Archive for the ‘Recovery’ Category

Physicians’ Decisions to Start Buprenorphine: The Key Factors

Just a little “If cats were doctors” humor.

 

 

 

 

Physicians are less likely to prescribe buprenorphine for patients who use illicit benzodiazepines or drink excessive alcohol, who have a spouse with a drug use disorder, or who have Medicaid as their form of payment.

This information comes from an article in the most recent issue of the Journal of Addiction Medicine (Jan/Feb, 2018). Knudsen et al. describe the findings from their investigation about the decision-making process of buprenorphine prescribers.

The authors sent surveys to 3553 physicians, selected at random from all fifty states and the District of Columbia, who were eligible to prescribe buprenorphine and had at least one patient for whom they prescribed buprenorphine. Of this group, 1174 (about a third) of those physicians responded.

These surveys contained twenty patient vignettes describing the various attributes of a prospective patient, then asked about the physicians’ willingness to prescribe buprenorphine for the patient. This study is based on conjoint analysis, which is a way to quantify the contributions of several factors in a decision-making process.

I read all about this method, and following the statistical analysis process was challenging. I wish I could explain it to my readers, but I can’t.

Seven patient attributes were described in the case vignettes, and were the basis upon which the physicians answered whether they would or would not prescribe buprenorphine from their office. The seven attributes were: type of opioid and route of administration, treatment history, risky substance use (benzodiazepine or alcohol use), co-occurring infections (HIV and Hepatitis C), spousal involvement in treatment and whether the spouse was also a drug user, employment status, and method of payment for the office visits.

Of those seven factors, the use of benzodiazepines (or alcohol) had the largest relative importance for the physicians in deciding if they would prescribe buprenorphine or not. In other words, out of all those seven factors, doctors were more influenced not to prescribe buprenorphine if the patient is also using sedative-type drugs.

That makes sense, and I was relieved to see this sample of physicians recognized the risks of this population of patients with opioid use disorders. We know that alcohol and benzodiazepines do increase the risk of mortality and of relapse in patients on medication-assisted treatment with buprenorphine or methadone.

Maybe the physicians felt the risk of treating such patients with buprenorphine is still less than no treatment at all, but that opioid treatment programs are safer settings to start these patients than an office-based setting. At opioid treatment programs, patients can be dosed with buprenorphine, but watched more closely. They can be evaluated for impairment every day when they come to the facility to get that day’s dose. Office-based physicians should be able to refer to local opioid treatment programs easily, and form close working relationships with these facilities.

The next most important factor determining the physicians’ willingness to prescribe buprenorphine was method of payment. Patients with Medicaid were less likely to be started on buprenorphine in the setting of office-based practices.

This did not surprise me.

Medicaid doesn’t pay physicians well for office visits. Medicaid pays much better for surgeries or procedures…that is, “doing” something…. but not well for thinking and patient management in the office setting.

Recently I tried to see how much Medicaid pays for an office visit for a patient being monitored on buprenorphine. It varies by area, but the going rate seems to be $40 to $45. Considering the visit takes about 15-20 minutes, which doesn’t count time spent coordinating care or meeting Medicaid paperwork requirements, that’s not great reimbursement. I don’t know if a practice could break even if they saw only Medicaid patients, unless they saw a high volume, and that’s no fun for patient or doctor.

This study underlines the importance of raising payments to physicians for seeing Medicaid patients, if you want primary care physicians to prescribe buprenorphine from an office setting.

Also, something must be done about eliminating the byzantine Medicaid requirements. It’s altogether too hard to become certified to accept Medicaid, so some doctors don’t bother with it.

The third most important factor was whether a prospective patient’s spouse was going to be involved in the patient’s care, and whether that spouse had an addiction issue too.

I completely get that idea. When I’m admitting a patient and they tell me they live with a significant other who is still using illicit opioids, I worry. Not only could the S.O.’s use of drugs be a trigger for relapse for my new patient, but also that might be at temptation to give some of his dose to the S.O.

We know from research that social contacts influence whether people take drugs or not. Having a stable, non-drug using spouse is a good prognostic sign.

The four other factors didn’t seem to affect whether this group of buprenorphine physicians would start buprenorphine or not.

HIV or Hep C status didn’t matter, and that’s a good thing. Patients with these infections should be able to access treatment.

Surprisingly, the type of opioid used and the route of administration didn’t matter very much. I would have thought that physicians may have considered heroin users higher risk patients than prescription opioid users, but that wasn’t the case. I was surprised that a history of intravenous use didn’t make prescribers hesitate.

In an office-based setting, I think the physician (or physician extender) should ask specifically if the prospective patient has ever injected buprenorphine. If the answer is “yes,” an opioid treatment program, with observed daily dosing until stable, is probably a safer and better choice for these patients. I ask my new patients, and most people who use intravenously have also injected buprenorphine.

Previous treatment episodes didn’t influence physicians’ decisions to prescribe buprenorphine, and neither did employment status.

I would have though physicians would be a little less inclined to start prescribing for a patient who is unemployed, but that wasn’t the case in this study.

I thought this was an interesting article, and showed some insight into how physicians who prescribe buprenorphine decide for whom they will start treatment, and which factors are deterrents to starting a new patient in treatment.

 

“We will not regret the past, nor wish to shut the door on it.”

 

 

 

 

I’ve written a version of this blog before, and I thought this would be an appropriate time to redo and re-post it. After all, the end of the year is a time of reflection. Not one of us is perfect; we’ve all fallen short of our own ideals this year. But a new year stretches before us, with plenty of room for the grace of change.

