Archive for the ‘Evidence-based Treatments’ Category

Stigma Abounds in Rural North Carolina

 

 

 

 

What Stigma Feels Like

The opioid epidemic has rolled on for more than twenty years now, but misunderstandings and ignorance about best practices regarding treatment of patients still flourishes in medical and dental professionals. Part of my job as an Addiction Medicine treatment professional is the gentle education of other medical providers. Over the past years, I’m more patient than I used to be, knowing that most providers just need information in order to do the best thing for our shared patients. If I’m polite and friendly, our interaction is more likely to go well.

And sometimes, it makes no difference.

This week’s drama unfolded around a patient who was recently diagnosed with cancer. This patient, being treated for opioid use disorder with methadone at 110mg per day, had to see an oral surgeon to have all of her teeth removed before she can undergo cancer chemotherapy. This is because she had extensive decay in all of her teeth which can be sources of infection during chemotherapy.

She saw me a few days after her initial consultation with the oral surgeon to whom her oncologist referred her. She was upset and distressed at what the oral surgeon had said.

She had just found out that all of her teeth, about twenty-one in all, must be removed. And her oral surgeon had told her he wouldn’t be prescribing any pain medication after surgery because she was on methadone.

I listened closely to her and got her permission to call this oral surgeon to talk to him about appropriate pain management for patients with opioid use disorder.

When I called, the surgeon wasn’t there. I was put on hold for four or five minutes, waiting on the surgeon’s assistant. While I was on hold, I listened to their recorded announcements about their practice. The recording told about the educational backgrounds of their two surgeons, then had a pitch about the doctor I wanted to talk with, about how he did missionary work for a certain religion.

Excuse me while I go off on a tangent.

When I heard the bit about missionary work, I felt foreboding. I’ve had past negative experiences with medical professionals who advertise their devotion to a religion as a selling point for themselves or their practices. I notice that sometimes people who profess devotion to a religion seem to be least likely to exhibit the qualities espoused by the leader of their religion: tolerance, patience, love, etc. And I recognize that’s a type of stigma that I hold, which may be unfair to the oral surgeon in question.

I was ruminating on these dark thoughts when the assistant came to the phone. I explained that I was the medical director at the local opioid treatment program, and that the patient being discussed had a diagnosis of opioid use disorder and was being treated with methadone, and that I wanted to discuss the plan for post-operative care with the oral surgeon. The assistant assured me that his doctor’s policy was not to prescribe opioids post-operatively for someone on methadone, because it is a red flag.

“Red flag for what?” I asked.

“That the person is a drug addict & shouldn’t be given any pain medications.”

I took a deep breath and made as effort to keep my tone friendly and cheerful. “Yes, you’re partly correct. As I said, the patient is being treated for opioid use disorder by me. The older term for this medical problem was addiction. She’s being prescribed methadone as treatment for her opioid addiction. It keeps her out of withdrawal and prevents cravings. However, it won’t adequately treat post-surgical pain.”

“In fact, she just had cancer surgery three weeks ago. She was prescribed post-operative oxycodone, 15mg every six hours by the surgeon. We had her mother hold the bottle of opioid pills and dispense as prescribed. This patient did very well and made it through without relapse. We could do something similar after her dental surgery.”

“No,” he said, “We leave it up to the pain clinic to prescribe the pain medication.”

I slapped my forehead and tried to keep an edge out of my voice. “We are not a pain clinic. I don’t prescribe medications for pain. I treat opioid use disorder with methadone and buprenorphine products. I do not prescribe opioids for dental procedures since I’m not an oral surgeon. I don’t know what to expect as far as intensity and duration of pain after extraction of a mouthful of teeth. However, since the surgeon doing the procedure knows how much pain such patients have, he would be the ideal person to prescribe for the post-op pain associated with the procedure that he is doing.”

“Well he’s not going to prescribe anything if the patient is on methadone,” he answered.

“Yes, that’s why I called. I’m trying to educate you about best practices for post-operative care for patients with opioid use disorder who are being prescribed methadone.” I was getting louder and could feel a muscle jumping over my right eye. “What I’m trying to tell you is that this patient’s methadone will not treat post-operative pain. It does keep her out of withdrawal and prevents cravings and helps her function normally, but it won’t treat acute severe pain.”

“Yes but I’m pretty sure the surgeon won’t prescribe anything for pain.”

I thanked him for his time and left my phone number for the surgeon to call me back. This was five days ago and I don’t expect a return call.

This patient is in a bind. She has cancer and can’t start chemotherapy until she heals from getting all her teeth extracted. Time is of the essence. Ordinarily, I’d tell her about the situation and recommend she find another oral surgeon, but she may decide to proceed with this surgeon only to get the whole process moving along.

It’s a real shame that this patient will be forced to suffer pain after her dental extractions. She will get by with Tylenol and ibuprofen, because she will do what she must. I just hate that she’s being treated this way.

