Archive for the ‘Governmental solutions to addiction’ Category



Last week, I told my readers about a letter I sent to my local newspaper, trying to explain the usefulness of methadone (and buprenorphine) treatment for opioid addiction. Happily, my entire letter was published in our local paper under the heading of “Guest Columnist.”

I was elated, especially since this piece of writing was on a topic about which I’m passionate.

I checked Friday’s paper to see if anyone had responded to my column. There were no replies, but there was another article in that issue, titled, “Task Force Targets Schools.”

This article was about the meeting of a drug abuse task force formed earlier this year by local people. Before you ask, yes, this is in the same county where Project Lazarus, founded in 2008 in response to high drug overdose death rates, has its headquarters. And no, I do not know why people in this new task force feel the need to re-invent the wheel, particularly in an area where the prior inventors of the wheel have had such success and nationwide praise. Indeed, many other areas of the country have copied the Project Lazarus model of addressing the multifactorial causes and contributors of addiction

Anyway, I don’t know the motivations of this new task force. Interestingly, this quote was found early in the article: “Education and dissemination of information appears to be the greatest way the task force can make a difference.” This was said one of the co-chairmen of the organization. This quote was in the context of providing information to youths to prevent drug use and drug addiction.

I sure as hell wish that statement also applied to facts around treatment of addiction.

At some point, methadone apparently became the topic of discussion, which was a shame, because task force members sound like they don’t know anything about methadone. I wish they would have read my guest column two days prior!

Here’s a quote from the paper from one of the task force members: “From the way I understand it, the methadone clinics are not weaning these people off methadone. They’re going for treatments and they’re just going and going and going,” According to the article, he also said that state government should be involved in requiring plans that give people certain amounts of time to be off methadone and then with helping them.

Then the co-chair of the task force, a law enforcement trainer at the local community college, said methadone clinics are supposed to have personalized plans for people who come in for treatment. “It doesn’t appear that those plans are followed exactly the way they should be,” he added. “It’s a business model.”

I’m not sure what qualifies this man to know how long methadone should be prescribed for the purposes of treating opioid addiction. He’s not a doctor.

Then another person in the task force said the goal is for a person going to one of the clinics to be off methadone in a year, “but that doesn’t happen…. It’s a business.” She said only a small percentage kick their addictions.

Who is this second person? She is – wait for it – a Licensed Clinical Addiction Specialist. She works for a program where we have referred patients in the past.

As all my readers know, I am a calm and patient person who never takes things personally (yeah that’s sarcasm). Even more fortunately, I’m not the litigious type, because when someone says at a public forum that the local methadone clinic keeps patients on methadone because it’s a business model, that’s a defamatory statement. That implies I prescribe methadone to make money and not to help patients. This statement attacks my character as the medical director of that program, and cast dispersions on my professional integrity.

Drug addiction treatment should be about science, not opinion.

I know the right thing to do, the grown-up thing to do… call task force members and politely offer to educate them about MAT.

I’ll get there. But right now, I’m not ready to be a grown up.

Heroin Epidemic versus Pain Pill Addiction Epidemic

aaaaaaaaaaaaaaaaaagraph of heroin deaths

I’m surprised at all the coverage heroin addiction has received in the past few months. Breathless headlines are appearing in all forms of media about our “new” addiction problem. Friends send me links to articles about addiction since they know that’s the field I work in. I’m as surprised to see all the media coverage now as I used to be puzzled about the lack of coverage five years ago. I’ve been treating opioid addiction for the last fourteen years, and the opioid addiction epidemic isn’t new. It’s been very well established for years.

Perhaps the idea of using heroin jolts people more than the idea of using prescription opioids. Maybe people don’t understand that prescription opioid addiction has the same physiologic process as heroin addiction. Manufactured pain pills have less variation in content than balloons of black tar heroin, so there may be less risk of overdose. However, the body responds the same to both types of opioids. The body develops addiction and physical dependency in the same way to both heroin and prescription opioids, and withdrawal symptoms and cravings are the same. Both overdose and death happens with both types of opioids.