This blog post contains what I feel are helpful concepts from 12-step recovery groups. I know 12-step recovery isn’t for everyone. Some people tell of bad experiences with 12-step groups. And I know millions of people have been helped by these groups, too. So, take what you like from this blog entry, leave the rest, and if you read something helpful, I’ll be happy. If not, try again next week because my topics fluctuate.

I talk to many recovering addicts who voice regrets about their past. The stories vary; the patients’ main theme is regret for behavior during active addiction. I understand those feelings, and feel tempted to tell patients how to deal with these feelings… but I don’t say anything, for fear that I’ll sound too “preachy.” Who am I to tell someone that they can examine past regrets, learn from previous mistakes, make amends when needed, and face the future with a clean slate? Isn’t that a conversation for a priest, imam, rabbi, or pastor?

Yes, it is. And yet, this person is in my office. Many times, my patients tell me they feel unworthy to join or rejoin a religious community, and feel judged by such groups. Some of my patients’ perceptions could be colored by their own shame, but I fear many of them are accurate in their perceptions. Addiction is still regarded as a sin by some religious groups. Other groups know addiction isn’t a sin but a disease, which can cause us to do and say things we regret, which are contrary to our values

Twelve step groups like Alcoholics Anonymous and Narcotics Anonymous have mechanisms for dealing with past regrets and ruptured relationships. These groups didn’t invent anything new. They use the same approach as other spiritual and religious groups, an approach which is also sound psychological advice. However, the twelve steps provide a handy framework for handling regrets.

First, in Step 4, the recovering person assesses past behavior, called a “moral inventory” in recovery parlance. That inventory is shared with themselves (ending denial), another trusted person, and the god of their understanding. Patterns of behavior emerge, giving information to be used in steps 6 and 7, where the person becomes willing to give up old behavior and ask the god of their understanding for help with this.

In step 8, the recovering person lists the people he has harmed while in active addiction. With the aid of a sponsor or trusted spiritual advisor, in Step 9 the recovering person makes plans for how best to make up for past behavior.

Amends can be as simple as saying, “I’m sorry,” to someone for past bad behavior, or amends can be more extended, like resolving to be fully emotionally present for loved ones.

Sometimes direct amends aren’t possible, if the person has moved away, died, or unable to be located. A more general amends can be made instead. For example, if a person shoplifted to support their addiction, it may be impossible to remember where and what was stolen. Part of the amends process is not to repeat the old behavior, but a more general amends may involve volunteering in the same community to help society in some way, like donating to a food bank or giving time to help a child in need.

If the recovering person feels guilty about stealing money, amends may include apologizing for the past behavior, and planning re-payment. For example, I know a person in recovery now for over 16 years who sends a check for $25 each month to a governmental agency to whom he owned money after a criminal conviction. He may never get the full amount paid off, but he’s taking action to fix what he broke.

Addiction taught harsh lessons that came at exorbitant prices, so we should learn from past mistakes. Our pasts contain gold mines of information that can help us in the future. Recovering people can move forward by planning amends for past actions, but also should consult a sponsor or spiritual guide for help. For example, if an addict stole money from a drug dealer, it should not be paid back, especially if it puts the recovering addict at risk. In some situations, the best amends may mean having no further contact with the person who was wronged.

Some recovering addicts have long lists of bad behavior to make amends for, and other recovering addicts’ lists may contain only a few people. Many addicts harmed only their immediate family, by not being completely emotionally available to their spouses or children during their addiction. Some recovering people feel just as bad about that as others feel about committing armed robbery for drug money.

The point of amends isn’t how bad the behavior was, but how the recovering person feels, and how he can leave behind guilt and shame and move forward.

Addiction, like some other diseases, affects behavior. Rather than living with regrets, recovery means facing regrets, learning from them, fixing what we can, and then moving on. It doesn’t matter what you call it: making amends, cleaning your side of the street, getting right with the god of your understanding, or some other term.

Therefore, in this end-of-the-year time of reflection, I’m going to take some time to evaluate my own life, shortcomings and all. I plan to reflect, learn from the past year, then pray to the god of my understanding to help me change into the person I want to be in 2018. I understand I will never be perfect, but I hope I can become a little bit better.

As we hear in 12-step meetings, “Progress, not perfection.”

 

 

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.

Harm Reduction and the Clothing Police

aaaathc

 

 

 

 

 

 

 

“Oh I know that’s not a marijuana leaf on your cap!”

I had just ushered a young lady into my office. She entered treatment the week before, and I wanted to check on how she was feeling. When I called her from the waiting room, I noticed a rhinestone design on her cap with one part of my brain. I like bright sparkly things, so it caught my eye. But by the time we walked the short distance to my office, it dawned on me what the design was, and I confronted her about it.

“What? Yeah, it’s marijuana. Sorry. I didn’t even think about it.”

“What part of you thought it would be OK to wear clothing promoting drug use to your drug addiction treatment program?” I continued.

Usually I’m more complacent about clothing our patients wear. Some programs have minimal dress codes: no pajamas, nothing too revealing, must wear shoes, no obscene tee shirts… I’ve never gotten too worked up about clothing, thinking that as long as they came into the building, it was a victory.

But for some reason, on that day, I went a little nuts. What can I say, I have bad days too.

My patient was apologetic, but said it was the only cap she had. I told her she could turn it inside out, which she did without hesitation.