Then today. Southern Scripts, an insurance company that one of my long-time patients just switched to, sent my office a prior authorization to fill out before it would OK coverage of buprenorphine/naloxone 8/2mg tabs, 8 mg per day. Among a host of other requirements, they need the patient’s height and weight before they’re willing to authorize payment.

Now that’s a new one. It’s hard for me to imagine what possible height/weight would disqualify a patient for this medication, but what do I know. I’m only the doctor.

Also today, I heard about an exchange one of my patients had with a Walgreens pharmacist. She wanted to fill her Suboxone 8mg film prescription two days early. I had already called ahead and left a message with the pharmacist that it was OK with me, since she had recently tapered from 16mg down to 12mg. She had more problems with that drop than we expected, and so she ran out 2 days early. Since the decrease in dose had been requested by the patient in the first place, and since I didn’t want her to be without medication for two days, I gave permission to fill it early. I did not think this was a big deal.

The patient said that she was third in line at the pharmacy, with six or eight people standing in the area waiting for service, when the pharmacist called out to her, asking why she ran out early. My patient didn’t want to compromise her privacy, so she shook her head, declining to answer. She says the pharmacist began to harangue her in front of all the other people, saying since she wouldn’t tell her why she needed to fill the medication early, she wasn’t going to get it from “her” pharmacy.

The patient left, tearful and humiliated, but not before she demanded the written prescription back from this hateful pharmacist. She took it to another Walgreens in her area and filled it with no problem.

I’m no longer shocked or surprised at the hassles my patients endure. But we are now several decades into this opioid epidemic. I think it’s time we insist on better education and treatment from medical, dental, and paramedical professionals. I’ve been patient and tried hard to approach outdated attitudes as an educational challenge.

Now I occasionally wonder if things will ever change. I find myself having the same conversations with other medical providers that I had fifteen years ago. Are we making any progress against the stigma our patients face? Only time will tell.

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Harm Reduction Dilemma

Harm Reduction Cat

 

 

 

 

What happens when harm reduction tenets clash with actual patient experience? That’s my recent dilemma.

Our opioid treatment center is blessed to have an organization that comes to our facility to do free testing for HIV and Hepatitis B and C. They also do needle exchange, or more precisely, they distribute clean needles to anyone who wants them.

Our patients have benefitted tremendously from the free HIV and hepatitis testing. Many of our patients have been diagnosed with active Hepatitis C. Since we now have a Federally Qualified Health Center in a neighboring town, about an hour away, our patients can get treatment for Hep C, even if they have no insurance or Medicaid. I’d estimate that two or three dozen patients have been diagnosed with Hep C, been referred for treatment, and are now cured of their Hep C.

The value of this can’t be overstated. Besides reducing the burden of Hep C in the community, these patients are free from worry that their Hep C will cause future problems. They don’t have to worry about it anymore, if they remain in recovery.

Our dilemma isn’t about this part of what they do, but about the needle exchange.

At our facility, we endorsed harm reduction as a healthy goal. If patients inject drugs, we want them to be as safe as possible, while still hoping they will be able to quit injecting once they get some traction in treatment.

However, some established patients, doing well now and free from illicit drugs, have told us the available free clean needles are a trigger for them to use drugs intravenously again.

This isn’t supposed to happen. Studies about needle exchange have not showed that clean needles influence people to inject drugs who weren’t already planning to inject drugs, which is why we’ve been supportive of the needle exchange.

But now we have some specific patients who link a relapse to intravenous drug use (usually intravenous methamphetamine or cocaine) to the available clean needles. These patient experiences contradict what the studies show us.

What should we do?

We need the services of Hepatitis and HIV testing, but we don’t patients to relapse, obviously. Do we ask the organization to keep do the free testing, but put the clean needles away and not mention them?

We had a spirited debate about the issue last week at our case staffing/treatment team meeting. This topic raised some passionate feelings both pro and con clean needle exchange, which surprised me a little. Some personnel thought patients shouldn’t be offered clean needles because, after all, these were patients in treatment who should be trying to be drug-free. Other people pointed out that continued intravenous drug use is inevitable, to some degree, in patients trying to get help, and we should want these patients to be as safe as possible while they inject, citing evidence about reduction of transmission of HIV and Hep C with needle exchange.

Some people felt the patients reporting that their drug use was triggered by being offered clean needles was an excuse, an effort to displace blame from themselves onto someone else. Those people felt these patients were going to use anyway and used needles exchange as a scapegoat.

I listened to everyone and decided there was possible truth to everything that was being said, but there was no way to know for sure.

In the end, we decided to ask our patients who were most vocal about the needle exchange program being a relapse trigger if they would talk to the personnel who work for the harm reduction agency that supplies the testing and clean needles. I thought offering information in both directions would be a good start.

