Archive for the ‘injecting drugs’ Category

Avoiding Overdoses

August 31: Overdose Awareness Day

 

 

 

“I’m not gonna overdose. I know my limits.”

I really hate hearing these words. Usually patients say this in response to my concerns about their pattern of drug use while I’m prescribing methadone or buprenorphine. But many patients feel like they are the experts. They can’t imagine making a deadly mistake with their drug use. But I’ve heard this phrase, or something close to it, from at least five people who are now dead from overdoses.

I was reminded of this situation after reading an article in the latest issue of Journal of Addiction Medicine. Najman et al. wrote an article titled “When Knowledge and Experience Do Not Help: A Study of Nonfatal Drug Overdoses.”

The author of the study looked at nonfatal overdoses in Australia in 2013, where overdose deaths have risen steadily since 2007. In that country, unlike the U.S., heroin use is declining while pharmaceutical opioid misuse is rising.

This study looked at nonfatal overdoses in people who inject drugs. These people, identified by the needle and syringe exchange programs in Australia, were interviewed about the circumstances surrounding these overdoses, in order to get a better understanding of the risks. A total of 50 people were interviewed for this study.

Most of these people were male, middle-aged, single, and unemployed. Nearly all were smokers. Half had a diagnosis of liver disease and almost all reported a mental health diagnosis. Most injected pharmaceutical opioids, though some also injected heroin and methamphetamine. These were very experienced drug users, with an average of 21 years of intravenous drug use.

Surprisingly, more than half of the study subjects were in some form of treatment for substance use disorder. This finding is contrary to other studies, which have found being in treatment lowered the risk for overdose. Around 46% were in medication-assisted treatment with either methadone or buprenorphine. However, some of the overdoses happened on days that the person missed dosing for some reason, and substituted another opioid such as heroin or fentanyl. Thirty-two percent of study subjects dosed with either methadone or buprenorphine in the twenty-four hours prior to experiencing their overdose.

Most of these overdoses happened in private homes, and around half received some sort of folk remedy for overdose such as being slapped, put into cold water, or being shaken. Naloxone kits weren’t routinely being distributed at the time of this study.

When asked about the cause of their overdose, many the subjects said they were impaired by alcohol or benzodiazepines. Over half said they used benzodiazepines within twenty-four hours of their overdose. Of the 50 subjects, 64% said they had been prescribed anti-anxiety medications sometime in the year prior to overdose, and 38% said they’d been prescribed sleeping pills. Another 36% said they’d been prescribed some sort of tranquilizer in the year prior to overdose. I’m assuming many of the subjects were prescribed more than one of these groups of medications.

Alcohol was not as prominent as sedative medications as contributory cause of overdose; only 34% of subjects said they had some amount of alcohol in the twenty-four hours prior to their overdose.

Over a third of subjects had used fentanyl, a very powerful opioid, leading up to the overdose.

The authors of the study concluded that these experienced drug users were aware of common risks for overdose, yet drug intoxication from sedatives such as alcohol or benzodiazepines may have clouded the user’s thinking when injecting opioids. They also found that unexpected availability of drugs contributed to overdoses.

It’s an interesting study, and a little disturbing to me, particularly the data about overdoses in people who were enrolled in medication-assisted treatments. It does underline the importance of daily dosing of MAT, and the importance of avoiding alcohol and benzodiazepines in patients on MAT.

And if you didn’t know…August 31 is International Overdose Awareness Day.

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Opioid Addiction from Different Perspectives

Perspective is Essential

 

 

 

 

 

 

 

 

I was asked to speak as a member of a panel about opioid use disorder, at the annual addiction conference at the University of North Carolina at Charlotte (UNCC) this month, called the McLeod Institute. This conference was named after Dr. Jonnie McLeod, a great leader in the field who passed away several years ago.

I’ve spoken at this conference several times before, and it’s always a treat. It lifts my spirits to see new recruits entering the field of substance use disorder treatments, all fresh-faced and enthusiastic.

One whole day of the conference was devoted to the problem of opioid use disorders, and I’m sorry I couldn’t attend the morning’s events. After lunch, the five of us on the panel took our seats.