Before you are tempted to write in about how marijuana is really a medication and will be legal someday, let me tell you this: I don’t care. I’d feel the same way if I saw a large, legal, liquor bottle outlined in sequins, or a big sequined Opana pill on a shirt. It’s a symbol of drug-using culture.

Today, I’m conflicted. One part of me still thinks it’s not OK to wear clothing promoting any kind of drug use, and this includes alcohol. After all, we are treating patients in whom drug use has caused significant problems. Some of them could be triggered by symbols of drug culture. Is it too much to ask our patients to think about the message they send with their clothing?

Other addiction treatment professionals endorse similar ideas. If our patients are to return to mainstream society, don’t we have an obligation to educate them about traits that may still associate them with active drug use?

For example, is it possible my patient wasn’t aware of the message she sends with her bedazzled marijuana cap? If my patient wanted to go for a job interview, for example, would wearing this cap work against her? Maybe it depends on the job, but overall I would say the cap would hurt her chances of being hired.

On the other hand, if we view the situation with a harm reduction eye, isn’t it good enough at this point that my patient is getting treatment for her addiction? If a patient wants to get help for some aspect of addiction, isn’t that good enough? Maybe it’s unreasonable to expect a patient in treatment for a short time to start viewing her wardrobe with a recovery-oriented eye. Maybe such issues can be addressed later, in counseling, or maybe not, but perhaps I should concentrate on more important issues. Like helping her get through the day without illicit opioids.

A harm-reduction model would recommend meeting that person where she is now, in her THC-wearing mindset. Harm reduction is an idea that says any change that reduces the risk of drug use is success, and that we need to accept her as she is. We should respect our patient’s choices and help in any way she is willing. Any reduction around the risk of her addiction is an acceptable goal, even if it doesn’t conform to what I may view as “real” recovery.

The question is, or course, where do we draw the line? If it’s OK to wear clothing glamorizing drug use, is it OK to allow patients to tell glamorized stories of drug use in the waiting room?  Is it OK for patients to use drugs on the premises? What about dealing drugs?

I endorse harm reduction principles, but have come to realize I have limits. The longer I’ve been doing this job, the more enthusiastically I approve of harm reduction principles. However, I still draw the line when one patient’s behavior affects the other patients. That’s why I won’t tolerate drug dealing on the premises, patient violence (against other patients or staff), or drug use on OTP grounds. But that’s a hard call to make, and it’s a decision best made at case staffing with input from other staff.

Harm reduction is a difficult idea for many of us. What one person sees as harm reduction, another sees as enabling. Here are some other quotes I’ve heard from other people. I’d like to give credit, but my memory’s not that great.

“Don’t allow the perfect to be the enemy of the good.”

“The enemy of the best is the good.”

“It’s OK to meet a person where they are, but it’s not OK to leave them there.”

“I don’t promote drug use. I don’t promote car accidents either, but I still think seatbelts are a good idea.”

“Dead addicts don’t recover.”

Readers, any thoughts?

 

Recovery Means…

aaaaaaaaaaaaaaaaarecovery

September is National Recovery Month, and it’s nearly over, so I wanted to make a special blog post to celebrate. I decided to write what recovery means to me, and I hope my readers will write in with their own definition of recovery.

Recovery means…

….taking the worst and most embarrassing thing in my life and turning it into my greatest asset.

….becoming less judgmental of other people.

….remaining teachable.

….having more free time, after the burden of looking for the “next one” has been lifted.

…looking in the mirror, and feeling content at what I see.

….being satisfied with the small pleasures in life.

….developing a thicker skin for judgmental people. They aren’t going to ruin my day.

….re-connecting with the human race.

….re-connecting with the God of my understanding.

…reconnecting with myself.

….doing what I need to do for my well-being, even if other people don’t approve.

….being happy when I make progress, no longer expecting perfection.

….talking frequently with other people who share my passion for recovery.

Recovery goes beyond 12-step programs or medication-assisted treatment. Recovery can apply to issues other than drug addiction. It can apply to eating disorders, co-dependency, gambling problems, sex addiction, or any other compulsive activity that is bad for our health. We can be in good recovery in one area of our life and be in active addiction in other areas. We have good and bad days. We relapse, and we try again, and we stop listening to the voice of addiction that tells us we should give up because we will always fail. We learn from our failures and come to look at them as opportunities for growth. We turn stumbling blocks into stepping stones. We lift up our fellow travelers when they weaken and they do the same for us.

We do recover.

Avoid Burnout

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There’s a high turnover in the field of addiction treatment. That’s not good, because people with the most experience leave the field for more attractive work environments. I’d like to offer some ways of avoiding undue stress that leads to burnout.

Before we get to stress, it’s important to talk about why there’s burnout in this field. Many people think it’s all from patient behaviors, but that’s not the only reason.

True, it’s not always easy to work with patients in treatment for drug addiction. Addiction can cause all sorts of behaviors that can interfere with treatment, and trigger anger on the part of treatment providers. In patients with addiction, old behaviors don’t disappear overnight, and we have no right to expect them to do so. For humans, change takes time.

Program administrators can cause stress for program workers. Administrators who aren’t familiar with what happens on the front lines of addiction treatment may make unworkable changes to how treatment is to be provided. As an example, I once worked for an opioid treatment program who instructed a nurse to operate three dosing windows at the same time, by herself, to reduce wait time for patients to dose. I am not making this up. Obviously this was unworkable and unwise, yet the nurse was required to “prove” the unworkability before this lame idea was discarded.