Patients are often the harshest critics of other patients who aren’t doing well. Many times, I’ve had a patient tell me I ought to kick another patient out of treatment because they were still using drugs. Of course, I have to tell them I can’t talk about any other patient, but in general, we try to keep patients in treatment rather than turn them away for drug use, although sometimes we do refer them to more intense treatment.

Sometimes patients say that other patients using drugs makes them feel triggered to use drugs too. I can’t deny anyone’s experiences. If someone says they are triggered, then they are. And we do want to provide a safe treatment facility. How much drug use should we tolerate if it negatively impacts other patients’ treatment experiences?

What do my readers think? Is offering clean needles at a treatment program going too far, as some of our OTP employees think? Is it not going far enough, and should we offer safe injecting sites if it were legally allowed, as it is in Canada and elsewhere?

The Tenth Annual NC Addiction Medicine Conference: A Success

 

I just got back from Asheville, the location of the yearly spring conference on Addiction Medicine. This meeting is sponsored by the NC Governor’s Institute on Drug Abuse and the North Carolina chapter of the Society of Addiction Medicine, among others.

I’m glad I took an extra day off work to go to the pre-conference. Last year the preconference was one of the best parts of the whole meeting, and this year was the same. I went to the Motivational Interviewing (MI) preconference, and got a nice refresher on the basic principles of MI. I also got a chance to practice my skills during the session, which can be daunting while being watched by other people.

MI is like that. When done by someone extremely skilled at this counseling technique, it looks so easy. I tell myself, “I can do that, no problem.” Then when given an opportunity, I get brain freeze and it’s not so easy. Like any skill, the only way to get better is to do it and keep doing it, and maybe have a person who is skilled at MI give feedback from recorded sessions (with patient permission, of course). I know the counselors at my OTP submitted recordings to their clinical supervisor for feedback on how well they adhere to MI technique. This feedback can be key.

The first day of the conference proper kicked off with an address by Dr. Elinore McCance-Katz, MD, PhD, who is the Assistant Secretary for Mental Health and Substance Use, SAMHSA. She talked about the federal response to the opioid use disorder epidemic, which includes strengthening the public health surveillance, supporting research, providing Narcan, advancing the practice of pain management and improving treatment access, among other things.

Then she talked about SAMHSA’s response to the opioid epidemic, including the STR grants authorized under the CURES Act, then about the State Opioid Response act, which has a budget of $1.5 billion. She also discussed four or five other important SAMHSA measures.

I appreciate her passion. I wanted to stomp my feet and say “Amen,” when she endorsed using only evidence-based treatments to treat opioid use disorders. She said we should stop doing detox only, unless patients were provided with depot naltrexone injections before leaving detox. Then she said of lab testing in medication assisted treatment that cost thousands of dollars: “This is nonsense.” Yes. Thank you, Dr. McCance-Katz.

Next to speak was Kody Kinsley who gave the NC update on the state of addiction. He described how we have spent our grant dollars so far, and about how Medicaid will change in the future. He talked specifically about how Medicaid expansion could help our state. I don’t think he had to convince this audience. Most of us have seen how dismal medical care (not only substance use disorder treatment) can be for people with no insurance and no Medicaid.

He lost me when he started talking about SPAs. I didn’t know what he was talking about, but I quickly learned he wasn’t talking about places to go for massages and facials. I got so bogged down trying to decide what a SPA was that I missed much of the last part of his message.

A talk from Sandra Bishop-Freeman from the NC Department of Epidemiology and Public Health was scary as hell.

This isn’t a good time in history to be someone with substance use disorder in general, and opioid use disorder in particular. Fentanyl and its analogues are potent, and small packages of these products contain a great deal of opioid firepower. This means it’s easier to smuggle into the country. These fentanyl analogues are sometimes made into counterfeit pills, to fool authorities, but these counterfeits often end up on the street. A buyer may think he’s getting a Vicodin pill when it’s really fentanyl.

And now cocaine is being laced with fentanyl, fueling a twin epidemic. This is scary because cocaine has made a resurgence in my county, or maybe never left in the first place. But this fentanyl-laced cocaine could cause quick overdoses for people not intending to use fentanyl.

Then there’s news about a 1000% increase in deaths from methamphetamines, designer benzodiazepines, and combinations of Imodium and Kratom that are causing deaths.

It was a great and informative talk, but a bit depressing.

The last of the plenary speakers was Dr. Corey Waller, an entertaining and informative speaker. He talked about integrating substance use disorder treatment into hospital systems with specific and practical ideas about making this happen. In this talk and another later in the day, he inspired me to want to try again to work with my local hospital.

I love hearing new ideas and learning about current trends, and I also love seeing old friends and meeting new people working in the field. I was able to talk with four or five other doctors I’ve known for years, and catch up with what happening in their lives. That’s always fun.

I was one of three presenters at a morning workshop about updates and challenges of prescribing buprenorphine (and methadone) for patients with opioid use disorder. It went very well.

