Archive for the ‘Overdose deaths’ Category

The Good, the Bad, and the Ugly

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The Good

 Probuphine

Probuphine was approved by the FDA. I’ve written about this medication in several other blog posts. Probuphine is an implantable form of buprenorphine that lasts for six months. It will be suitable for buprenorphine patients who are stable at 8mg per day or less.

I think logistical problems will prevent this medication from becoming mainstream. I hear it must be implanted in a surgical suite, which makes little sense. Maybe it’s more involved than I realize, but I had been under the impression it could be done in an office setting, like Norplant.

I’ve also read that the physician must purchase and store the Probuphine implant, which adds financial risk and DEA scrutiny to a buprenorphine physician’s already crowded schedule.

As I’ve said before, I predict Probuphine will be administered at a few specialty centers, but isn’t likely to be done by most mainstream addiction medicine doctors. Still, it’s another option that hopefully will work well for patients on less than 8mg per day.

Watch your language

The field of Addiction Medicine is pushing for non-stigmatizing language to be used by treatment professionals. Words are important, and some words carry hidden and pejorative meaning in the general public.

For example, I’ve always cringed when I hear the term “dirty” or “clean” urine drug screen. I have to quash my desire to be sarcastic towards the speaker. The proper terms are “positive,” meaning a substance was found in the urine, or “negative,” meaning a given substance wasn’t found in the urine. Addiction Medicine gurus continue to emphasize the importance of using proper clinical terms. I enthusiastically agree with their efforts.

Now experts in the field want to get rid of the term “addict” and “opioid addiction.” They want to replace those words with terms such as “person with opioid use disorder,” and “opioid use disorder,” respectively.

I understand the reason behind these recommendations, and I agree with them, but it’s going to be tough to replace a two-syllable word with a ten-syllable phrase.

Besides, when I say the word “addict,” I suspect I mean something very different than the average person using the word. In my mind, the word “addict” has come to mean “person with the disease of addiction who is probably more likeable and interesting than an average person.”  But then, I chose to spend my career treating these people, so of course I think that way.

Contrast that to an average person in the community, to whom the word “addict” means a bum in the gutter with a needle hanging out of his arm. Most of the time, people are surprised when then encounter real addicts, or to use the new term, people with an opioid use disorder. Because since anyone can develop opioid use disorder, these people usually don’t look different from the rest of us.

Government Support for Addiction Treatment

When the President of the United States endorses medication-assisted therapies, we have arrived. That’s old news now, since he has been discussing MAT in some of his addresses since last year, as a way of addressing the opioid overdose epidemic. But now the promised money is starting to become available.

Available grant money fueled plans for new, collaborative opioid use disorder treatment programs in our state…

One primary care low-cost clinic just started working with their local opioid treatment center to provide needed primary care to patients in that OTP. Referrals should flow both ways, with the OTP sending patients to the medical clinic for needed healthcare, and the medical clinic will detect opioid use disorders in their patients, and refer them for treatment at the OTP.

An exciting initiative to connect people involved with the criminal justice system with appropriate medication-assisted treatment is in the planning phase. With this program, prisoners being released and people under parole and probation will be evaluated by addiction medicine doctors. Where appropriate, they will be offered methadone, buprenorphine, or naltrexone, to better treat their illness, and they will get increased counseling.

Prescription Monitoring Programs Work!

I had a few spare hours last week, and was able to look at around 125 of my 450 OTP patients. I discovered only one patient with some questionable findings, and she’s scheduled to talk with me this week.

What a change from 2007, when over 20% of all my OTP patients had serious prescriptions for opioids, benzodiazepines, and/or stimulants. These were prescriptions about which I knew nothing. Patients had filled prescriptions and there was no way for me to know about it, until our prescription monitoring program came online in mid-2007.By the time I got access late in the year, I found data indicating over a fifth of our patients were filling prescriptions that could harm them with the methadone I was prescribing.

Over the last nine years, our system has improved, making it ever easier and more accurate.

The Bad

All Use of Methadone is Toxic?

Perhaps in response to my blog post that was critical of the medical examiners in North Carolina, a medical examiner called me.