Addiction treatment providers don’t make a great deal of money. Addiction treatment professionals earn an average income of $38,000 per year, with a range of $24,000 to $60,000 per year depending on experience, credentials and and treatment setting.

Counselors at OTPs have tremendous workloads. State and federal regulations say OTPS can have no more than fifty patients assigned to each counselor. Even within that limit, there’s not enough time to attend to all patient needs. And besides time spent with the patients, the time spent on documentation and paperwork is overwhelming.

In the past, addiction counselors tended to be in recovery themselves, with their personal experience as their only credential. Now there’s a push for the substance abuse treatment field to become more professionalized. The pressure to prove competency causes ever-increasing paperwork to pop up like mushrooms after a rain. And the documentation forms change all of the time. Just as workers get used to one form, it’s changed again.

To paraphrase Terri Moyers, a world-renowned addiction treatment professional, the substance abuse field is addicted to documentation and they are in denial.

OK, so there are stresses working in the field. Maybe the field will improve someday. Until then, here are some ideas about dealing with burnout:

1. Take care of your physical health. We tell patients to do this, but are we setting good examples? Eat right, go to the doctor for routine medical health screens, get to the dentist periodically, and get enough sleep. We all know what to do.
2. Have a life outside of work. This is big. I have to remind myself of this one frequently. Don’t let work become your whole identity. When you are at home, is your mind also at home, or are you thinking about a work situation? Try to keep your mind and your feet in the same place.
3. Have a creative outlet. Right now, I’m weaving rugs. I love it; it’s creative and I enjoy the process of making a rug. It’s fun to give them as gifts, too. Right now I buy old ratty leather items at the local thrift stores, cut them into strips and weave them into rugs. In times past, I’ve made quilts. I seem to be drawn to the textile arts. What is your artistic outlet? It could be a non-traditional art form, like cooking or decorating your house.
4. Don’t take things personally. We all have bad days, and another person’s nasty response to you may have nothing to do with you. Make allowance and let it roll off.
5. Don’t stuff your feelings, either. If there’s a situation at work that you don’t like, don’t wait until you explode in anger to say something about it. Go to your supervisor or other appropriate person and state your feelings about what’s going on. You’re more likely to be heard if you’re calm and logical and not spew-y.
6. Don’t have unrealistic expectations. Drug addicts use drugs. Expect this to happen during the treatment of the disease. Relapse is never OK, but if the patient is lucky enough to live through it, help them figure out why it happened so they can avoid a similar situation in the future.
7. Do some kind of aerobic exercise if your physical condition permits. Besides health benefits, exercise can make a huge difference in my ability to handle stress. It doesn’t have to be heavy exercise; even going for a walk can reduce stress.
After I broke my leg last spring, I couldn’t exercise like I was used to, and I really missed it. I felt much better after my leg healed enough to do some of my normal activities.
8. Nurture your spiritual health. This doesn’t necessarily mean participation in an organized religion, although for some people it may. For me, anything that connects me to other people and to the God of my understanding is spiritual. I feel better and more centered when I regularly make time for prayer and meditation. Obviously people find different things that nurture them spiritually.

Despite the stresses, many of us prefer to work in the field of addiction treatment, for various reasons. For those people, working in the field of addiction treatment is an avocation, not just a vocation.

For me, I love to see the positive changes in patients’ lives, and to feel like I had some small part in that. In this field when addicts find recovery it isn’t just their lives that improve; families and then communities benefit, too. I didn’t see that when I worked in primary care.

I have the best job in the world.

Each State Gets a Report Card

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You have got the check this out…an organization called Trust For America’s Health, or TFAH, supported by the Robert Wood Johnson foundation, has released a report called, “Prescription Drug Abuse 2013: Strategies to Stop the Epidemic.” You can find the report at their website at: http://www.healthyamericans.org

This report grades each state on its policies for managing the prescription pain pill epidemic.

The report begins with a description of the scope of the problem: current estimates say around 6.1 million U.S. citizens are either addicted to or misusing prescription medications. Sales of prescription opioids quadrupled in the U.S. since 1999, and so have drug overdose deaths. In many states, more people die from drug overdoses than from motor vehicle accidents. The costs of addiction and drug misuse are enormous; in 2011, a study estimated that the nonmedical use of prescription opioids costs the U.S. around 53.4 billion dollars each year, in lost productivity, increased criminal justice expenditures, drug abuse treatment, and medical complications.

The report identifies specific groups at high risk for addiction. Men aged 24 to 54 are at highest risk for drug overdose deaths, at about twice the rate of women, although the rate of increase in overdose deaths in women is worrisome. Teens and young adults are at higher risk, as are soldiers and veterans. (Please see my blog of October 19th for more information about veterans.) Rural residents are twice as likely to die of an overdose as urban residents.

TFAH’s report declares there are ten indicators of how well a state is doing to fix the opioid addiction epidemic. This report grades each of the fifty states by how many of these indicators each state is using. TFAH says these ten indicators were selected based on “consultation with leading public health, medical, and law enforcement experts about the most promising approaches.”

Here are their ten indicator criteria:
 Does the state have a prescription drug monitoring program?
 Is use of the prescription drug monitoring program mandatory?
 Does the state have a law against doctor shopping?
 Has the state expanded Medicaid under the ACA, so that there will be expanded coverage of substance abuse treatment?
 Does the state require/recommend prescriber education about pain medication?
 Does the state have a Good Samaritan law? These laws provide some degree of immunity from criminal charges for people seeking help for themselves or others suffering from an overdose.
 Is there support for naloxone use?
 Does the state require a physical examination of a patient before a prescriber can issue an opioid prescription, to assure that patient has no signs of addiction or drug abuse?
 Does the state have a law requiring identification to pick up a controlled substance prescription?