At one end was the operator of an abstinence based, 12-step oriented non-profit outpatient treatment program, one of the best in Charlotte. To his left was a Charlotte-Mecklenburg police officer whose focus was on interdiction of heroin flooding the streets of Charlotte. Then there was me, and to my left was Donna Hill, program director for Project Lazarus in Wilkes County. At the extreme left was Jennifer, a social worker from New Jersey with many years of experience in the substance use disorder counseling field.

We all introduced ourselves and said a little about how we approached the treatment of opioid use disorders. When it was my turn, I did my usual spiel about how treatment of opioid use disorder with medications including methadone and buprenorphine and naltrexone are the most evidence-based treatments available, yet still have the most stigma against them. I told them our country overused treatments that don’t work, sometimes over and over. I told the audience I worked for an opioid treatment program and had my own office-based practice where I prescribe buprenorphine.

The whole point of the panel was to allow the audience to hear the different viewpoints on our nation’s problem with opioid use disorders, and the panelists didn’t disappoint.

Of course the director of the 12-step oriented, abstinence-based outpatient program advocated for that form of treatment. He made some neutral-to-negative comments about MAT, but he wasn’t as vehement as I expected.

The police officer, not being involved in treatment, mainly gave facts about how awful the heroin problem is in Charlotte. He said it was one of the two hubs, along with Columbus, OH, that drug cartels were using as a base for sales to all the other towns in the Eastern U.S. He explained how the purity had risen and how fentanyl and carfentanil were now being added to heroin or being sold as heroin, because they were cheaper to make and many times more potent. He repeated the account of a police officer who had to be treated for a severe overdose that happened just from brushing heroin off his sweater. (I did read about that on the internet and had some questions regarding the story but wasn’t about to quibble with a man with a gun.)

Donna from Project Lazarus probably could have justified talking the longest, since Project Lazarus is active in so many aspects of treatment, prevention, education, and community outreach, among other things. She gave a nice summary of all the things Project Lazarus does, and encouraged people to call them if they wished to set up a similar organization in another place.

Jennifer the social worker said some good things about how all of us treating opioid use disorder need to work together and communicate, but then, in my opinion, she blew it when she said she disapproved of how treatment programs take advantage of people with opioid use disorders by charging them money to be in treatment. At first I didn’t know exactly who she was targeting but when she said clinics discouraged patients from getting off methadone and buprenorphine only because it was bad for their business, I felt my ire rising.

You know I had something to say about that.

I got a little heated, and said I didn’t think it was fair to imply opioid treatment programs were unethical because they charge patients money to be in treatment. I said other medical specialties charge money for their services, and that this was the way this country approached healthcare. I went on to say that opioid treatment programs don’t keep patients on methadone because it’s a business model; it’s because patients who leave methadone treatment at an OTP have an eight-fold increase in the risk of dying, and a high risk of relapse with all the misery that can come with it: poorer mental and physical health, fractured relationships, damaged self-esteem, lowered personal productivity.

After all, I said, is there any other medication for any other disease that reduces the risk of death by eight times, that has the stigma against it that methadone does?

OK…it’s possible I’m more lucid as I’m writing this than I was in the moment, but I blurted out something to this effect.

Other than that incident, I was relatively well-behaved.

I liked all my fellow panel members, even though we didn’t agree about everything. We all agreed on the most important thing – we all want to keep people from dying from opioid use disorder, and we all want them to find a good quality of life in their recovery.

I stayed to listen to the second panel, composed of people in recovery from opioid use disorder. There were six people on that panel, and of the six, five were either neutral or critical of methadone or buprenorphine. These five people all said that 12-step recovery in Narcotics Anonymous allowed them to quit using drugs and live a successful recovery.

The last patient was different. She gave a brief history of her recovery, and said that though she found 12-step recovery helpful, she needed methadone to return her to a place where she could function normally. She described being off opioids for some months, but being plagued with post- acute withdrawal that ultimately lead to a relapse. Now, she considers methadone a necessary medication for her, and said if she had to be on it for the rest of her life in order to feel normal, she could accept that.