Perhaps heroin is perceived as the hardest of hard drugs, and therefore data about heroin addiction captures more attention than pain pill use. Maybe the use of heroin crosses a line that’s not perceived by prescription opioid addiction.

Can it be that there are still people who believe if it is a prescription medication, that it’s safe? Or is it just easier to justify the misuse of a pain pill? Communities with years of rampant pain pill addiction are only now wringing their hands because of heroin addiction. These communities are now demanding action from our government.

I’m glad for the attention to the problem of opioid addiction because I’ve seen way too much complacency about this issue for way too long.

I’m also irritated.

In 2009, I wrote a book about pain pill addiction. I was extremely lucky to get an agent, and she shopped my book to four or five mid-level publishing houses. They weren’t interested because they felt the book didn’t have a broad enough appeal. I ended up self-publishing, and sold around 500-600 copies. That’s not too bad for a self-published book, but distribution could have been much broader through a publishing house. Having my book turned down by publishers with an utter lack of interest in the subject matter undoubtedly causes some of my irritation.

I went to the ASAM conference where the head of the CDC pledged to get involved in the treatment and prevention of opioid addiction. Don’t get me wrong; that’s a wonderful thing to hear. The problem is, that was in 2012.

For all who’ve just joined the movement to help opioid addicted people get help, welcome. I’m glad you’re here, and we can use your help. And forgive me for wishing you had been interested in this problem ten years ago.

Mandating Physician Education


In May of this year, Massachusetts Senator Ed Markey proposed a new bill titled the Safe Prescribing of Controlled Substances Act. This Act, among other things, calls for mandatory education of the nation’s physicians about, as the name implies, safer prescribing of controlled substances. It also calls for mandatory education about identifying patients with substance use disorders.

Physicians get very little education about this tremendously important problem. Some medical schools and residencies have added addiction trainings, but change happens slowly. Plenty of doctors in the U.S. are still mis-prescibing

Physicians are not going to like this legislation. We hate being told we have to do anything, especially by politicians. But obviously, the present generation of physicians is NOT able to prescribe controlled substances properly, as evidenced by our epidemic of prescription drug addiction.

The bill extends to any prescriber of controlled substances, meaning that physician assistants and nurse practitioners will also be required to take this training, at least in states where they are allowed to prescribe controlled substances.

Senator Markey’s bill says the Department of Health and Human Services is responsible for producing this training and that it will be free and available online.

The bill specifies the training should include, “methods for diagnosing, treating, and
managing a substance use disorder, including the use of medications approved by the Food and Drug Administration and evidence-based non-pharmacological therapies.”

If everyone interprets this paragraph as I do, this would mean all doctors who want to prescribe controlled substances should be educated about medication-assisted treatments of opioid addiction, among other things.

That would be wonderful. How nice it would be for my patients to go to their other doctors, and hear, “So glad you are on methadone for the treatment of addiction. Good job.” instead of the usual insults about being on of MAT. How nice for me to be able to call other doctors who don’t think I’m a drug pusher for prescribing MAT!

Also, Senator Markey sent letters to the VA, Defense Department, and IHS, urging them to included prescribing information to their patients on their state’s prescription monitoring program. Many patients being cared for by these agencies are prescribed controlled substances, but doctors outside those systems have no way to know what is being prescribed. Presently, they don’t report to the prescription monitoring programs. I hope these military agencies chose to participate in the PMPs. It would be a way to keep those patients safer when they seek care outside the military system.

On May 15, 2015, the Huffington Post had an online article about another bill, the Recovery Enhancement for Addiction Treatment Act, also sponsored by Senator Markey and Senator Rand Paul. This legislation would lift the one-hundred patient limit placed on office-based buprenorphine doctors.