My complaint in the June 5, 2016 blog is that any patient who dies while on methadone maintenance is said to have died from methadone toxicity, regardless of clinical information.

This doctor and I had a cordial yet frustrating conversation. The physician introduced himself and said he was calling me because he had promised to do so after I spoke with him last year about a patient of mine who had died. When we last spoke, the toxicology results had just been sent off. He called yesterday to tell me that the level of methadone in this patient was toxic, and that along with the cocaine found in her system, he was reporting cause of death as “Methadone toxicity, cocaine toxicity.” I already knew this from reading incident report data, but I didn’t interrupt him. I was hoping he would give me additional information, but he didn’t.

When he was done, I informed him, again, that she had dosed at 130mg of methadone for months in the several years prior to her death. At her request, we started a slow taper. She came down on her dose by 5mg every couple of weeks, and she had been dosing at 60mg for several weeks prior to her death. I asked him how, with that information, could he still say she died from methadone toxicity?

He didn’t have an answer, and just repeatedly said her methadone level was “toxic.” He read the level to me, and I told him that I have patients with trough levels  higher than that.  I told him toxic for an opioid-naïve patient may be just what one of my patients needs for stabilization.

I don’t think he ever heard what I was saying. He never got off the topic of drug levels, and implied perhaps she could have obtained methadone from another source.

I suppose this is possible, but unlikely. For this patient to have overdosed on methadone, she would have had to gotten a supply of the medication from another source. I know she didn’t get a prescription for it, since I checked the state prescription monitoring database. And why would she buy illicit methadone off the street when she could just ask to go back up on her dose if she were in withdrawal?

I appreciate that this doctor took the time to call me. He didn’t have to do that, and it probably wasn’t an easy conversation for him. I don’t doubt he’s conscientious at his job.

I only wish he could have heard what I was saying.

What I heard him was saying was more of the same: the medical examiners will base their decision about cause of death on the methadone level, and will not consider any clinical information from me, or presumably from any another other opioid treatment program physician, if a patient dies under my care.

This increases the risk of being a doctor at an opioid treatment program. Because no matter how cautious we are, we treat a group of people who die at higher rates than age-matched controls. Nearly all of our patients smoke cigarettes. Of course they can die from methadone overdose, but they also die at higher rates from cancer, heart disease, liver failure, and other medical problems created from a life time of drug use, including nicotine.

But we now know in advance that methadone will be blamed no matter what. And that’s bad news

The Ugly

Heroin Comes to Town

Last week, several people who should know and have no reason to lie told me heroin can be bought in Wilkes County. I am really sad to hear this.

Heroin has already invaded many small communities. It crept in after black market prescription opioids pain pills became scarce. Indeed, at my state’s yearly Addiction Medicine conference, most OTP doctors said they’ve been treating heroin use disorder for several years.

For some reason, the people I admitted to our opioid treatment program have thus far been around 98% pain pill addicts. Last week, more than half of the new patients were using heroin. One patient came to treatment because the first time he used heroin, he overdosed, nearly died, and woke up in the ambulance. That scared him enough to propel him into substance use disorder treatment.

You may question if heroin addiction is that much worse than pain pill addiction. I think it is, though I could be wrong about this. With pharmaceutical grade pain pills, the user has an idea, usually, of how strong the product is. There’s not much variation from one pill to another. But with heroin, the batch one day could have only a few percent of pure heroin, or 100% pure heroin. There’s no way to know. There’s no way to gauge how strong it is, unless the user dose a “tester shot.” This is when the user uses a small amount of the purchased heroin to see how strong it is. This tester shot is recommended by Harm Reduction Coalition as a way to reduce overdose risk.

Heroin manufacturers usually don’t care about quality control. The heroin could be cut with God knows what else. Some of these substances cause special problems, since they weren’t meant to be injected into the human body.

Quinine, for example, has been found as a contaminant. I’m not sure why it’s used to dilute heroin, but it is. Quinine can cause kidney damage, bleeding disorders, and severe allergic reactions. Some experts believe many heroin overdoses are really fatal allergic reactions to products used to cut the heroin. In the street parlance, adding substances to a drug is called “stepping on it,” meaning diluting it so it can go farther and make the seller more money.