I was so impressed with this lady’s courage. It had to be hard to follow five peoples’ stories that all centered on abstinence-based recovery with her story of being in a form of treatment with so much stigma against it. I was very pleased by what she was saying, and felt like she was speaking for all the people who have benefitted from medication-assisted treatment.

I was disappointed there wasn’t more diversity on this panel. I don’t doubt the other five peoples’ recovery stories, but they were very similar. One of them spoke very negatively about methadone, but later revealed she misused her methadone to an extreme degree and came off a relatively high dose “cold turkey,” which of course is not recommended. Another six people in recovery from opioid use disorder may have the opposite experience with 12-step recovery and medication-assisted treatment

I was socializing with some of the panel members before leaving, and to my surprise, the operator of the non-profit abstinence-based outpatient program told me he was sorry if it sounded like he was trying to bash methadone treatment. I was surprised and pleased, and thanked him.

I’m glad I was there, and I’m glad to see fresh recruits joining the effort to help people with opioid use disorder in their recovery.

Naloxone in Action


At the recent American Society of Addiction Medicine (ASAM) conference, I read a poster describing a study entitled “Lives Saved with Take-home Naloxone for Patients in Medication Assisted Treatment.” The article, by Katzman et al., from the University of New Mexico School of Medicine, described the outcomes from providing naloxone overdose reversal kits to patients enrolling in medication-assisted treatment of opioid use disorders

The study subjects were admitted to medication-assisted treatment over three months in 2016. The poster didn’t say whether they started buprenorphine, naltrexone, or methadone, but I’m guessing the patients were admitted to methadone maintenance.

In the end, 244 subjects enrolled and had education about opioid overdose and how to use a naloxone auto injector kit.

Twenty-nine subjects were lost to follow up, leaving 215 subjects available for inclusion in the study. Of these 215 subjects, 184 didn’t witness or experience overdose.

That means 31 subjects either experienced or witnessed at least one opioid overdose episode.

The scientists conducting the study interviewed these 31 subjects, and discovered that 39 opioid overdoses had been reversed and all of those lives were saved. Thirty-eight people were saved with the naloxone kits distributed by the opioid treatment program, and one study subject was revived by EMS personnel.

When study authors looked at who was saved by these study subjects, they discovered 11% of people saved were acquaintances of the study subjects, 16% were family members, 58% were friends, 6% were the significant others of study subjects, and 13% were strangers.

The study authors concluded that “a significant number of lives can be saved by using take-home naloxone for patients treated in MAT [medication assisted treatment] programs.” The authors also felt the study showed that naloxone isn’t usually on the patient who entered treatment, but more frequently on friends, relatives, and acquaintances that the MAT patient encounters.

I was intrigued by this study because it mirrors what I’ve heard in the opioid treatment program where I work. We are fortunate to get naloxone kits from Project Lazarus to give to our patients. It’s rare that one of our patients enrolled in treatment needs naloxone for an overdose, but much more frequently, I hear our patients say they used their kit to save another person’s life.

If anyone doubted the abilities of people with opioid use disorders, and felt they couldn’t learn to give naloxone effectively, this study should put that idea to rest. If anyone mistaken thought people with opioid use disorders wouldn’t care enough about other people to put forth an effort to save another person, this study should put that idea to rest, too.

In fact, I’ve seen a real enthusiasm among our patients to make sure they have a kit, in case they get the opportunity to save a life. They are eager to help other people, and I find that to be an admirable attitude that’s nearly universal among the people we treat.

Sometimes I get into discussions with patients about what they think about the naloxone kits, and where they think the kits can do the most good. I’ve heard some good ideas. One patient said every fast food restaurant should have a naloxone kit, since she knew many people with opioid use disorder inject in the bathrooms of these facilities. Actually, I just an online article discussing something similar: http://www.wbur.org/commonhealth/2017/04/03/public-bathrooms-opioids  

This article expresses the problems that injection drug use has become for public restrooms, and makes a case for safe injection centers. This is presently illegal in the U.S.

Even Massachusetts General Hospital armed its security guards with naloxone kits, so they could give this life-saving medication to people they found who had overdosed in the hospital’s public bathrooms.