In the past, I supported lifting the one-hundred patient cap, but I’ve come to believe the cap isn’t all that relevant, at least in my area. Around here, I think the only physicians who honor the cap are conscientious doctors who would do a good job without legislation.

Around here, physicians have more than one hundred buprenorphine patients, and skirt the regulations by saying some of them are prescribed it “for pain.” Physician extenders without DEA “X” numbers already prescribe buprenorphine in this state. When the North Carolina medical board was notified about this, they declined to take any action.

In other words, the present regulations are flouted without consequence, so lifting them isn’t going to make a big difference. (That may not be the case in all areas of the country.) But mandating education about addiction and its treatment may help treatment providers deliver better care.

The Billionaire Pill


In a recent Forbes magazine article about this nation’s twenty richest families, the Sackler family was number sixteen on the list. The Sacklers are estimated to be richer than the Mellons, Rockefellers, and Busches. (

You say you don’t know the Sackler family? I’ll remind you. They own one-hundred percent of Purdue Pharma, a pharmaceutical company best known for manufacturing their block-buster drug OxyContin.

This is a bitter pill for me to swallow.

I started working in the field of opioid addiction treatment in 2001. At that time, nearly every opioid addict I saw was using OxyContin as their main drug. Opioid addiction in general and OxyContin addition in particular plagued many small towns and rural areas where I worked.

OxyContin was widely prescribed for pain. This powerful drug was advertised as “The one to start with and the one to stay with,” during sales pitches to rural physicians. OxyContin flooded the black market. Opioid addict quickly discovered OxyContin’s time-release coating could be easily defeated, and the pill was often snorted or injected for the rush of opioid euphoria it produced.

I was certainly not the only doctor to notice the rise of OxyContin addiction.

Barry Meier’s book Pain Killer: A “Wonder” Drug’s Trail of Addiction and Death (Rodale Books, 2003), tells the story of small town doctors trying to get the attention of Purdue Pharma, the government, or anybody else who could help change the destruction OxyContin was doing to Appalachia around that time.

I remember attending a pain and addiction conference around sometime around 2003 or 2004. At the end of the lecture explaining how opioids could be prescribe safely, a doctor from Virginia dared to ask the experts something along the lines of, “What are we going to do about OxyContin?” I thought to myself that I was glad someone had finally said what I was thinking.
This was a long time ago; I don’t remember exact words, but my memory is that he was soundly rebuffed for daring to mention one specific drug by name. He was scolded and told that the real problem was with opioids in general, and one drug company (who happened to have some of the lecturers on their payroll) should not be singled out as the problem.

I remembered wishing those experts could spend a day at my treatment program talking to the OxyContin addicts.

Eventually, the U.S. General Accounting Office asked for a report about the promotion of OxyContin by Purdue Pharma. By 2002, prescriptions written for non-cancer pain accounted for 85% of the OxyContin sold, despite a lack of data regarding the safety of this practice. By 2003, primary care doctors, with little or no training in the treatment of chronic non-cancer pain, prescribed about half of all OxyContin prescriptions written in this country. By 2003, the FDA cited Purdue Pharma twice for using misleading information in its promotional advertisements to doctors. [1, 2] Purdue Pharma also trained its sales representatives to make deceptive statements during OxyContin’s marketing to doctors. [3]

Testifying before Congress in 2002, a Purdue Pharma representative said the company was working of re-formulating OxyContin, to make it harder to use intravenously. This representative claimed it would take several years to achieve this re-formulation. The re-formulated OxyContin was finally approved by the FDA in 2010, eight years later. Currently, this medication forms a viscous hydrogel if someone attempts to inject or snort the medication. It isn’t abuse-proof; probably no opioid will ever be so, but it is much more abuse-deterrent than the original.

Did Purdue Pharma drag their feet in this re-formulation? Experts like Paul Caplan, executive director for risk management for the drug company, said there were issues about the safety of incorporating naloxone into the pill to make it less desirable to intravenous addicts. He also pointed out that some delay in approval was due to the FDA.