Other regular heroin contaminants include caffeine, talcum powder, powdered milk, chalk, or flour.

Recently there’s been a tendency to include fentanyl in the heroin product, making it an even stronger opioid. This has caused many overdose deaths, particularly in the Northeast. I strongly suspect that’s what my patient with the near-fatal overdose injected.

 

 

 

 

 

 

 

 

 

Action by the North Carolina Medical Board

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Last month, the North Carolina Medical Board (NCMB) announced they will query our state’s prescription monitoring program and investigate physicians identified as having worrisome prescribing habits. In order to help combat the prescription opioid overdose death crisis, this is part of an action that the NCMB is calling the Safe Opioid Prescribing Initiative.

Announced last month, the initiative will focus on three groups of physicians. This is taken directly from the NCMB’s website:

  1. The prescriber falls within the top one percent of those prescribing 100 milligrams of morphine equivalents (MME) per patient per day.
  2. The prescriber falls within the top one percent of those prescribing 100 MMEs per patient per day in combination with any benzodiazepine and is within the top one percent of all controlled substance prescribers by volume.
  3. The prescriber has had two or more patient deaths in the preceding twelve months due to opioid poisoning. (The initial group of prescribers under investigations were reviewed for the period beginning July 2014 and ending June 2015.)

The NCMB also says letters were issued to the first 72 prescribers (physicians and physician assistants) in April, most of whom were identified under the third criteria. Since nurse practitioners are also allowed to prescribe controlled substances, they will be scrutinized by the North Carolina Board of Nursing.

Responses to this new NCMB initiative have been mostly supportive. In my local newspaper, an editorial applauded the board’s actions, and advocated more such actions, to reverse the crisis of opioid overdose deaths in the state. The Charlotte Observer carried an article that said the NC General Assembly criticized the NCMB for not doing enough to combat prescription opioid overdose deaths

I’m probably not the NCMB’s biggest fan, but I don’t think it’s fair to blame that board for not doing more about the prescription overdose death crisis. The medical board wasn’t even allowed to access the prescription monitoring program’s data until the law changed last year to allow them to do so. Before that, they had no authority to do what the Safe Prescribing initiative outlines. In the past, they could investigate a physician only if they received a complaint about him or her.

Members of any state medical board have a thankless job. They are asked to make perfect judgments about medical professionals who may present a danger to the public. If they appear to be too lenient, they are criticized by the public for “protecting their own.” (This isn’t accurate anyway, since at least in my state, over one-third of board members aren’t physicians.) If they take strongly punitive stances, they are criticized for overstepping their authority and ruining the livelihoods of the professionals they license.

The professionals on my state’s medical board spend hours evaluating cases, for little or no pay. I think they may be paid nominal reimbursements for travel expenses, but I’m certain it doesn’t come close to making up for the time these people lose from their own businesses and practices.

Contrary to public opinion, state medical boards exist to protect the public, not to advocate for the doctors they license.

The NCMB initiative won’t be easy to implement, either. Just because a physician prescribes a whole lot of opioids doesn’t necessarily mean he’s a bad doctor. For example, a physician working with hospice patients, doing end of life care, should be expected to prescribe large amounts of opioids, and have frequent patient deaths.

Peer review of physicians will be essential. The NCMB will send charts of doctors identified by the three criteria above to be reviewed by other doctors in the same subspecialty. That means, hopefully, that doctors will be judged by other doctors in the same field of medicine.

This is important. This means that good pain management doctors may have to be evaluated and judged by other pain management doctors, through the NCMB. That will no doubt be unnerving, but the outcome should ultimately be positive, if the doctors are taking appropriate precautions.

Only doctors failing to meet accepted standards will have action taken on them by the NCMB, and only those actions will become public.

The NCMB has a big job ahead. They will need to separate the sheep of the doctor world from the goats, and decide appropriate actions to take. I do not envy them this task.

The NCMB has already taken action against many of the pill-mill type doctors, starting over a decade ago. If the board received a complaint, investigated a prescriber, and found him or her to be engaging in worrisome prescribing practices, that practitioner either lost the license to practice medicine, or was prevented from prescribing controlled substances, or was asked to take educational courses in proper opioid (or other controlled substance) prescribing.