Another patient suggested giving naloxone kits to people living in trailer parks.

I know that feeds into a kind of stereotype of those who live in trailer parks, but apparently there is some basis for saying such residential areas have high density of people with opioid use disorders. It’s worth looking at.

Several patients said that all people receiving opioid prescriptions for chronic pain should also be prescribed naloxone kits, and I think that’s been recommended by many health organizations too.

Most communities have at least talked about arming law enforcement and first responders with naloxone kits, and hopefully that’s a trend that will continue to spread.

Naloxone isn’t a permanent solution for opioid use disorder, but it can keep the people alive until they can enter opioid use disorder treatment. Because dead addicts don’t recover.

 

Fentanyl is the New Heroin

aaaaoverdose-deaths

 

 

 

Big drug labs in China and Mexico have found it’s cheaper to manufacture the potent synthetic opioid fentanyl than it is to harvest and process opium into heroin. Therefore, much of what is sold as heroin is now mixed with fentanyl and its more potent analogues, sufentanil and carfentanil.

This is causing heroin overdose deaths in the U.S.  The National Institute on Drug Abuse issued a recent report saying that heroin overdose deaths increased over six-fold from 2002 to 2015. This is shown in the graphic at the beginning of this blog.

This problem is worse in some regions of our country than others; the Northeast has traditionally been plagued with heroin deaths at a high rates, but other areas of the country have higher rates of increase in heroin deaths.

There’s no way to know the potency of drugs sold as heroin, making it much easier to overdose and die.

There are some basic precautions that drug users can take to prevent overdose deaths. This is data all comes from the Harm Reduction Coalition:

  • Don’t use alone. Use with a friend, and stagger your injection times so that one person is alert enough to summon help if needed.
  • Have a naloxone kit available and know how to use it. You can get a free kit from many places, including harm reduction organizations. http://harmreduction.org/issues/overdose-prevention/tools-best-practices/od-kit-materials/
  • Do a test dose. This means instead of injecting your usual amount, try a tiny bit of the drug first, to help assess how strong it is.
  • Use new equipment, if possible. Some pharmacies are willing to sell new needles and syringes with no questions asked. Other drug users in your community may be able to tell you which pharmacies are willing to do this.
  • Remember that if you’ve had a period of time where you’ve been unable to use any drugs, your tolerance may be much lower. Highest overdose risk is seen in patients who have just been released from jail, from detox units, or from the hospital. Do NOT go back to the same amount you were using in the past.
  • Don’t mix drugs. Opioid overdose risk increases when other drugs are used too.
  • Consider getting into addiction treatment. https://findtreatment.samhsa.gov/

 

aaaaodpills

 

Treatment Implications for Intravenous Buprenorphine Use

Hokey Pokey

 

 

During the admission of new patients for opioid use disorder treatment, I ask about prior use of all drugs. I include the medications we use for treatment. I’ve done this since I started working at opioid treatment programs (OTPs) fifteen years ago.

Over the last few years, more patients say they’ve used illicit buprenorphine in the past. At first, I saw patients who were using it sublingually (under the tongue), as recommended, though still illicitly. Most of them wanted to see if this medication would work for them before they committed to the time and expense of entering a treatment program.

Over the past six months, I’m seeing more and more new patients who say they’re using buprenorphine intravenously. This past month, I’d estimate that a fourth of the patients who use buprenorphine illicitly are injecting it. Only a few said they snort buprenorphine.

This presents a big wrinkle to the treatment process.

I see why people use intravenous buprenorphine. It has low sublingual bioavailability, at around thirty percent. That means injecting two or three milligrams gives the same blood level as eight milligrams sublingually. In the short term, people injecting buprenorphine feel like it saves them money. In the long term, I’m certain it will cost more than they can imagine.

Buprenorphine tablets and films were not designed to be injected. Pills and films have fillers in them, and they aren’t sterile. Heating a mixture prior to injection will kill off some of the bacteria, so that’s a harm reduction practice. Using a filter can remove some of the particulate matter, also reducing the potential for harm. However, heat and filters can’t remove all the risk of injecting.