For comparison, Sterling Pharmaceutical, when it became widely known patients were abusing their pain medication Talwin, re-formulated within a year, adding naloxone to the medication and reducing its desirability on the black market. Since this was in the 1980’s, I would assume there was less technology to help back then, compared to 2002.

I’ll let readers draw their own conclusions.

In May of 2007, three officers of Purdue Pharma pled guilty to misleading the public about the drug’s safety. Their chief executive officer, general counsel, and chief scientific officer pled guilty as individuals to misbranding a pharmaceutical. They did no jail time but paid $34.5 million to the state of Virginia, where the lawsuit was brought.

The Purdue Pharma Company agreed to pay a fine of $600 million. Though this is one of the largest amounts paid by a drug company for illegal marketing, Purdue made 2.8 billion dollars in sales from the time of its release in 1996 until 2001.

None of the Sackler family members were charged, because they were not involved in the day to day running of the company.

And now the Sackler family is worth billions.

1. General Accounting Office OxyContin Abuse and Diversion
report GAO-04-110, 2003.
2. United States Senate. Congressional hearing of the Committee
on Health, Education, Labor, and Pensions, on Examining
the Effects of the Painkiller OxyContin, 107th Congress, Second
Session, February, 2002.
3. Washington Times, “Company Admits Painkiller Deceit,”
May 11, 2007, accessed online at http://washingtontimes.
com/news/2007/may/10/20070510-103237-4952r/prinnt/ on

New Book About the War on Drugs


I’ve got a great new book to recommend to anyone interested in the U.S.’s failed war on drugs. It’s “Chasing the Scream: The First and Last Days of the War on Drugs,” by Johann Hari. Published in 2015, I heard about this book at an Addiction Medicine conference when it was highly recommended by one of my colleagues.

As the title implies, the first part of the book describes how the war on drugs was initiated, not by the Reagans, but by Harry Anslinger, our first drug war general, back in the 1930’s. Anslinger is portrayed as an arrogant man, close-minded, filled with hubris, and lacking in compassion. He played on the public’s worst prejudices in order to get draconian drug laws passed, and showed no mercy enforcing them. He fanned the flames of public fears of drug-intoxicated minorities in order to expand his scope of power and prestige. His statements, preposterous from a medical point of view, still echo in the mouths of politicians today.

The author says Anslinger helped to create U.S.’s first drug lord, Arnold Rothstein, who is only the first of many ruthless gangsters to follow. Demand for drugs in the face of strict drug laws creates irresistible opportunities for criminals. The book describes how the war on drugs re-incarnated Anslinger and Rothstein with each generation; the names change but the tactics and destruction remain the same.

It’s an interesting concept.

Part Two of the book describes the lives of drug addicts. The author shows how people with addiction are forced to behave like sociopaths in order to maintain their supply of drugs. For example, many addicts deal drugs on a small scale to help finance their own drug use, an action they would be unlikely to undertake without the strong motivation of their own addiction.

The author goes on to illustrates how police crackdowns on drug dealers actually lead to increased gang violence. When top drug-dealing gang members are jailed, it creates a power vacuum, which leads to increased violence as rival gang members jockey for positions of power. Ultimately, the amount of drug dealing remains the same.

His reasoning does make sense, and is backed by interviews from urban bystanders in the violence of drug wars, both in the U.S. and Mexico.

This section of the book also discusses the inequalities of the drug war. The war on drugs is really a war on people who use drugs, and minorities are much more likely to targets of the drug war. Black drug dealers are more likely to be arrested than white dealers. People with money and influence aren’t targeted, while police go after the downtrodden, less likely to mount legal defenses if treated unfairly. Police do this in order to meet arrest quotas with less trouble from those targeted.

I could believe this, but then in the same section, the author also accuses police of expanding their budgets by confiscating high-dollar cars and homes from the rich people caught in the drug wars. So that was a little contradictory.