 Does the state’s Medicaid program have a way to lock-in patients with suspected drug abuse or addiction so that they can get prescriptions from only one prescriber and pharmacy?

I thought several of these were bizarre. Several are great ideas, but others…not so much. For example, I think a law against doctor shopping leads to criminalization of drug addiction rather than treatment of the underlying problem. The addicts I treat knew that doctor shopping was illegal, but still took risks because that’s what their addiction demanded of them. Such laws may be a way of leveraging people into treatment through the court system, however.

And where are the indicators about addiction treatment? Toward the very end of this report, its authors present data regarding the number of buprenorphine prescribers per capita per state, but make no mention of opioid treatment program capacity per capita for methadone maintenance. Buprenorphine is great, and I use it to treat opioid addiction, but it doesn’t work for everyone. And there’s no data about treatment slots for prolonged inpatient, abstinence-based treatment of opioid addiction.

Expanded Medicaid access for addiction treatment is a nice idea… but not if doctors opt out of Medicaid because it doesn’t pay enough to cover overhead. If expanded access is not accompanied by adequate – and timely! – payment to treatment providers for services rendered, having Medicaid won’t help patients. Doctors won’t participate in the Medicaid system. I don’t. I have a few Medicaid patients whom I treat for free. It’s cheaper for me to treat for free than pay for an employee’s time to file for payment and cut through red tape.

In one of the more interesting sections in this report, each state is ranked in overdose deaths per capita, and the amount of opioids prescribed per capita.

The ten states with the higher opioid overdose death rates are: West Virginia, with 28.9 deaths per 100,000 people; New Mexico, with 23.8 deaths per 100,000; Kentucky with 23.6, then Nevada, Oklahoma, Arizona, Missouri; then in eighth place is Tennessee, with 16.9 deaths per 100,000. In ninth and tenth places are Utah and Delaware. Florida came in at number 11, with 16.4 deaths per 100,000.

North Carolina placed 30th in overdose death rates. We’ve had a big problem with prescription drug overdose deaths. From 1999 until 2005, the death rate rose from4.6 per 100,000 to 11.4 per 100,000. But at least our rate has not increased since 2005. The rate in 2010 was still 11.4. It’s still way too high, but many agencies have been working together over the past six years to turn things around. In a future blog, I intend to list the factors I think helped our state.

Use of the ten indicators does appear to correlate with reduced rate of increase of overdose deaths. In other words, states with more laws and regulations have had a slower rise in overdose deaths than states with fewer laws and regulations, though there are some exceptions.

This report also compares states by the amount of opioids prescribed per year, in kilograms of morphine equivalents per state per 10,000 people. Florida, not surprisingly, came in at number one, with 12.6 kilograms per 10,000 people. Tennessee and Nevada tied for second and third place, with 11.8 kilos per 10,000 people. The next seven, in order, are: Oregon, Delaware, Maine, Alabama, West Virginia, Oklahoma, and Washington. Kentucky was 11th, with 9.0 kilos per 10,000. North Carolina doctors prescribe 6.9 kilos of opioids per 10,000 people per year, in 27th place and less than the national average of 7.1 kilos.

It appears to me that amount of opioid prescribed per capita does correlate, somewhat, with overdose death rates.

Let’s look closer at Tennessee, the state who, just a few months ago, rejected a certificate of need application for an opioid treatment program to be established in Eastern Tennessee. In 1999, Tennessee had an overdose death rate that was relatively low, at 6.1 per 100,000 people. By 2005, it zoomed to 10.4 per 100,000 people, and by 2010, rocketed to 16.9 per 100,000 people, to be in the top ten states with highest overdose death rates. Furthermore, Tennessee is now second out of fifty states for the highest amount of opioids prescribed per 10,000 people. Only Florida beat out Tennessee. And lately Florida has made the news for its aggressive actions taken against pill mills, which may leave the top spot for Tennessee.

West Virginia is no better. It was the worst state, out of all fifty, for overdose deaths, at 28.9 per 100,000 people in 2010. Wow. If you think lawmakers are asking for help from addiction medicine experts…think again.

West Virginia legislators recently passed onerous state regulations on opioid treatment programs. That’s right, lawmakers with no medical experience at all decided what passed for adequate treatment of a medical disease. For example, they passed a law that said an opioid addict had to be discharged from methadone treatment after the fourth positive urine drug screen. In other words, if you have the disease of addiction and demonstrate a symptom of that disease, you will be turned out of one of the most evidence-based and life-saving treatments know to the world of medicine. West Virginia passed several other inane laws regulating the medical treatment of addiction.

Getting back to the TFAH study, the report calculates that there are 21.6 million people in the U.S. who need substance treatment, while only 2.3 million are receiving it. This report identifies lack of trained personnel qualified to treat addiction as a major obstacle to effective treatment.

This report makes the usual recommendations for improving the treatment of addiction in the U.S… They recommend:

 Improve prescription monitoring programs. Nearly all states have them, except for Missouri and Washington D.C.

States should be able to share information, so that I can see what medication my North Carolina patients are filling in Tennessee. Right now, I have to log on to a separate website to check patients in Tennessee, so it takes twice as much time. Tennessee is already sharing data with several other states, but not with North Carolina, or at least not yet.