I can’t say I enjoy doing presentations, but there’s nothing like a presentation to force me to thoroughly investigate a topic, so I learn even if no one else does. And I feel good about doing the occasional presentation, because I’m doing my part to help educate new prescribers.

I had some material to cover toward the end of the session, and I thought the other two physicians would use up the bulk of our time. In other words, I didn’t think I would have to talk for very long. But the two other physicians were gracious and wanted to allow me enough time to talk, so they left me with a half hour.

That worked out well, because after my fifteen minutes talking about how opioid treatment programs and office-based buprenorphine providers could work together, we still had fifteen minutes for audience questions. And this audience asked some great questions, covering our most difficult issues: misuse of monoproduct versus combo product; co-occurring use of benzodiazepines either by prescription or illicit; law enforcement investigations of buprenorphine prescribers; when – if ever – to terminate treatment for noncompliance; maximum dose for buprenorphine products; the cost of treatment and grant funds, to name but a few.

During lunch, Dr. Frederick Altice gave an informative and concise presentations on Hepatitis C. He made me wish I had enough time to treat our patients at the opioid treatment program who have Hep C, instead of needing to refer them to the nearest FQHC (federally-qualified health center). It’s getting very easy to treat these patients, with liver biopsies and interferon being a thing of the past.

Late in the afternoon, I facilitated our closed opioid treatment program session. This session is meant only for providers working at OTPs, and we usually talk about topics specific to treatment at OTPs. This year, the topic was advocacy.

This topic was based on a case that I blogged about September 16, 2018. They provider involved in the case, Lisa Wheeler, PA, gave an excellent and passionate presentation about the specific case, but went farther into the issue. She explained how and why stigma exists, and the negative consequences we see when provider-based stigma cuts into patient care.

She presented the full case, explaining how a patient of hers, brand new to treatment, was diagnosed with endocarditis and told that per hospital policy, she couldn’t get a second surgery on an infected artificial heart valve. She was also denied visitors and was forced to give up all electronics in order to be admitted for treatment, leaving her with no cell phone or internet access and very lonely indeed.

Lisa Wheeler also gave us the glorious follow up of the case: she – eventually, after long hours of advocacy by Lisa and other people – was transferred to UNC Chapel Hill where she underwent life-saving cardiac surgery. She now is doing very well, healthy, with seven months of recovery.

Then we had a general discussion about other cases we’ve seen where healthcare providers denied care to patients on medications to treat opioid use disorder. Of the twenty or so providers in the room, many had similar cases.

We talked about what we can do to combat stigma, and came up with some general ideas. Sometimes just calling our colleagues, to try to educate them in a friendly way, can be the best approach. We can be informal and friendly, and educate in a gentle way. We need to remember that many providers didn’t get much education about substance use disorders and their treatment during medical school or residency. Those of us working in this field can be a source of information for other providers, who often change their approach when they have more facts.

When bias is egregious and causes harm to patients, sometimes it’s necessary to get more outspoken with advocacy. We identified the Legal Action Center, located in New York City, as a group with some materials that can be useful. They have a MAT “toolkit” with sample letters, to be adapted to specific situations, such as if a patient is charged with driving while impaired while on a stable dose of methadone or buprenorphine. There’s a sample letter to send to a patient’s lawyer, to help explain MAT with its benefits. ( https://lac.org/mat-advocacy/ )

In the end, a handful of providers agreed to form a committee to try to form better advocacy ideas. I’ll keep you informed how that goes.

The entire conference was great, and I’ve only described part of the first day. I could go on & on, but in the interest of keeping this blog post to a readable length, I’ll end with an exhortation to my readers: if you provide treatment to people with substance use disorders, you need to go to this yearly conference. Now there’s also an “Essentials” conference in Raleigh in the fall, which presents a second opportunity to learn.

You can go to this website for more details: https://addictionmedicineconference.org/

A Bridge to Treatment

 

 

 

 

 

In my last blog, I lamented the lack of communication and cooperation between medical professionals involved in the care of patients with opioid use disorders.

Opinion about medication-assisted treatment has split the field in half. Most old-school, 12-step-based, abstinence-only programs discourage patients with opioid use disorder from seeking treatment with medication like methadone and buprenorphine. Some providers at opioid treatment programs rail against the lack of knowledge and open-mindedness of these programs, yet don’t inform stable patients on buprenorphine about their office-based options, which may be more appropriate and less restrictive (an option usually not available to methadone patients). Office-based providers accept patients from opioid treatment programs without bothering to get records that could give essential information that could make treatment safer.

Hospitals lack information about appropriate referral sources to treat opioid use disorders, and emergency departments let patients leave after a near-fatal overdose with only a list of phone numbers to call for help.

It’s time to break down barriers and put the welfare of patients first.

At the American Society of Addiction Medicine (ASAM) conference this year, I heard a possible solution.