The author points out how a youngster who gets arrested for a drug offense is unemployable for the rest of his life, and how he can’t get student loans or public housing. To me that sounded a little overblown, since I know people who have managed to go to school, get their GED, then get a college education and even an advanced degree. I’m sure having a crime in one’s background makes this more difficult, but not impossible. That makes me question the accuracy of the author’s other assertions. For example, I have no idea if a drug charge eliminates all possibility of public housing.

Part three of the book is hard to read. In it, the author describes inhumane treatment of addicts who have been jailed. Arizona is noted for being a particularly brutal state for addicted inmates.
Inmates in general in the U.S. are treated horribly but no one seems to care, since few people have compassion for criminals.

This same section of the book also describes the horrible violence in Mexico brought about by the U.S. demand for illicit drugs. With so much profit to be made, drug cartels become ruthless. The author says in order to make sure other potential rivals stay in fear, dealers must engage in ever-increasing violence and depravity.

The fourth section of the book presents interesting ideas. First of all, the author claims the desire to get high is nearly universal. Far from being a deviant desire, the author advances the theory that the desire for intoxication is found in all humans in all civilizations at all times of human existence. He questions the goal of eliminating all drug use, and says it isn’t realistic.

I agree with him. The desire for euphoria is hard-wired into humans. When that urge runs amok, we may seek to satisfy that desire incessantly with drugs or other destructive behaviors.

The author then describes how life events affect the risk of addiction as if this were something new, but we’ve known for years that stress affects addiction risk. People who have experienced abuse and deprivation as children are more susceptible. But then the book connects our society’s present method of dealing with addiction, which is to shame addicts and cause them more pain. This approach is, predictably, counterproductive.

He says the more drug addicts are stressed, forced to live in poverty, are ostracized and shamed, the less likely they are to be able to find recovery.

Then the book goes into a weird tangent, saying that opioid withdrawal really isn’t all that bad, and the withdrawal is mostly mental in nature. He quotes some scientists who say that people living interesting and productive lives don’t get addicted, because they are happy. The book implies that the biological model has been overblown and scientists ignore the psychosocial components that cause addiction.

He’s wrong. Experts in addiction and its treatment haven’t forgotten the psychosocial components of addiction. But for decades, people have argued addiction is just bad behavior. They say addicts need punishment, rather than coddling in treatment programs. These people completely denied scientific components of the disorder. As a result, scientists interested in treating addiction poured money, time, and energy into proving the scientific portion of the disease. But now the same people who said there was no science to support addiction as a disease complain that scientists ignore the role of psychosocial factors that cause addiction.

In reality, both biologic AND psychosocial factors influence who becomes addicted. It isn’t either/or but both/and. It isn’t productive to argue about which is more important, because both types of causative factors need to be addressed in the disease of addiction.

The fifth part of the book is the most interesting. Chapters in this section describe the changes that occurred when drug addiction was treated more as a public health problem and less like a crime.

In a grass roots organization in Vancouver, Canada, a heroin addict managed to mobilize people to approach heroin addiction in a completely new way. This addict unified addicts and the people who care about them to create political pressure. This group attended town meetings, protested, and organized people who cared about the marginalized addicts of Downtown Eastside of Vancouver. Eventually, this organization managed to create such a stink that the mayor of Vancouver met with this addict-leader, and was so impressed by the insights and arguments that he authorized the establishment of a safe injection house.

Ultimately, Vancouver had one of the most progressive and harm-reduction oriented policies on drug addiction. Their overdose death rate plummeted. Health status of addicted people improved.

Similar harm reduction policies were enacted in Great Britain and in Switzerland, with similar reduction in overdose death rates and in improved health status for drug addicts. In Great Britain, physicians could legally prescribe heroin for opioid addicts for a period of time, from the mid-1980’s until 1995, when this program was ended. All of the health gains – reduced overdose deaths, reduced crime, reduced gang activity, and improved physical health for the addicts – were instantly reversed as soon as the program was stopped.