I have other concerns about the third criteria of the NCMB’s Safe Prescribing Initiative.

First of all, how will the NCMB know if a prescriber has had two or more patient deaths in the preceding twelve months? I suspect the only cases examined by the NCMB will be those found to be opioid poisoning per the North Carolina Office of the Chief Medical Examiner (NC OCME).

Deciding if a prescribed opioid caused a patient death can be tricky. It depends to a large degree on the tolerance of the decedent, which needs to be determined by patient history. A dose of opioids that would kill one person won’t even make another person drowsy, if they have tolerance.

That factor is particularly important with methadone. My colleagues and I bemoan the fact that when our patients die, it WILL be blamed on methadone, no matter what. One doctor grimly remarked that if one of his methadone patients got shot in the head, the cause of death would still be listed as methadone toxicity. I think he’s exaggerating, but only by a little

The problem is that the North Carolina Office of the Medical Examiner has no standard case definition of what constitutes a methadone overdose death, which inevitably leads to mistakes about cause of death. According to information on their website and what I’ve learned by speaking with them, the decision is made by the blood level of methadone in the deceased.

I’ve felt the sting of being unfairly accused of killing patients. On several occasions, I’ve called the OCME about one of my patients who died while on methadone. I wanted to provide information about the patient’s dosing history before they determined the cause of death. I felt I had important information that could help them…but it did no good.

In one case, my patient had dosed on methadone 130mg for about a year, and then started a slow and steady taper. One year later she was dosing at 60mg per day when she died suddenly and unexpectedly. At autopsy, she had cocaine in her system, and she had a history of heart trouble. I suspected a fatal cardiac arrhythmia caused by cocaine, but the OCME announced the cause of death was: “Methadone toxicity, cocaine toxicity.”

Apparently they based their decision on post-mortem blood levels, known to be inaccurate. After death, the methadone stored in the liver can leak back into the blood vessels, causing elevated readings on which their determination was made, regardless of the history I gave them about her dose.

Five or so years before, another patient of mine died of what I thought was a severe asthma attack. In fact, she called 911 herself, saying she was having an asthma attack. Sadly, by the time EMS arrived, she had stopped breathing and couldn’t be resuscitated. I called the OCME to see what they found at her autopsy. The physician who did the autopsy said he found mucus plugging and bronchial casts, classic findings of status asthmaticus, which is a severe and sustained asthma attack. I was sad about her death, and told him I had treated her for many months for opioid addiction, and that she had dosed daily on methadone 75mg for at least two months.

When the death certificate was issued months later, after the toxicology report was available, I was surprised to see the cause of death listed as “methadone toxicity.” I called the medical examiner again and asked why this was listed, and the answer was that it was based on the drug level of methadone in her system.

Thankfully those types of cases are relatively rare.

I worry much more about all the people who die from opioid overdose who are never identified as a coroner’s case. That’s a bigger issue.

Consider the ways in which a deceased person becomes a coroner’s case. Of course, all instances where foul play is suspected require autopsies. Young people with no known medical issues should be investigated. Sometimes, deaths that occur in hospitals or nursing facilities require autopsy, if unexpected. Deaths that occur in police custody always require an autopsy..

In the community, if a person dies unexpectedly, a coroner is called to come to the scene to look for foul play. If there is none, the coroner calls the person’s doctor, to see if there’s an obvious cause of death like cancer or heart disease.

If you are a doctor freely prescribing opioids and/or benzos, what would you say to a coroner? Possibly, you’d say the decedent was ill with various problems and that the death was expected. It could be convenient to describe as “cardiac arrest.” (Technically, all deaths are ultimately due to cardiac arrest, but that doesn’t tell us the cause of death) This would be less upsetting for the family, keep the doctor out of trouble, and save the cost of an autopsy to the state.

Besides, no doctor wants to think the medications he prescribed killed a patient, or even contributed to the person’s death, so that inevitably biases judgment about cause of death by the prescriber.

I wonder how many overdose deaths slip through unnoticed and unexamined. Current data shows a very high incidence of prescription opioid overdose deaths, but I fear it is even higher.