People on the internet insist the bioavailability of snorted buprenorphine is higher than sublingual use, but I doubt that. Either way, you bypass the liver because it crosses to the bloodstream via the veins of the nose or tongue. Plus, alkaline environments increase absorption and bioavailability for this drug, and the mouth is more alkaline than the nose.

Of course there is another reason people with opioid use disorder inject or snort their medication. Their brains associate the act of injecting or snorting with pleasure and euphoria, and can become addicted to the process and feeling of both means of ingestion.

Due to the ceiling on buprenorphine’s opioid effect, it is… arguably… one of the safest opioids a person could inject. But intravenous use is never safe.

Here’s only a partial list of complications from intravenous drug use:

  1. Overdose resulting in death, brain damage from low oxygen, stroke or heart attack from prolonged low oxygen
  2. Pulmonary edema (lungs fill with fluid)
  3. Skin abscesses and cellulitis
  4. Endocarditis (infection of heart valve that is life-threatening)
  5. Deep vein thrombosis (blood clot)
  6. Septic thrombophlebitis (infected blood clot)
  7. Contracting infections: HIV, Hep C or B
  8. Bacterial infections and abscesses in weird places like the spine, brain, joints, spleen, muscles, or eye
  9. Necrotizing fasciitis – rapid, “flesh- eating” infection, also botulism
  10. Pneumonia
  11. Septic emboli – when infected clots break off and go to the lungs, brain from infected heart valves
  12. Fungal blood/eye infections – (seen frequently when pills mixed with saliva are injected)

I have seen patients with every one of these complications. Most of them were in the distant past, when I was an Internal Medicine resident during the late 1980’s, but not all of them. Over the past six months, I’ve seen two patients with spinal abscesses from injecting drugs, though not necessarily buprenorphine.

The last time I posted about intravenous use of buprenorphine (November 2015), Dr. Wartenberg M.D. (pioneer in the addiction treatment field) wrote about the mitochondrial disease, which has caused liver failure, in European IV buprenorphine drug users. This disorder is specific to buprenorphine

So what are the treatment implications for a new patient who has injected buprenorphine?

First of all, these patients aren’t appropriate for office-based practices, even if the physician plans to prescribe the combination product with buprenorphine/naloxone. Clearly there are some patients who inject combination products and monoproducts. Granted, it’s less common, but it still occurs. There’s usually not enough oversight available at office-based practices to treat more complicated patients. I think they should be referred to opioid treatment programs, where they can be offered treatment with methadone.

What if the patient refuses methadone for some reason, or their risk with methadone is at too high from a medical view? Should patients with a history of injecting buprenorphine ever be treated with buprenorphine?

I think they can be – with great caution and daily dosing, on-site at the opioid treatment program.

At our OTP, we ask all buprenorphine patients to sit in a designated area while their dose dissolves. It usually takes around ten minutes, and they are watched by program personnel. Before they leave, each buprenorphine patient shows one of the staff their mouth, to show the medication is completely dissolved. It does feel a little “police-y” but we had a high incidence of diversion until we started this close observation.

If a patient tries to spit out their medication, they meet with me. I’m rarely willing to continue to prescribe buprenorphine if it appears they are trying to divert their medication. I meet with the patient and we discuss the option of methadone. If they refuse methadone, we try to refer them to another form of treatment.

If a patient with a history of injecting buprenorphine wants treatment with buprenorphine, I tell him I’m willing to give it a try, but that he can’t expect take home doses for a very long time, after months of observed dosing and stability. So far, this approach seems to be working. These patients are getting counseling, and haven’t attempted to divert their medication, so far as we can see. I’ve checked these patients for track marks, which in all cases appear to be healing, with no new marks.

When/if to grant these patients take homes remains a huge question. I don’t want to unduly burden a patient by insisting he must come every day forever, but I also don’t want to give the patient take home doses that could lead to a relapse back to intravenous use.

Harm Reduction: Use Precautions

aaaaaainjecting

 

 

I’m worried about the people in my community who have opioid use disorders. The rate of opioid overdoses appears to have risen, according to my local newspaper, along with the number of overdose deaths. I think it’s at least partly due to the arrival of heroin in our county. I think it’s time I re-posted some harm reduction suggestions for people who are using opioids.