An entire chapter is dedicated to the changes seen in Portugal, where drugs are now decriminalized, but not legalized. This means thought drug use is not a crime, selling these drugs is still illegal. This chapter describes the changes that happened in Portugal, where harm reduction and public health strategies were enacted beginning in 2001. The nation has one of the lowest rates of illicit drug use in the world, though it’s important to understand that heroin has traditionally been the main drug of this country. Addicts’ lives are more productive and death rates are down. Crime rates dropped, and now the whole country supports these harm reduction strategies to the draconian drug laws that Portugal had in the past.

Near the end of the book is a chapter about what is happening in Uruguay, a small South American country where drugs are now not only decriminalized but legalized.

Anyone interested in the creation of a sound drug policy needs to read this book. It’s extensively researched, and the author spoke with many of the key individuals responsible for changes in drug policy all over the world. I haven’t critically researched all data he quotes in his book about the results of drug decriminalization and legalization, but he gives references for much of what’s contained in the book so that any interested reader can do so.

This book is uniquely interesting because the author combines data and statistics with personal stories of various addicts and their families. This technique combines the power of individual story with the facts of a more objective and detached view.

I don’t agree with all of the authors conclusions. For example, when he tries to say addiction is more about a person’s socioeconomic and emotional status rather than about the drugs…nah. Addiction is not all about the addictive nature of the drug itself, but it is a major factor. When you discount the euphoric attraction of opioids, cocaine, and the like, you risk misunderstanding a huge part of addiction. When a substance produces intense pleasure when ingested, it’s more likely to create addiction. After all, we don’t get addicted to broccoli…

It’s important to know this author has been in hot water in the past, accused of plagiarism. Knowing this made me a little distrustful of his interviews with people throughout the book, but I think the ideas illustrated by the interviews are still valid.

It’s a book filled with food for thought.

Durham, North Carolina: First in the South to Provide Naloxone to Departing Inmates


The county jail’s addiction treatment program in Durham County, North Carolina, just started giving naloxone overdose prevention kits to inmates leaving their program.

This program, called STARR (Substance Abuse Treatment and Recidivism Reduction) consists of around 83 hours of group therapy, addiction treatment education, and weekly 12-step meetings. STARR participants are also taught how to respond to an overdose, and how to use naloxone. Inmates completing this program are also eligible to enter an additional voluntary four-week program known as GRAD. All graduating inmates are offered a naloxone kit.

At any one time, the STARR program has about 40 inmates in treatment.

Only three county jails in North Carolina offer addiction treatment services. Besides Durham County, Mecklenburg and Buncombe Counties have similar addiction treatment programs, but neither of the latter two offer naloxone kits. The development of education and prevention of overdose was achieved only after long efforts by the STARR program’s director, Randy Tucker, collaboration with the Harm Reduction Coalition.

Durham County is setting the right example for the rest of the nation.

It’s important to teach inmates with addiction how to avoid overdose. Inmates with addiction are at high risk for a fatal overdose during the first few weeks after their incarceration. While in jail, their tolerance has dropped. If they leave jail and relapse using the same amount as before they went to jail, an overdose is likely, particularly if they are using opioids.

Studies on all continents show this marked increase in overdose death among opioid addicts leaving incarceration. The degree of increased risk is debatable. Some sources say the risk is increased four-fold and others estimate a hundred-fold increase in overdose deaths risk, mostly within the first two weeks after leaving incarceration.

Last year, four people leaving the Durham County jail had fatal overdoses.

If the US treated addiction as the public health problem that it is, all state, county, and federal jails would provide naloxone upon dismissal from incarceration. (I won’t even get into the arguably more important issue of providing adequate addition treatment to inmates whose main problem is addiction). But we don’t do that in this country, still preferring to see addiction as bad behavior by deviants.

Ferguson, Missouri…Baltimore, Maryland…think how the attitudes and outlook of citizens could change, if jailers started handing out naloxone kits to departing arrestees.