 

After the Overdose

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I just read an astounding and completely believable study in a recent issue of the Annals of Internal Medicine. [1]

This study, done by Dr. Larochelle and associates at Boston University Medical Center, did a retrospective study of prescription opioid overdoses. They looked at patients who were being prescribed opioids long-term for non-cancer pain who had a non-fatal overdose. The study lasted from May 2000 until December 2012, and included over twenty-eight hundred patients. All of these patients had commercial insurance, and were between 18 to 65 years old.

This study found that after having a non-fatal overdose, 91% of these patients resumed getting prescription opioids, and that 70% got them from the same doctor.

The lead author said he was shocked to find so many survivors continue to be prescribed opioids after having an overdose from these very opioids. He had hoped after a near-fatal experience, prescribers would do something different to address pain, in order to prevent future overdose.(https://hereandnow.wbur.org/2016/01/13/opioid-prescriptions-after-overdosing)

From other studies, we know that the best predictor of a future overdose is a past overdose, which is why I ask every patient entering the opioid treatment program (OTP) if he has ever had an overdose.

The author of this study postulated that with our fragmented healthcare system, the prescribers may not have known the patient had an overdose. Not knowing about any problems, the doctor continued to prescribe opioids.

I have no problem envisioning how this happens.

Not long ago, one of my opioid treatment program (OTP) patients missed two days of dosing. Per our protocol, her counselor called her on the first day she missed dosing. The patient told her counselor that she had been admitted to the hospital for trouble breathing, and was being treated for asthma.

Also per out protocol, we request hospital records for every patient of ours who gets admitted to the hospital, and our patient gave permission for this.

When I got the records four days later, imagine my surprise when I read that she had respiratory failure due to an overdose. Her drug screen at the hospital was positive for methadone and also benzodiazepines, and indeed she was now positive for benzos at the OTP too. This information lead to a drastic change in this patient’s treatment plan.

If we had not called to see where our patient was, she could have returned in several days and not told us about her hospital admission.

Our local hospital did not call our OTP to tell us our patient was hospitalized with an overdose. Indeed, they didn’t call to tell us she was in the hospital. To my patient’s credit, she did tell them she was a patient of ours, since it was recorded in her hospital record.

When our patients are admitted to the hospital for medical reasons, the admitting doctors continue to prescribe the usual dose of methadone, and I am happy about that, but they don’t call us to confirm the dose. They take the patient’s word for what the dose has been, instead of making a quick phone call. I worry that someday, one of our patients, in a misguided effort to feel an opioid effect, will tell his hospital doctor he’s been dosing at a higher dose than he actually is, and catastrophe could ensue.

In contrast, the big teaching hospital an hour away, which is where our patients go when they are really sick, routinely calls to confirm each patient’s dose.

The Larochelle study seems to indicate there’s a lack of communication in other medical communities as well. Emergency department physicians may administer Narcan and revive a patient, but no one thinks to take the next essential step: call that patient’s prescriber about the drug overdose.

We can’t assume the patient, now revived from a near-death experience, will tell her doctor about what happened. If that patient has an addiction, she might keep quiet about prescription mishaps, fearing her supply of opioids may be cut off.

Family members might tell the prescribers, and that’s very helpful, but often patients are told the doctor can’t release any information. That is true, but the family can certainly give information to the doctor.

I know hospitals and emergency departments are busy. Healthcare professionals are all busy. We are being asked to do more and more in less and less time. But this is a communication issue, and it need not be a physician- to- physician communication. A nurse or even a social worker from the hospital could call or fax valuable information quickly. Privacy laws can be blamed for some lack of communication, but there are exceptions in life-threatening situations.

And please, let’s make medical records readable. Even when I finally get local emergency department records about one of my patients, I have a hard time deciphering them. I’ll admit to being a bit of a Luddite when it comes to electronic medical records, but partly because most electronic records are not all that helpful.

For example, on our local emergency department records, I quickly can find the results for Ebola screening (it’s on the first page, at the top), but often I am left scratching my head about what the doctor’s final diagnosis and treatment plan was for the patient.