Dr. Sarah Wakeman and Dr. Laura Kehoe, both associated with Harvard Medical School, talked about their Bridge Clinic. This program is set up to be a bridge between acute hospital or emergency department care and long-term primary care for patients with substance use disorders.

This model is “low barrier” or “low threshold” care, which means eliminating obstacles between the patient and appropriate care. The clinic’s mission is to provide on-demand, compassionate care to patients in all stages of addiction.

Most of their patients have opioid use disorder, and around 77% are treated with buprenorphine products. Around 11% are treated with naltrexone. I assume the others are treated for alcohol use disorder or other substance use disorders.

The Bridge Clinic serves as an immediate access clinic for Massachusetts General Hospital patients with substance use disorders who don’t have a primary care provider. This clinic provides both drop- in and scheduled appointments for patients. It’s been in operation for the past several years and has grown quickly, indicating a need for their services. In some cases, patients elect to remain in treatment at this Bridge Clinic rather than go on to primary care, office-based medication-assisted treatment.

This clinic is opened seven days per week, from 9am to 5pm. The physicians who staff this clinic are very aggressive with starting same day pharmacotherapy for substance use disorders, not only MAT for opioid use disorder. They refer to opioid treatment programs when that level of care is most appropriate, or if the patient needs methadone rather than buprenorphine.

They also work with families, and connect patients with other needed services.

The clinic staff includes an addictionologist, family practice physician waivered to prescribe buprenorphine, recovery coach for peer support services, resource specialist who finds other programs to help patients with their needs (food, housing, etc), and administrative assistant and a patient service coordinator. Extended care in the overnight hours can be provided by the colleagues at the emergency department.

Patients are referred from Massachusetts General Hospital, where patients with substance use disorders are offered induction onto medication-assisted treatment while hospitalized.

That’s right. I said that. Patients with opioid use disorder are started on methadone and buprenorphine during hospitalizations for other medical ailments. For example, a patient with endocarditis from IV opioid use disorder can be started on treatment with methadone or buprenorphine before ever leaving the hospital, and the Bridge Clinic can take care of the patient during the gap between hospitalization and arrival at an office-based or opioid treatment program.

This is treatment nirvana!

Patients with near-fatal overdoses can be started on buprenorphine before they even leave the emergency department, and use the Bridge Clinic to link them with care.

This wonderful new idea has substantial evidence to show it works. D’Onofrio et al., [2] published results of a randomized study of patients with previously untreated opioid use disorder who presented to the emergency department. In one arm of the study, patients got treatment as usual, which was referral to treatment facilities. In the second arm, patients received brief intervention counseling and referral to care to an outpatient buprenorphine provider. In the third arm, patients were started on buprenorphine and linked directly with outpatient buprenorphine treatment, with no gap in treatment. In this last group, nearly 80% of patients followed up with buprenorphine treatment and had significantly less opioid use than patients in the other two arms.

For this reason, the Bridge Clinic wanted physicians who worked in the emergency department to get their waivers to prescribe buprenorphine, and accomplished this. When they see patients with opioid use disorder, they either do the induction onto buprenorphine in the ER, or send the patients home to do a home induction by providing a two-day pack of buprenorphine. Since the Bridge Clinic is open seven days a week, such patients can be seen quickly.

This is wonderful, since we know from studies that patients who are started on MAT while in the hospital or emergency department have much higher rates of treatment retention. We also know that higher treatment retention means fewer opioid overdose deaths.

Around half of the patients referred to the Bridge Clinic from the hospital or emergency department are seen within 24 hours of being referred.

The clinic endorses a harm-reduction model, and does not discharge patients for continued drug use. They staff attempt to build trust by offering services without attempting to control the patients’ intake of drugs. The patients are included in the plan of care. They have low no-show rates, and are aggressive at getting patients back in to treatment if they miss appointments.

The Bridge Clinic’s goal is to eventually transition care, after acute stabilization, to somewhere closer to where the patient lives. Sometimes this can be worked out easily, and sometimes there may be problems. Bridge Clinic staff attempt to work out these difficulties.

Some patients need the Bridge Clinic short-term, and others for longer. Their average length of stay is around three months. This program provides help to patients with ongoing drug use, homelessness, pregnancy with substance use disorders, chronic pain patients, and to patients leaving incarceration, eager to find help prior to a relapse.

I was so inspired by the description of this program. It was obvious that these women excelled at gaining the cooperation of their colleagues at their hospital and in the primary care practices. It really sounds like the ideal situation, with everyone working for the good of the patient, no matter what their needs are. There are no waiting lists, and no senseless obstacles for patients to surmount.

Every community needs a bridge clinic, I think. How wonderful that would be, with a warm and friendly place to send patients in crisis, open every day of the week. Patients could be assessed, stabilized, then referred to the best treatment program nearest to where they live.