Even without words, this action would go a long way toward giving arrestees the message that law enforcement saw their lives are valuable and worth saving.

New OTP Guidelines Issued by SAMHSA


Our nation’s Substance Abuse and Mental Health Services Administration just published new guidelines for opioid treatment programs, released in late March. SAMHSA updates the guidelines in order to re-interpret the existing federal regulations in the face of changing medical issues faced by opioid treatment programs in this country.
I can’t list all the updates in a single blog entry, but I’ll comment on those I find most interesting and relevant. If you want to read the entire SAMHSA document, you can get a free download at:

First of all, near the beginning of the document, it says the new guidelines reflect the responsibility that OTPs have to deliver “patient-centered, integrated, and recovery oriented standards of addiction treatment and medical care in general.”

I’ve long marveled at how, in the mental health and addiction treatment field, so many words can be used without saying much of anything. (I once heard the head of a federal government agency talk for forty-five minutes and say absolutely nothing. That is a gift.) Also, words and phrases in this field take on meaning beyond what those words traditionally mean. Innocent-looking phrases take on coded meanings.

For example, “recovery-oriented”…what does that mean? Part of what this phrase seems to mean is the same as what “harm reduction” meant in the past, except it became so controversial that we needed a new phrase.

Recovery-oriented means a patient’s recovery program may not look like what we’ve imagined in the past. Maybe the patient isn’t fully abstinent from all drugs, but if the patient is doing better than in the past, we accept that as a worthy accomplishment. Rather than black and white thinking of abstinence as the only recovery and any drug use as a full relapse failure, recovery-oriented approach means accepting any change for the better as a worthy goal.

I am fine with this. The field of medicine is harm-reduction. At least, that’s what it’s like in primary care. It may be different in surgery, where the diseased gall bladder can be cut out and the patient is permanently cured of gallstones. But much of primary care is all about keeping the patient as healthy and functional as possible, for the longest time possible, despite some non-compliance on the patient’s part. It makes sense to view the treatment of addiction in the same way.

Integrated: the bane of my existence…it means all people caring for the patient, plus the patient, TALK to one another. I’ve whined on this blog before about the difficulty of talking to my patient’s other doctors so I agree it’s a big problem but SAMHSA’s kind of preaching to the choir with that one.

It also means getting the patient’s family and/or friends involved if possible and if OK with the patient, along with other supports available in the community.

These new SAMHSA guidelines also tackled new technologies, like telemedicine.

Patients in remote locations can now communicate with care providers using new technology, sometimes called telemedicine, or e-therapy, or telehealth. This technology can make care more convenient for patients who live in remote areas, and encourage more participation in care by making it easier to access. These are worthy goals, but of course there are also risks.

Since Medicaid and Medicare services already has guidance for this type of care, the new OTP guidelines remind us of we have to do if we treat patients with Medicaid or Medicare… and want to get paid.

The new OTP guidelines make several points. They remind us that providers need to follow their own states’ laws around telemedicine, and to make sure transmissions of data during telemedicine are secure, relatively resistant to hacking. The guidelines also remind us telemedicine can’t expand a provider’s scope of practice (what the provider is allows to do, medically speaking), and that telemedicine can’t be used in situation where physical exam is necessary.

At first, I interpreted this to mean that admission to opioid treatment programs cannot be done by telemedicine, since a physical exam is required. But then I read this sentence: “…[telemedicine] may be used to support the decision making of a physician when a provider qualified to conduct physical examinations and make diagnoses is physically located with the patient.”

So can a physician assistant do the exam and relate finding to a physician who then can order the starting dose? I think that’s allowed by this sentence, at least by federal standards. State standards may vary, though.

This discussion naturally leads to another big expected change in the new guidelines. Many people working at OTPs expected these new guidelines to permit physician extenders like nurse practitioners and physician assistants to do admission history and physical exams for OTP patients, give induction orders, and do dose change orders.