We’ve got to fix this communication problem. It’s great when an overdose is treated and prevented. But let’s do just a little more, and communicate to the prescriber of the overdose medications.

It is life and death.

  1. Ann Intern Med. 2016;164(1):1-9. doi:10.7326/M15-0038

Overdose Danger In Chicago

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Apparently heroin mixed with fentanyl is making a new appearance in Chicago, IL. An article in the Chicago Tribune two days ago (http://www.chicagotribune.com/news/local/breaking/ct-heroin-overdoses-met-20151002-story.html ) described how that city has seen 74 overdoses in 72 hours, all from heroin suspected to be laced with fentanyl.

The article says that most of the overdoses were reversed with naloxone, better known as Narcan, but that emergency workers had to use two and three times the amount of Narcan as usual. However, at least one death is suspected to be from the dangerous heroin. Lab tests are still pending, and expected to confirm the presence of fentanyl.

This latest distressing news comes against a backdrop of decreased funding for the treatment of addiction. In fact, the Republican governor of Illinois, Gov. Bruce Rauner, re-wrote a bill that originally required Medicaid to pay for addiction treatment medication and counseling. The Governor took out that portion of the bill, saying the state couldn’t afford the expense. This re-written bill was rejected by the state senate.

Supporters of the original bill pointed out that studies show money paid for addiction treatment saves money in the long run, usually due to lower incarceration costs and lower medical costs.

Today, the Chicago Tribune also ran an article about how some states are requiring school nurses to have access to naloxone in middle schools, junior high, and high schools in some states. The National Association of School Nurses has asked for naloxone to be part of each school’s emergency first-aid kits.

This news about overdoses is appalling. I hope the state will look harder at whether they can afford NOT to fund addiction treatment for Medicaid patients. We know from prior studies that for every one dollar spent on addiction treatment, taxpayers are saved anywhere from $4 to $11.

Consider one heroin addict who contracts endocarditis (life-threatening infection of heart valve). The duration of treatment with intravenous antibiotics is usually six weeks. If the patient requires heart surgery and valve replacement, costs go even higher. A conservative estimate for the cost of hospitalization might be tens of thousands to hundreds of thousands of dollars. But a year’s worth of medication-assisted treatment costs around forty-two hundred dollars for one person. For further perspective, I recently read that the cost of incarcerating one person for one year is around $24,000.

Treatment saves taxpayer money. Even if citizens of Illinois don’t care about the health and well-being of addicts, they should care about the added taxpayer expenses of untreated drug addicts.

Also, I want to remind readers of my blog who may still be using IV drugs of the following safety ideas:
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.
2. Get a naloxone kit to reverse an overdose. Contact your local Harm Reduction Coalition via the internet, or Project Lazarus.
3. Use new equipment. Many pharmacies sell needles and syringes without asking questions. 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.
4. 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.
5. 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 recent overdoses in Chicago illustrate how change in potency can be fatal.
6. 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.
7. 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.
8. Opioid overdoses are much more likely to occur in an addict who hasn’t used 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.
9. Don’t mix drugs. Many opioid overdoses occur with combinations of opioids and alcohol or benzodiazepines, though overdose can certainly occur with opioids alone.
10. 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. Use a naloxone kit if you have one.

The Benzo Conversation

Glass head full of pills

Not all of my patient interactions are easy. One of my colleagues, after reading my blog, remarked, “It sounds like you have really easy patients.” While that’s true for the most part, of course there are more difficult patients, as in any practice. Some patients, eager to get into treatment to stop opioid addiction, may not be at all ready to stop other drugs of addiction. That’s not a deal-breaker for me, unless those drugs could be fatal when mixed with methadone or buprenorphine. This means the use of alcohol, benzodiazepines, and sedatives of other kinds must be discussed in detail.

I’ve noticed a conversational merry-go-round that I call “the benzo conversation.” I’ve had versions of this conversation more times than I can remember.