However, North Carolina isn’t Massachusetts. We have a higher percentage of people with no health insurance, while Massachusetts has expanded Medicaid, which helps pay for this sort of treatment.

But at least we have a model for quick-access, low-barrier care for people in crisis with substance use disorders. If we can ever muster the cooperation and will for such a program, these people can teach us how to do it.

  1. Sordo et al., 2017, British Medical Journal
  2. D’Onofrio et al., Journal of the American Medical Association, 2015, Apr 28; 313(16): 1636-1644.
  3.  

ACLU Sues to Allow MAT During Incarceration

 

 

 

I was sent a link to this article that made my day:

https://bangordailynews.com/2018/07/26/mainefocus/aclu-lawsuit-demands-maine-man-get-addiction-treatment-in-jail/

This article reports that the ACLU (American Civil Liberties Union) has taken the case of a man in recovery on medication-assisted treatment who must serve a nine-month jail sentence starting in September in Maine. This man, Zachary Smith, has been in recovery on a buprenorphine product for the past five years. Ordinarily, the jail has a policy of NOT continuing medication-assisted treatment to inmates, leading to forced withdrawal from these medications.

Opioid withdrawal doesn’t (usually) kill healthy adults but can be fatal to people in fragile health. Acute withdrawal does cause significant suffering, and it leaves the person at increased risk of death from overdose upon release from incarceration.

The ACLU says there are two reasons why denying this medical care is against the law. First, denying medical treatment to inmates violates our 8th amendment against cruel and unusual punishment. Second, the Americans With Disabilities Act recognizes opioid use disorder as an illness covered by that Act. This means denying appropriate medical treatment for this condition is discrimination.

The ACLU filed a preliminary injunction to speed up a hearing of the case prior to the beginning of the jail sentence. This means the case will be heard – hopefully – before Mr. Smith must show up for his sentence in early September.

I was so happy to see this case. I think it could be a watershed moment for this nation, one way or the other. I have never understood how it could be legal for a person to be denied medical care while incarcerated, yet it happens across this country every day. In most jails, patients in treatment for opioid use disorder with medication-assisted treatment are denied their medication.

I’ve blogged about this before. I’ve even called the NC chapter of the ACLU myself, many years ago, to ask for help, but was told I had no standing, and that it needed to be the patient to contact the ACLU for help. But my patients sentenced to jail are often reluctant to bring an action against their local jail, feeling they might receive retribution of some sort – a very realistic concern, at least in my area.

Can you imagine the uproar if any other group of patients with chronic illness were denied medical treatment? What if patients with heart disease were denied life-sustaining medications during incarceration? What if diabetics were denied their insulin? For all I know, this may be happening. If it is, citizens of this country should not stand for this. We shouldn’t stand for it for people with substance use disorders, either.

Since all of this is happening in Maine, I was curious if North Carolina has any similar cases pending. I went to the website of the North Carolina chapter of the ACLU and found nothing advocating for inmates to be continued on medication-assisted treatment for opioid use disorder.

However, I did find that our state chapter of the ACLU filed a federal class action lawsuit against North Carolina’s Department of Public Safety’s policy of denying treatment for Hepatitis C to incarcerated people with the virus. The current class action suit was filed on behalf of all people incarcerated in NC with Hepatitis C.

https://www.acluofnorthcarolina.org/en/press-releases/aclu-incarcerated-people-sue-nc-failure-provide-life-saving-treatment

Current expert recommendations are that all incarcerated people receive Hep C testing, since according to data from the Center for Disease Control, around one-third of all prisoners are infected with Hepatitis C.

In the past, recommendations were to wait until the person with the Hep C virus developed liver damage before treating. Those expert recommendations have changed. The current recommendation is that all people with active Hep C infection should be treated. Experts now also recommend treatment even if the patient has not stopped illicit drug use.

The NC Department of Public Safety’s present policy is that incarcerated people with Hep C infection that’s caught early, when at its most treatable, are forbidden to receive treatment while incarcerated.

This article says there’s no law for universal testing of prisoners for Hep C, and the decision to test is left up to personnel at each jail site.

Both issues are important, though to me, continuing access to medication-assisted treatment appears more pressing, and could prevent more deaths in the short term.

I will follow these cases, and give updates to my readers.

 

 

Who Should NOT Be in Medication-Assisted Therapy with Methadone or Buprenorphine?

Liquid methadone

 

 

I spend much time and effort explaining how medication-assisted treatment for opioid use disorder works for many people. It occurred to me that I should explain who isn’t a good candidate for such treatment.

I enthusiastically support medication-assisted treatment (MAT) for opioid use disorder, but no treatment works for everyone. Some patients may be too ill for this form of treatment and some may not be ill enough, and find other treatments that work for them. Here are some reasons a patient may not be suitable for MAT:

The patient doesn’t have opioid use disorder. That seems obvious, but occasionally I encounter an addict who wants to be started on methadone even though he’s not using opioids. Rarely, people using cocaine, benzodiazepines or other drugs will come to the OTP after they have heard how well it worked for other people, who do have opioid use disorder. After I explain that buprenorphine (Suboxone) and methadone only work for opioids, some of these patients have become angry.

