their Suboxone prescription is being sold or given away to other people. Because of confidentiality, we may not even be able to confirm that your loved one is a patient, but we can always take information from you. We may do pill counts or other things to confirm what you are telling us, and then take action.

What are the possible consequences of continued diversion of Suboxone? Some authorities are talking about changing the DATA 2000 law. Others are clamoring for buprenorphine to be re-scheduled into a schedule II opioid, which would disqualify it under DATA 2000 for use in an office. It would still be available at an opioid treatment program. And many OTPs (opioid treatment programs) do now offer buprenorphine.

I advocate for continued availability of office-based buprenorphine treatment, but now I believe some patients should start at an OTP, and transfer to office-based program only if they do well. Some patients are so strongly addicted to other drugs that they don’t do well in office-based treatment.

I now work at a wonderful opioid treatment program that offers both buprenorphine and methadone upon admission. I’ve switched a few selected patients to my office-based practice. This means I see them and write a prescription for them to fill at a pharmacy, no longer chaining them to daily OTP dosing. I still see them at regular intervals, usually every one to two weeks. These patients can still contract with the OTP for individual counseling and drug testing. This allows the OTP to have a wider variety of treatment options for their patients, gives me a stable patient, and gives patients who are doing well more freedom and treatment at a lower cost. Win, win, win.

I hope more OTPs will begin to offer buprenorphine as a real option to methadone, so that patients who don’t do well in office-based programs can still be on buprenorphine. And I hope they direct the stable patients to office-based programs.

Drug Tests for Patients on Suboxone or Methadone

“Why do I have to do a drug screen? Don’t you trust me?”

Lately a few of my Suboxone patients seem to be questioning the need for drug screens. Some of them resent the tests, and resent paying for them.

So why do I do drug tests?

  • It’s good medical practice. Like many chronic illnesses, relapses happen. It’s better to detect these as early as possible, to discuss what happened, and if/how we need to change their treatment. If a patient has relapsed to opioids, it may mean that I need to increase the dose of Suboxone, if they were still able to feel an opioid high. If the relapse was to other drugs, it usually means we need to increase the “dose” of addiction counseling.
  • There’s a gold mine of information in relapses. I ask my patient what happened immediately before the relapse. Was she around people who were using drugs? Did she use drugs to try to get rid of an unpleasant emotion? Did she use drugs because she became complacent? The answers can help decide how best to avoid relapses in the future. If a patient is fortunate enough to live through a relapse, she can get information she can’t get any other way.
  • Drug screening benefits the patient by giving them accountability. Some patients are less likely to relapse with accountability. I’ve had patients say that the thought of having to talk about a relapse is enough to keep them from using drugs. This surprises me, but I’m glad.
  • Drug screening also shows them I’m serious about their recovery. I’m not just going through the motions of writing a prescription and getting paid for the visit. I really want my patients to recover and get their lives back.
  • Patients in treatment don’t always tell me when they’ve relapsed. In order for addiction to thrive, lies must be told. Otherwise honest people sometimes tell outrageous lies while they are in the throes of addiction. I see this as part of the disease. It’s not about them. It’s not about me. It’s the addiction.
  • I’m not a human lie detector. In the past, I smugly thought I could tell if someone had relapsed, so drug screens just confirmed what I already knew. After more experience, I know that’s not true.
  • It’s the standard of care. Even if the other reasons aren’t compelling enough to do drug screens, the vaguely increased regulatory oversight of doctors who prescribe Suboxone should induce them do drug screens. I know if my charts are ever audited by the DEA (unlikely), my state’s department of health and human services, or my state’s medical board (more likely), I want to show I’m doing things in the proper manner.
  • I don’t want to prescribe medications that will be diverted to the black market. Some doctors say, with some justification, that buprenorphine is a safer drug than most other illicit opioids, and we should look at black market diversion of buprenorphine as a form of harm reduction. However, governmental types don’t see things that way. The DEA certainly doesn’t. I don’t want to prescribe buprenorphine to people with the criminal intent of selling part or all of it. When I do urine drug screening, if there’s no buprenorphine present, that’s a serious matter. If the patient isn’t using what I prescribe, it’s likely they are selling it. Since such diversion of Suboxone endangers the whole program, it’s essential to stop prescribing for people who sell their medication.

These are my reasons for drug screening. Since I’m not going to stop doing them, addicts who object to screening have had to find new doctors. New opioid addicts who come to my office are told, both verbally and in writing, that I do drug screening. They can make their own decision about whether they want to see me as their doctor or go elsewhere.

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