This conversation occurs during my initial assessment of a new patient presenting for medication-assisted treatment. I always look on my state’s prescription monitoring program for each new patient on the day of admission. If they have prescriptions for benzodiazepines (like Xanax, Valium, or clonazepam), or other sedatives (Soma, Ambien, etc.) I need information about the pattern of use. Is my patient taking his prescribed daily dose? Is he then physically dependent on benzodiazepines? Is he selling them? Is he giving part of the prescription away, and taking the rest? Does he binge on benzos for the first few weeks of the month, and then run out for several weeks? Or is he bartering the benzos for opioids, and not taking any of them, despite filling a large prescription each month?

I really don’t care if the patient is breaking the law or not; I just want to get the complete picture of my patient’s health status.

Following is a typical conversation with a new patient whom I will call “Bob.”

Bob sought admission to our methadone maintenance treatment program for his opioid addiction. He had snorted pain pills for six years, and wanted help. He had little if any denial about his opioid addiction. He denied taking any prescription medications, saying he got all his opioids off the street, used no other drugs or medications, and had no other medical problems.

However, when I checked his name on my state’s controlled prescription monitoring program, he was filling a prescription for Xanax 2mg, ninety per month, from a local Dr. Feelgood. This prescription had been filled every month for the last four years. My patient’s admission urine drug screen also tested positive for benzodiazepines.

As part of my initial history and physical, I asked him about the Xanax prescription. I explained to Bob that benzos have the potential to cause a fatal overdose when mixed with opioids. I told him that benzos are especially risky with methadone, and I was concerned about his use of them.

Bob said, “Oh, I don’t use benzos now. I haven’t used Xanax for years.
“But you’ve been prescribed it every month and picked up the last prescription of ninety pills just two weeks ago.”
“Yes, but I don’t take them. I quit them long ago.”
“And you do have benzos in the urine sample you gave us.”
“Well, that’s probably from a little piece of Valium I used four days ago.”
“Ummm…, Valium’s also a benzo, in the same family as Xanax, so when you say you’ve stopped, that doesn’t make sense to me.…”
“As I told you, I don’t take benzos anymore.”
“But four days ago is pretty recent.”
“No,” he said, getting a little worked up. “As I’ve already told you, I stopped benzos years ago!”
“So what do you do with the Xanax pills you pick up at the pharmacy every month?”
“I don’t know. They’re in the house somewhere. But I don’t take them.”
“So you have…how many bottles do you have at home?”
“Bunches, I don’t know.”
I could tell I was annoying him, but this as an important clinical issue, so I pushed on.
“Would you be willing to bring all those bottles in tomorrow so the nurse can watch you dispose of them?”
He sighed deeply, annoyed by my questions. “Yes. I suppose I can. Now can I get my dose?”
“No, I’ll leave an order for you to be able to start tomorrow after you bring in the medication to dispose, since you tell me you haven’t taken them. I worry about a fatal overdose if methadone were combined with all that Xanax you have at home.”
Now he was mad. “I don’t have any Xanax at home! I’m not going to overdose! I know what I’m doing.”
“Will you give me permission to call the doctor prescribing the Xanax, so we can talk about your entry into treatment here? Maybe your doctor would be willing to taper your dose so that we can make it safer for you to be in treatment with us.”
“No! I don’t want everybody to know my business. My doctor is friends with my ex-wife and if she finds out I’m being treated for addiction, she’ll cause trouble. He can’t find out.”
“I’m sorry, but that’s a deal-breaker for me. I’m not going to prescribe methadone for you unless I can talk to your other doctor. It’s just too risky. All of your doctors need to know all medications that you’re on.”
“So you’re telling me to go back out there and use drugs? That I can’t get help unless my ex-wife finds out I’m an addict?” The veins in his neck were standing out.
“No. I’m not telling you to use drugs. I’m telling you…
“I want my money back, since I’m gonna have to go buy dope again ‘cause you won’t help me. It’s just not right. I came here to get help.” He stalked off toward the receptionist, where I heard him demanding his money back, despite the hour he spent with a counselor and the time spent with me in an evaluation. (For some reason, patients who don’t get admitted to the program don’t feel they should have to pay for their evaluation)

This was a difficult, tense conversation, and one I’ve had too many times to count. This patient wasn’t a bad guy, but he was not ready to address his benzodiazepine use. The outcome wasn’t what I’d hoped, and this patient didn’t come into treatment.