A few weeks ago, a woman came to our opioid treatment program who hadn’t used opioids for nine months, and – by her history – never had an obsession or compulsion to use them in destructive ways. When I explained to her why our treatment wasn’t appropriate for her, she became angry, and said it was her right to get treatment because of the CURES grant.

This made no sense to me, and I tried to explain myself several times, but she left, angry she was being denied a treatment that the government was paying for, because she felt that meant she was entitled to the medication if she wanted it.

The patient takes opioids for pain, but has never developed opioid use disorder.

Such a patient may be physically dependent, but lacks behaviors that indicate loss of control over opioids. The patient denies any misuse of medication, or obsession and compulsion to continue using opioids despite adverse consequences.

Opioid treatment programs (OTPs) have stringent regulations put on them by both federal and state governments. OTPs are designed to treat patients with opioid use disorder; these are patients who have lost the ability to control their intake of opioids, so the OTP regulates a maintenance dose of either methadone or buprenorphine to keep the patient out of withdrawal and able to function normally.

If a patient has only pain and no opioid use disorder, there’s no reason to enroll in an opioid treatment program, because patients without addiction are still able to take opioid medication as prescribed. Pain medication can be prescribed by any doctor with a DEA license.

While opioid treatment programs aren’t set up to treat chronic pain, many of our patients with both opioid use disorder and chronic pain find methadone and buprenorphine helps with pain. That’s a nice benefit. Many of these patients feel less pain once they’re out of the miserable cycle of intoxication and withdrawal. So less pain is a happy side effect of our treatment.

Having said this, there are those unfortunate patients who have been dismissed from pain clinics for reasons other than misuse of opioids. They don’t meet criteria for opioid use disorder, but they are clearly physically dependent on opioids and can’t find timely treatment. I have – at times – admitted these patients, under an exception filed with SAMHSA, with the understanding that they would be better served by eventually transferring to another pain management program.

The patient with opioid use disorder asking for maintenance treatment has been physically dependent for less than one year.

Methadone is difficult to taper off of, and federal and state regulations say it cannot be prescribed for people with opioid use disorder with less than one year of physical dependence. This is a somewhat arbitrary cut off, and the OTP physician can ask for an exception to this regulation if she feels it’s in the best interest of the patient.

Even if the OTP wants to treat the patient with maintenance buprenorphine (Suboxone), which is usually much easier to taper off of than methadone, permission must be sought from state and federal authorities before enrolling a patient who has used opioids less than one year.

This doesn’t apply to office-based buprenorphine practices, who don’t have to follow federal and state regulations for opioid treatment programs. If buprenorphine is prescribed in the office setting, the prescribing physician can use her best judgment about who is appropriate for treatment, without needing government approval.

To further confuse this issue, patients who have been on MAT in the past may be re-admitted onto MAT even without a year of physical dependence, if that patient thinks that relapse back into active opioid use disorder is imminent. Also, pregnant patients with opioid use disorder don’t have to meet the one-year requirement because of the benefits to both mom and baby with MAT.

The person with opioid use disorder can go to a prolonged inpatient residential treatment program.

This is controversial, because some doctors think medication-assisted treatment should be given to everyone because of its success rate compared to abstinence-only treatments.

But who gets the best of medical treatment in our country? Possibly it is medical professionals like doctors and dentists, airline pilots, politicians, and celebrities. They usually get the gold standard of treatment for whatever disease ails them.

If such people have opioid use disorder, they are often treated with inpatient medical detox, using buprenorphine to ease withdrawal, followed immediately with prolonged inpatient residential drug addiction treatment. I know doctors and dentists who spent six to nine months in treatment. After treatment, they must sign monitoring contracts with their licensing boards in able to go back to work. These contracts usually involve a mandated number of group sessions per week and random drug testing. With this kind of support and accountability, these medical professionals have excellent outcomes. Studies show that more than 80% are still off all drugs and alcohol at five years after entering treatment.

If only everyone could get that kind of treatment!

If this kind of treatment is available to the addict…take advantage of it. But most people with opioid use disorder can’t access this kind of treatment, with extensive post-treatment counseling, monitoring, and accountability.

A person with opioid use disorder is also physically addicted to alcohol, benzodiazepines or other sedatives.

These drugs can be deadly when mixed with methadone or buprenorphine. I prefer such patients enter a medical detox unit to get off these sedatives prior to entering treatment in an OTP. However, it’s a complicated problem, and the admitting physician needs to make a judgment about the risks of starting treatment while the patient is physically dependent on sedating medications, compared to the risks of delaying treatment for the opioid use disorder.