The ultimate harm reduction measure is to get treatment and get into recovery, but if you aren’t ready for that, please be careful when you use drugs.

You can access all the following information, and more, at: http://harmreduction.org/drugs-and-drug-users/drug-tools/getting-off-right/

This is a link to a booklet about how to inject drugs more safely, downloadable for free, or available in hard copy for a small fee. It contains excellent information which could be life-saving.

  1. Don’t use alone. Use a buddy system, to have someone who can call 911 in case you stop breathing. Do the same for another addict. Obviously you shouldn’t inject at the same time. Stagger your injection times.

Many states now have Good Samaritan laws that protect the overdose victim and the person calling 911 for help, so that police don’t give criminal charges to people who do the right thing by calling for help for an overdose.
Take a class on how to give CPR so that you can revive a friend or acquaintance with an overdose while you wait on EMS to arrive.

  1. Get a naloxone kit. I’ve blogged these kits before, and they are becoming more available. So far, about seven or eight of my opioid treatment program patients have used their kits to save other people. The kits are easy to use and very effective. You can read more about these kits at the Project Lazarus website: http://projectlazarus.org/

Evzio is a commercially available kit, very easy to use, that gives verbal instructions about how to use the kit.

Some states, like North Carolina, now have third party prescribing, meaning if you have a loved one with opioid use disorder, you can request a naloxone kit prescription from your own doctor, to have on hand for your loved one with addiction.

  1. Use new equipment. Many pharmacies sell needles and syringes without asking questions. Other people with opioid use disorder probably can tell you which pharmacies are the most understanding.

    Don’t use a needle and syringe more than once. Repeated use dulls the needle’s point and causes more damage to the vein and surrounding tissue. Don’t try to re-sharpen on a matchbook – frequently this can cause burrs on the needle point which can cause even more tissue damage.

  2. Don’t share any equipment. Many people who wouldn’t think of sharing a needle still share cottons, cookers, or spoons, but hepatitis C and HIV can be transmitted by sharing any of this other equipment. If you have to share or re-use equipment, wash needle and syringe with cold water several times, then do the same again with bleach. Finally, wash out the bleach with cold water. This reduces the risk of transmitting HIV and Hepatitis C, but isn’t foolproof.
  3. Use a tester shot. Since heroin varies widely in its potency, use small amount of the drug to assess its potency. You can always use more, but once it’s been injected you can’t use less. The overdoses on heroin are thought to be due to fentanyl added to the heroin, making it more powerful and more dangerous.
  4. Use clean cotton to filter the drug. Use cotton from a Q-tip or cotton ball; cigarette filters are not as safe because they contain glass particles.
  5. Wash your hands thoroughly before preparing your shot, and clean the injection site with an alcohol wipe if possible. Don’t use lemon juice to help dissolve heroin, as it carries a contaminant that can cause a serous fungal infection.
  6. Opioid overdoses are much more likely to occur in a person who hasn’t used recently or has used less than usual for a few days, weeks, or longer. Overdose risks are much higher in people just getting out of jail and just getting out of a detox. Patients who have recently stopped using Suboxone or Subutex may be more likely to overdose if they resume their usual amount of IV opioids.
  7. Don’t mix drugs. Many opioid overdoses occur with combinations of opioids and alcohol or benzodiazepines, though overdose can certainly occur with opioids alone.
  8. Don’t inject an overdosed person with salt water, ice water, or a stimulant such as cocaine or crystal methamphetamine – these don’t work and may cause harm. Don’t put the person in an ice bath and don’t leave them alone. Call for help, and give mouth-to-mouth resuscitation if you can. And use naloxone if you have it.

To people who believe I’m giving addicts permission to use, I’d like to remind them that people using opioids don’t care if someone gives them permission or not. If they want to use, what other people think matters little. But giving people information about how to inject more safely may help keep them alive.

The Harm Reduction Coalition has excellent information on its website: http://harmreduction.org

In North Carolina, we are fortunate to have a robust Harm Reduction Coalition chapter. You can read more about their remarkable work at:   http://www.nchrc.org/

If you are a person who uses drugs and never plan to quit, your life has purpose and meaning. Use these safety tips to stay around for it.