TFAH also recommends linking prescription monitoring information with electronic health records.

 Easy access to addiction treatment.

Duh. The report accurate describes how underfunded addiction treatment has been, and says that only one percent of total healthcare expenditures were spent on addiction treatment. We know how crazy that is, given the expense of treating the side effects of addiction: endocarditis, alcoholic cirrhosis, hepatitis C, gastritis, cellulitis, alcoholic encephalopathy, emphysema, heart attack, stroke, pancreatitis, HIV infection, gastrointestinal cancers, lung cancer…I could go on for a page but I’ll stop there.

Access to treatment is limited by lack of trained addiction professionals. Doctors abandoned the field back in 1914, when it became illegal to treat opioid addiction with another opioid. Even with the dramatic success seen with methadone and buprenorphine treatment of opioid addiction, there are relatively few doctors with expertise in this treatment.

This reports shows that two-thirds of the states have fewer than six physicians licensed to treat opioid addiction with buprenorphine (Suboxone) per 100,000 people. Iowa has the fewest, at .9 buprenorphine physicians per 100,000 people, and Washington D.C. had the most, at 8.5 physicians per 100,000 people.

North Carolina has 3.2 buprenorphine physicians per 100,000 people, while Tennessee has 5.3 physicians per 100,000. This makes Tennessee look pretty good, until you discover than many of Tennessee’s physicians only prescribe buprenorphine as a taper, refusing to prescribe it as maintenance medication. If these doctors reviewed the evidence, they would see even three month maintenance with a month-long taper gives relapse rates of around 91% (1)

I’m really bothered by the lack of attention to the number of methadone treatment slots per capita. That’s information I’d really like to have. But the authors of this report did not deign to even mention methadone. Even with forty-five years’ worth of data.

**Sigh**

 Increased regulation of pill mills.

 Expand programs to dispose of medications properly. In other words, make sure citizens have a way to get rid of unused medication before it’s filched by youngsters trying to experiment with drugs.

I know many tons of medications have been turned in on “drug take-back” days. But I’ve never seen any data about how much medication is addictive and subject to abuse, versus something like outdated cholesterol lowering pills.

 Track prescriber patterns. Another benefit of prescription monitoring programs is that officials can identify physicians who prescribe more than their peers. Sometimes there’s a very good reason for this. For example, a doctor who works in palliative care and end-of-life care may appropriately prescribe more than a pediatrician.

I get uneasy about non-physicians evaluating physicians’ prescribing habits, though. I think this is best left up to other doctors, enlisted by the state’s medical board to evaluate practices. Other doctors are better able to recognize nuances of medical care that non-physicians may not understand.

 Make rescue medication more widely available. In this section, the report’s authors make mention of Project Lazarus of Wilkes County, NC, a public health non-profit organization dedicated to reducing opioid overdose deaths, not only in that county, but state-wide. Project Lazarus is well-known to me, since I work at an opioid treatment program in Wilkes County.

 Ensure access to safe and effective medication, and make sure patients receive the pain medication they need. Obviously, we want opioids available to treat pain, especially for acute pain. Hey, you don’t have to convince me – read my blog from this summer about how grateful I was for opioids after I broke my leg. Opioids were a godsend to me in the short-term, and knowing what I do about opioids, I didn’t use them after the pain subsided.

It was an interesting report, though I saw some unfortunate gaps in their information, particularly regarding opioid addiction treatment availability.

But at least this is another agency looking at solutions and making some helpful recommendations.

1. Weiss et al, “Adjunctive Counseling During Brief and Extended Buprenorphine-Naloxone Treatment for Prescription Opioid Dependence,” Archives of General Psychiatry, 2011;68 (12):1238-1246.

Suboxone: Miracle Drug or Manacle?

Yesterday in my office, I saw patients for whom I prescribe buprenorphine (better known under the brand name Suboxone). It was not my typically pleasant day. Usually, I see the positive changes occurring in the lives of my patients: they are getting families back, getting jobs or better jobs, getting health and dental care needs addressed, and overall feeling happier and more productive.

 But yesterday I had two patients who were bitter about being on Suboxone. Both were having great difficulty tapering off of Suboxone. Both had also been reading materials on the internet that described the hopelessness of ever tapering off this medication.

 This frustrates me for several reasons. First, not everything you read on the internet is correct. Second, people don’t appear in my clinic requesting Suboxone for no reason. All of my Suboxone patients were addicted to opioids before I ever prescribed Suboxone. Even assuming no patient ever gets off Suboxone, it’s still so much better than what they were doing before. Third, I’ve never said it’s easy to get off Suboxone. It can be done, but it’s still an opioid. When you stop opioids, you will have withdrawal. There’s no way around that. 

Overall, most people say withdrawal off Suboxone is easier than other opioids. But people and their biochemistries are different, and I accept that some people have a worse withdrawal than other people. I’ve had a few people say methadone withdrawal was easier than Suboxone withdrawal. I have to believe that’s their experience, but I think that’s unusual, and not the experience of most people. 

Some doctors think patients on maintenance medications, like methadone or Suboxone, should always stay on these medications, given what we know about the rates of relapse and even death for patients who leave these programs. And some patients have continued sub acute withdrawal symptoms for weeks or months off opioids, and just don’t feel right unless they are on maintenance medications. These people seem to do better if they stay on maintenance medication. 