This did not happen. Apparently, according to discussion at the AT Forum ( ) SAMHSA’s lawyers put a halt to this, and said physician extenders could not do these things. The lawyers said that implementation regulations say “dosing and administration decisions shall be made by a program physician familiar with the most up-to-date product labeling.”

I have mixed feelings about allowing physician extenders, by which we mean nurse practitioners and physician assistants, to do admission orders. Often, patients presenting for OTP admission are complex, with both chronic pain and addiction issues, sometimes also with severe mental health disorders. I don’t think a new nurse practitioner graduate with little experience could do the job without a whole lot of special training. On the other hand, I know a physician assistant, working in the Addiction Medicine field for years, who is as good if not better than many doctors in the state. He’s competently been doing admissions and dose changes for years.

Thankfully, a sort of compromise has been proposed. Treatment programs can ask their state opioid treatment authority (SOTA) for an exemption from usual regulations, to allow a qualified physician extender to do admission orders and dose changes. Both the program’s medical director and program sponsor must give a clear reason why an extender is necessary to improve care. Then SOTA decides if allowing this particular physician extender enhances the care of patients at that treatment center.

For example, a program in a remote area may have problems finding physicians to work as many hours as the program needs. In that case, the medical director may know a physician extender who is experienced and mature, who could safely meet patients’ needs. That program could explain all of this to their SOTA and get an exemption, permission for the extender to do work ordinarily not allowed by state and federal regulations.

This seems like the best of both perspectives. Well-trained and competent physician extenders can get permission to do this work, while the state can withhold approval for an extender with little experience or training. Hopefully exemptions will be given for legitimate need, and not just because extenders are cheaper to hire than physicians.

Finally, I was pleased this version of the OTP guidelines frankly discusses the dangers of benzodiazepines: “…Benzodiazepines are highly associated with overdose fatalities when combined with opioids. Patients known to be using benzodiazepines even by prescription should be counselled as to their risk and provided with overdose prevention education and naloxone.” The guidelines go on to recommend providers consult IRETA’s best practices guidelines around how to manage the benzo issue without overreacting in either a too permissive or too restrictive manner.

Regular readers of my blog will recall I did several blog posts, in 1/26/14 and 2/2/14, about the IRETA guidelines when they were first published.

In the past, SAMHSA guidelines didn’t speak to the dangers of mixing benzos with MAT, leading some doctors to underestimate the dangers to MAT patients. In some areas, where benzos are prescribed appropriately, it’s not a big issue. However, in geographic areas (like the South) where benzos are commonly prescribed outside of accepted guidelines, it’s a huge problem. I often see patients prescribed benzos literally for years, despite guidelines which say benzodiazepine usefulness is limited to a few weeks to months. There’s no evidence benzodiazepines are of benefit past that, and mounting evidence indicates that they can be harmful (overdose, increased risk of falls and motor vehicle accidents, broken bones especially in the elderly, etc.)

I did find one sentence on naloxone, the medication that reduces opioid-overdose deaths, under the section on orientation to treatment. It says OTPs should provide patient education, including “Signs and symptoms of overdose, use of the naloxone antidote (prescriptions should be given to patients on entry into treatment), and when to seek emergency assistance.”
It’s not much, but it’s a start.

Use of prescription monitoring programs was mentioned repeatedly in these new guidelines. In 2007, when the last guidelines were published, many states didn’t have prescription monitoring programs. My state’s PMP was just becoming available in 2007, so it was a new and exciting tool.

Sections of the present SAMHSA guidelines strongly recommended the PMP be used upon admission to an opioid treatment program, and periodically during OTP treatment. The guidelines suggest the PMP be checked quarterly, which should be do-able.

I think SAMHSA’s new guidelines bravely addressed some of the problem areas of OTPs and gave some direction to programs about these issues. It’s not a perfect document, but it appears much thought and discussion was given to these issues.


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