Buprenorphine: Current Practices

NCSAM

I just got back from the NC Society of Addiction Medicine annual conference. (Yes, I’ve been to several conferences lately.) One of the sessions I attended was a lively discussion of the current practices in office-based prescribing of buprenorphine, for opioid addiction.

The session was run by two experienced, knowledgeable addictionologists, who mediated topics and shepherded the dialogue. One physician works in North Carolina and the other in Tennessee. The room was packed with at least fifty people, most of us doctors who prescribe buprenorphine for addiction.

Deliberations were collegial but we didn’t agree on all issues, of course. Dissenting opinions were respected and debated.

The first topic I can recall was about how often buprenorphine patients need to be seen. Most practitioners agreed that new patients needed to be seen at least weekly initially. As stability develops, we gradually extend the time between visits to one month. One doctor opined that no patient should be allowed to go any more than one month between physician visits. When the moderator asked if anyone disagreed, I raised my hand, and the moderator asked me to explain.

With some trepidation, I told the audience that I had a super-stable group of patients in my practice. I inherited most of them from another physician who was one of the first in the area to prescribe buprenorphine. This group of patients all have over five years of stable and relapse-free recovery. A few have been in stable recovery for nearly ten years. These people work, and have happy and productive lives.

So yes, I do allow these patients to go two months between visits.

No one booed or hissed me, but I got the feeling I’m doing something with my patients outside the realm of normal for most doctors prescribing buprenorphine. Thankfully, the moderator made the point that we should use our clinical judgment and adjust treatment to best fit each situation, which made me feel better.

I was mulling this over later, and maybe I do have an unusual group of patients, who have been stable on MAT for so long. Some of these patients elected to stay on sublingual buprenorphine because they are doing so well on it, and they fear relapse if they taper off of it. Others plan to stay on buprenorphine because they developed addiction as a complication of chronic pain treatment. Happily, the buprenorphine works as well for their pain as it does for their addiction, so we get the two birds with the one stone.

There’s another unusual thing about these super-stable patients: almost all of them are deeply involved in 12-step recovery. Many were in Alcoholics Anonymous prior to their opioid addiction. They developed addiction to opioid pain pills after receiving prescription opioids for an acute or chronic pain condition. Once they started on buprenorphine to treat the opioid addiction, they continued going to Alcoholics Anonymous (a few go to Narcotics Anonymous).. Other patients didn’t start going to AA until after they entered MAT on buprenorphine.

I’ve had many people write comments to my blog, furious when I even mention 12-step recovery and MAT in the same sentence. But I have living proof in my practice of multiple patients on medication-assisted treatment of opioid addiction who have been able to make 12-step programs work for them.

Getting back to the conference…we spent much time discussing the monoproduct buprenorphine versus the combination product buprenorphine/naloxone. All of us agreed there’s a need for caution with prospective patients who insist they can take only the monoproduct (this is the equivalent of the brand name Subutex), because it does have a higher street value than the combination product.

Of course, there are people who inject the combination product (Suboxone film, Zubsolv, etc.), but overall, people seeking to inject buprenorphine are much more likely to prefer plain buprenorphine. Black market prices are higher for the monoproduct than the combination product, underscoring the preference for monoproduct.

One outspoken doctor said the monoproduct should rarely if ever be prescribed. Another doctor echoed my feelings on the matter when he said something to the effect that some patients really do have a bad reaction to the naloxone in the combination products, and if we are cautious, we can prescribe the monoproduct. However, the general opinion was that financial reasons weren’t sufficient to take the risk of prescribing the monoproduct.

I disagree with that, but kept quiet, already feeling like maybe I’m a bit too liberal.

I have had patients, stable on a buprenorphine combination product (usually brand name Suboxone films), who suddenly lost their health insurance. If such patients had negative drug screens for years, and no history of intravenous use, I switched them to the generic monoproduct because it’s the cheapest buprenorphine product on the market. These patients could not have stayed in treatment if I’d made them stay on the much more expensive brand names. Most of those patients prefer the films, and when they got new insurance, asked to switch back to the films.