And on the other hand, many people are able to taper off opioids and remain off of them, and lead happy, healthy lives. I keep thinking about two groups of recovering opioid addicts who do well off of all opioids, on no maintenance medications: members of 12-step recovery groups, and recovering medical professionals.

 Off the top of my head, I can think of a dozen recovering opioid addicts who are members of Alcoholics Anonymous or Narcotics Anonymous, and who aren’t on any maintenance medications. They feel fine, and have been abstinent from opioids for years. If you don’t believe me, go to an open Narcotics Anonymous meeting. Ask the recovering addicts there if they have been addicted to opioids in the past. Chances are that around a fourth of the people you talk to are recovering from opioid addiction. There may be a few people who are on methadone or Suboxone, but many are completely free from opioids.

 Look at doctors in recovery. Opioids were the drug of choice for many addicted doctors, and they are “real” addicts, having used remarkable amounts of opioids before getting into recovery. But doctors have one of the highest rates of drug-free recovery. This isn’t because we are so smart or special, or because we have Charlie Sheen’s tiger blood. It’s because we are held tightly accountable by our licensing boards. If we want to practice medicine, we have to participate in recovery. Licensing boards often hold our licenses hostage unless we do the work of recovery. This may mean three to six months of inpatient residential treatment, after a medical detoxification. It may mean four recovery meetings per week for the first five years of recovery, along with monthly random drug screen, and a monitoring contract for five years.  (1,2)

If every addict seeking recovery could have that degree of treatment and accountability, I suspect relapse rates would be uniformly low. Sadly, that’s just not possible for most opioid addicts, because of financial constraints, and because there’s less leverage with most people than with licensed professionals. 

Not all opioid- addicted doctors do great off opioids. Many have multiple relapses, and would probably be much healthier and happier if they got on maintenance medications like methadone or Suboxone, but isn’t allowed – at present – by the licensing boards in most states. Again, one type of treatment doesn’t work for everyone.

 My point is that it is possible for many people to get off Suboxone, and live a happy drug free life. And for other people, lifelong maintenance is probably the best and safest option. At present, we don’t have a way to predict who might do well off of Suboxone (or methadone). We do know that a taper should be slow, and probably takes four to six months for a taper to give best results.

 I believe in Suboxone. It’s saved many lives, just like methadone has. I wouldn’t prescribe it if I didn’t know it works. I think what I’ve been hearing and reading is a normal backlash against the unrealistic expectations many people had for Suboxone. It’s been called a miracle drug, but it’s not. It’s still an opioid, and there is still a withdrawal when it’s stopped. It’s a great medication for many people. It can allow many opioid addicts to get their lives back and enjoy a normal life, except for having to take a daily dose of Suboxone. But isn’t that still drastically better than active addiction? 

  1. Ganely, Oswald H, Pendergast, Warren J, Mattingly, Daniel E, Wilkerson, Michael W, “Outcome study of substance impaired physicians and physician assistants under contract with North Carolina Physicians Health Program for the period 1995-2000,” Journal of Addictive Diseases, Vol 24(1) 2005.
  2. McLellan, AT, Skipper, GS, Campbell, M, DuPont, RL, “Five Year outcomes in a cohort study of physicians treated for substance abuse disorders in the United States,” British Medical Journal,2008;337: a 2038.

Opioid Blockers: Do They Take All the Fun Out of Life?

According to an interesting article in the most recent copy of the American Journal on Addictions, the answer appears to be, “No,” at least for some people. (1)

 This article described a study where researchers asked patients on the extended-release opioid blocker naltrexone to rate the amount of pleasure they obtained from things like eating good food, sex, and exercise. These patients were on naltrexone for the treatment of alcoholism, but of course, the information may be helpful for opioid addicts who are treated with opioid blockers to prevent relapse back to opioid use. The subjects were asked to rate, on a scale of 1 to 5, the amount of pleasure they obtained from activities such as sex, eating good food, exercise, talking with friends, and other usually enjoyable things in life. A score of 1 meant they felt no pleasure at all, and 5 meant they felt much pleasure.

 The good news is that pleasure scores for these patients were relatively high. For example, the average score for pleasure from eating good food was 4.14, out of a possible 5. For listening to music, it was 4.00 out of 5. For sex, it was 3.92. For drinking alcohol, it was only 2.57 out of 5, which supports the use of this medication for alcoholics.

 In summary, the study found that subjects on extended-release naltrexone still experienced a good amount of pleasure from life.

 There were limitations to this study, however. We don’t have a pre-naltrexone baseline for these patients. In other words, we know pleasure ratings were fairly high while on naltrexone, but it’s possible these subjects had even higher pleasure scores before naltrexone. Also, there was no placebo control in the study. Maybe people getting pretend, or sham, treatments would have had higher pleasure scores, but we don’t know. 

In my mind, the biggest weakness was that the study enrolled 187 patients, but only 74 completed the intended survey. That means about 60% of the subjects dropped out of treatment, and the article doesn’t say why they dropped out. Maybe the drop-outs were the ones to feel a lack of pleasure in their lives from being on naltrexone, and the ones who stayed on it didn’t have this same side effect. If so, this would obviously skew the results.

 But even with these admitted weaknesses, and even though the study was paid for by the company that manufactures the sustained-release naltrexone (Vivitrol), this article gives hope that Vivitrol may work for opioid addiction. It may help prevent relapses, without interfering with life’s pleasures. And we need every tool we can get to fight addiction.