The FDA issued a statement in 2017 saying that “the opioid addiction medications buprenorphine and methadone should not be withheld from patients taking benzodiazepines or other drugs that depress the central nervous system…” They issued this statement after releasing the black box warning in 2016, saying opioids combined with benzodiazepines or other sedatives was dangerous and could result in death.

I believe this more recent statement was their way of indicating the risks may be outweighed by the benefits for patients contemplating admission to treatment for opioid use disorders with MAT. After all, patients with active opioid use disorder can die.

The person with opioid use disorder also has acute, severe mental illness. An actively suicidal patient is too sick for an outpatient opioid treatment program. So is an acutely psychotic patient who is having hallucinations and delusions. These patients often can’t to understand what is real and what isn’t. Ideally these patients need inpatient treatment at a facility that will treat both mental illness and opioid use disorder. Sadly, it’s getting ever harder to find such facilities for patients who need them.

Some patients may have neurologic dysfunctions that impair their ability to understand and consent to treatment. Such patients usually have people authorized to make decisions for them, and we must bring that person into the discussion and get consent to treat from them.

If a patient has some sort of temporary condition that impairs their ability to understand and consent to treatment, we may ask them to return on another day. For example, we sometimes have a new patient present for intake who is impaired to the point where consent is impossible. We make sure a responsible party can drive them home, and make plans for them to return the next day.

A patient has behavior that interferes with treatment.

OTPs have an obligation to all their patients to maintain a safe and orderly treatment environment. Patients who start physical fights, threaten staff or other patients, or sell drugs shouldn’t be kept in treatment. I know that sounds harsh, but OTPs have a hard enough time maintaining good standing in their communities without having to face accusations about illegal behavior on premises.

Patients need to be emotionally stable enough to conduct themselves in a non-threatening manner to be able to remain in treatment. Some patients, after being counseled about acceptable behavior, are able to comply with requests for behavioral changes. Some patients have erratic behavior due to mental illness, and shouldn’t be blamed, but their behavior still may be too disruptive for the OTP setting.

The patient has serious co-existing physical health problems.

Actually, I can’t think of any physical health problem that would make the treatment of opioid use disorder with methadone riskier to the patient than untreated opioid use disorder. We know for sure that untreated opioid use disorder produces high risks of death and disability.

Issues like severe lung disease and specific heart rhythm problems do increase the risk of medication-assisted treatment, especially with methadone. I try to contact the patient’s other doctors and consult with them before the patient goes above a low dose of methadone.

Ideally, I’d like to talk to the patient’s other doctors on the day of admission, before methadone is started, but that can’t always be done. With the time pressures doctors are under, it’s getting ever harder to claim some of their time for a patient consultation.

Some of these patients could be started on buprenorphine instead of methadone, which is safer with these health conditions, and has fewer medication interactions.

The patient has transportation difficulties.

Some patients can’t get a ride to their treatment program every day, which interferes with delivery of quality treatment. With buprenorphine, federal requirements for daily dosing were lifted, but states still have varying regulations. With methadone, the patient must come for treatment daily. During the first two weeks of stabilization, it’s important for medical personnel to be able to evaluate the patient every day, to assess the effects of dose increases. Most opioid treatment programs are open seven days a week for dosing.

A patient who enters treatment expecting to be completely drug free in the near future.

I try to make sure patients entering treatment with methadone or buprenorphine understand that I am not switching them from illicit opioids to these medications because tapering off of them is easier. Particularly with methadone, it is not. But both methadone and buprenorphine are so long-acting, they can be dosed once per day, giving the patient a steady level of opioids. This allows the addict to function normally, without withdrawal or impairment, once the dose has stabilized.

Both medications give the person with opioid use disorder time to regain physical and mental health. Once on a stable dose, the recovering person can make changes in his life, with the help of counselors and other OTP workers. He can get back to work, any criminal activity, form better relationships with his family and himself, and recover a better quality of life.

Will that person ever do well off methadone? There’s no way to know. Some patients can taper off methadone, if they bring the dose down slowly enough that they don’t feel intolerable withdrawal. Some, perhaps most, recovering people find they will do better if they stay on methadone.

All this is to say that the goal of entering an opioid treatment program isn’t necessarily to get off the treatment medication.

If a patient seeks to enter methadone treatment but also expresses a desire to be off buprenorphine or methadone within weeks to months, I tell them their expectations aren’t realistic. I try to explain these medications don’t work like that. If the patient wants to get off all medications quickly, I can give referrals to programs that can help them. This way, patients can’t later say they were misled, and feel like they have liquid handcuffs, chained forever to methadone, with its many regulations for treatment.

I hope this gives a little guidance as to which patients are most appropriate for medication-assisted treatment.

 

 

 

 

Not Dying: A Worthy Goal

 

 

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

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

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

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

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

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

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

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

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

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

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

So what does this study tell us?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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