I did not suspect these patients would sell their medication for profit. You have to know them, but these patients had stable jobs and no leanings toward criminality. And I am by no means a gullible person.

Since then, a generic combination product came onto the market. Still more expensive than the monoproduct, it’s less expensive than all the name brands.

Next we discussed how to deal with patients who say they are allergic to naloxone, and thus can’t take the combination product (Suboxone, Zubsolv) but only the monoproduct (Subutex).. Patients usually don’t mean an actual allergy, but rather intolerance to naloxone. These patients report headache, nausea, etc. when they ask their physician to prescribe the monoproduct. Of course, this raises suspicion with physicians that such patients plan to misuse the medication by injecting or snorting.

Should physicians just accept what patients say at face value, or should we say sorry, I only prescribe buprenorphine in combination with naloxone? After all, there’s no way to “prove” a headache or nausea. There’s no test we can order that will give any useful information. One doctor said he sent such patients to a neurologist for evaluation of the headache, or to a gastroenterologist to decide the cause of nausea. He says most patients fail to follow through, and so he weeds such prospective patients out of his practice that way.

An audience member suitably questioned this habit, asking how could a specialist be expected to determine if a medication caused headache or nausea? I think it’s kind of a sneaky way to get rid of patients who want buprenorphine monoproduct.

I have the same fears when fielding new calls from prospective patients. I’ve instructed my patient contact representative (who is also my office’s licensed professional counselor, after-hours contact person, pharmacy liaison, licensed clinical addiction specialist, prior approval wrangler, and fiancé) to tell these people that I do not prescribe the monoproduct to new patients. I have no problems saying “no” upfront to these patients, and try to explain why I’ve made this decision for my private practice (even though, as above, I have prescribed it for patients I know very well).

I use the monoproduct in the opioid treatment program where I work, because those patients dose with us every day until they have a period of stability. The dosing nurses roughly chop the tablets, to minimize diversion, and patients stay on-premises until the medication has dissolved, also to make diversion more difficult. These patients don’t get any take home doses until we feel they have stabilized.

We also discussed how long to keep patients on buprenorphine. The bottom line is that no one knows. Best outcomes are seen in patients who stay on buprenorphine, since there’s still a high relapse rate back to opioids in patients who stop buprenorphine. I ask my patients periodically if they wish to start a slow taper, if they’ve been stable for over a year. I don’t push them to taper if they’re not ready, but if they are, I recommend they taper slowly. From the discussion at this meeting, it sounds like most of my colleagues do the same.

We discussed the maximum daily dose of buprenorphine. According to studies, a daily dose of 16mg saturates most of a patient’s opioid receptors, and increasing the dose to 24mg only gives about a 4% increase in the number of covered opioid receptors. Some doctors say this shows buprenorphine should never be dosed more than 16mg per day.

However, about a third of the doctors in the room raised their hands when the moderator asked if they had any patients who seemed to require 24mg per day to stabilize.

I didn’t interject anything into the discussion, but I just went to a session at the national ASAM meeting where this same topic was discussed. While it’s true that basic pharmacology would indicate 16mg is probably the just as effective as 24mg in most patients, several studies have shown better patient retention in treatment when higher doses (24-32mg per day) are used.

It’s possible this isn’t a physiologic effect, but more of a mental process. We can’t be sure. But for whatever reason, if my patient does best at 24mg, I’ll allow her to stay on that dose.

For patients on higher doses, we need to make sure they aren’t diverting some of their medication. Patients sometimes ask for a higher dose than they need, in order to get enough medication to treat a friend, family member, or significant other. Some doctors call this “piggy-backing.” Even though it means a suffering addict is getting treatment, the piggy-backer won’t get any counseling. Also, law enforcement types use examples of diversion to demonstrate that buprenorphine is a bad street drug, contributing to the stigma against patients doing well in their treatment. Diversion threatens the whole concept of office-based treatment program.

All in all, we had two hours of lively interaction on the finer points of office-based prescribing of buprenorphine. I don’t think all doctors will agree about everything, but it’s nice to hear what other physicians are doing, to make sure I am not too far out of line with the standard of care.