There’s no way I could know what this patient was doing with his benzodiazepine prescription. I couldn’t tell if this patient was telling the truth, in denial, or lying. Without being able to talk to his prescribing doctor, I wasn’t willing to start medication-assisted treatment. This didn’t mean he didn’t need treatment, only that perhaps a different form of treatment will be safer for him. I wish I could have given him information about other treatments, but he left too quickly and too angrily.

Sometimes patients tell me I’m violating their privacy by looking at their information on the prescription monitoring database. I tell them I don’t see it that was at all, since they are asking me to prescribe a medication that could have a fatal interaction with other medications. Not only is it my business, it’s my responsibility.

Some doctors would fault me for not admitting this patient despite his refusal to allow me to talk to his prescribing doctor, given the increased risk of death for patients in active opioid addiction who are not in any treatment. But I would feel terrible if I’d admitted this patient and he died during the first few weeks of a methadone/benzodiazepine overdose. Either way, there’s a lot at stake, and I feel stress about these decisions.

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

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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.

Is Heroin the New Opana?

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From CDC data released 3/15

From CDC data released 3/15

The Center for Disease Control and Prevention (CDC) released new data last month showing a rapid rise in heroin overdose deaths. While total overdose deaths from opioids remained level for the past few years, deaths involving heroin escalated sharply.

The rate has tripled since 2010, and nearly quadrupled since 2000. Males have a four times higher rate than females with the highest rate seen in white males aged 18 to 44. All areas of the country had increased heroin overdose death rates, but the highest were seen in the Midwest, with the Northeast right behind them. The South, for a change, had the lowest rate of heroin deaths, after the West.

Those of us treating patients at OTPs knew heroin was moving into areas where pain pills once dominated, but I had no idea deaths had tripled in three years. That is appalling even to me, and I see appalling things all of the time. I can’t stress enough how bad this is.

Why is this happening? I’ve read and heard various opinions:

 Some people speculate that since marijuana became legal, that crop is less profitable to Mexican farmers, who switched to growing opium poppies. This is just a theory, though the timing supports the premise. I don’t know how it can be proved, short of taking surveys of Mexican farmers, which seems problematic and unlikely to happen.

 As we implemented measures to reduce the availability of prescription opioids, the price increased. Heroin is now cheaper than pain pills in many areas, and heroin’s purity has increased. Many addicts who can’t afford pain pills switch to heroin to prevent withdrawal. NIDA (National Institute for Drug Addiction) estimates one in fifteen people who use prescription opioids for non-medical reasons will try heroin at some point in their addiction.

Maybe that’s why the South still has the lowest heroin overdose death rates: we still have plenty of prescription opioid pain pills on the black market.

 With the increased purity, heroin can be snorted instead of injected. Many people start using heroin by snorting, feeling that’s safer than injection. It probably is safer, but addiction being what it is, many of these people end up injecting heroin at some point.

 Heroin has become more socially acceptable. In the past, heroin was considered a hard-core drug that was used by inner city minorities. Now that rural and suburban young adults are using heroin, it may have lost some of its reputation as a hazardous drug.

Most experts in the field agree that much of the increase in heroin use is an unintended consequence of decreasing the amount of illicit prescription opioids on the street. But we are doing the right thing by making prescription opioids less available. Physicians are less likely to overprescribe and that’s essential to the health of our nation.

Now it’s critical that we provide all opioid addicts with quick access to effective treatment, no matter where they live.

The face of heroin addiction has changed. It is no longer only inner-city minorities who are using and dying from heroin; now Midwestern young men from the suburbs and rural areas are the most likely to be using and dying from heroin.

In the past, when drug addiction was seen as a problem of the poor and down-trodden (in other words, inner-city minorities), the general public didn’t get too excited. But when addiction affected people in the middle classes, there was a public outcry. The Harrison Act of 1914 was passed due to public demand for stronger drug laws.

I think the same thing will happen now. Suburban parents will organize and demand solutions from elected officials for this wave of heroin addiction. Indeed, I think that’s already started to happen.

Let’s make sure a big part of the solution is effective treatment.

Let’s make treatment as easy to get as heroin.