  1. 1.      O’Brien, Charles; Gastfriend, David; Forman, Robert; Schweizer, Edward; Pettinati, Helen, Long-Term Opioid Blockade and Hedonic Response: Preliminary Data from Two Open-Label Extension Studies with Extended-Release Naltrexone, American Journal on Addictions, Vol. 20 (2), March/April 2011, pp106-112.

The Story of a Recovering Addict

Following is an interview with a successfully recovering opioid addict. He received treatment at methadone clinics off and on for years, and finally achieved medication-free recovery after going to an inpatient treatment program for 42 days. Later, he began to work in the field of addiction treatment as a methadone counselor. He was promoted multiple times over the years to his present position as director of the narcotic treatment program at his clinic. This is his perspective about his own experience and what he’s seen with methadone treatment.

JB: Can you tell me your title at the opioid treatment clinic where you work?

KS: Director of Narcotic Treatment, which is our opioid treatment program. [He supervises counselors working at multiple clinic sites, with a total census of around thirty-four hundred methadone patients]

JB: Can you please tell me about your own opioid addiction, and how you got into recovery, including what kind of substances you may have used, what kind of treatments, and your experiences with them?

KS: I started out using pain killers, mostly Percodan tablets, back in the late 70’s, which lead me to using heroin. Heroin wasn’t easy to get [where I lived], so I started using Dilaudids [a name brand of the drug oxymorphone]. I started using Dilaudid on a regular basis in the county I lived in. That was the primary drug I used for quite a few years.

[My] first experience with methadone treatment started in 1978, with a brief episode of treatment, a matter of a month or so, with no success. Pretty much during the 1980’s, I was on and off methadone programs with little or no success, because I refused to participate in group or individual sessions. At the time, there was very limited counseling going on [at methadone clinics]. If there was a problem, you saw your counselor, and that didn’t happen a whole lot. Patients were simply trying to get more methadone. At that point, the methadone dosages were very low. I think the average dose back then was somewhere between forty and fifty milligrams. And we [patients on methadone] didn’t know that. We didn’t know that. We just found out through….

JB: You didn’t know what dose you were taking?

KS: Oh, no. We didn’t know what dose we were taking, for a number of years. As a matter of fact, that didn’t change until right before 2001.

JB: Wow

KS: Yeah.

JB: Could the patient find out if they wanted to? [the dose they were taking]

KS: We were blind dosed then. That didn’t change until just before 2001.

JB: Was that unusual for methadone clinics to do?

KS: To my knowledge, I think we [the clinic where he now works, and previously was a patient] were one of the last ones to keep doing that. It was just something we had done over the years and never changed it. [The patients] didn’t know what their dose was.

Through the 1980’s, I was on and off methadone programs, sometimes for a few years at a time, and sometimes had some success. The biggest benefit I had from taking methadone and being on the program was that I was able to work. I held a job the entire time, and I wasn’t doing anything criminal.  It served the purpose it was supposed to serve there, because I had to work, and I was able to function fairly normally. But I never moved into actual recovery, and still used some opiates from time to time. So that was pretty much the 80’s. Two good things happened in the 80’s. In 1981 my son was born, and in 1989, I got clean.

JB: Big things.

KS: Two monumental things in my life. So, I went through that period of time I had talked about, when I started using opiates, in about 1974. Then I started getting on the methadone programs, on and off, [starting] from ’78, but I continued to use. I was using Dilaudids on a daily basis for a number of years. When I got on the methadone program, I would curtail that, but always wanted to go back to Dilaudid. That [Dilaudid] became my drug of choice.

I was on the methadone program in 1989, and having some problems with alcohol. Prior to getting on the program, I was told, “We’re not going to allow you on the program, unless you go on Antabuse.” So I did that and I was successful at stopping drinking, and had some success with methadone. I decided I wanted off the methadone, started detoxing off, and had a series of positive drug screens for a variety of opiates: morphine, Dilaudid, and several different things I had access to. The methadone center said, “We’re going to make a recommendation that you enter residential treatment.” And I said, “Sounds great to me, I’ll do that in a couple months.” And they said, “No. We’re going to make a recommendation you do that… pretty quickly.”

And that’s what happened. I said, “I don’t think I can do this. I’ve got some things to do.” And I remember it like it was yesterday. The counselor got up and walked out of the room and he left me sitting there by myself. Then he walked back in, said, “We’ve got you a bed.” And that’s what lead me to [inpatient treatment].

So I went to forty-two days of residential treatment, and actually entered that program ready to quit using and get into recovery. And from that point on, recovery has been the most important thing in my life….family, of course…but I’ve pursued recovery since May 3, 1989. I followed all the suggestions. [I’m] still really involved with 12- step meetings, and still really involved with some of the same things I did when I first came in [to recovery]. Obviously, I don’t go to as many meetings, but still go to meetings on a regular basis

JB: Do you have any regrets about either type of treatment? The forty-two day inpatient or the methadone?

KS: I do believe that in my case, I needed to be taken away from my environment, simply because of the people I was associated with. That’s not the case for everyone. In my case, I needed to be away from my environment. So the detoxing from the methadone and going into a residential program, that’s what worked for me. Obviously, people can do that other ways. But I still had people in my life that were negative influences.

JB: If you had an opioid addict who presented for treatment for the first time, what would you recommend? If money were no object?

KS: I’d recommend that individual seek inpatient treatment. Now, if they had an extended history of opiate dependency, then that person’s success rate in residential treatment is obviously going to be limited….and…it would just depend on the individual. Methadone treatment might be the way for them to go. I know that’s kind of teetering on the fence. I’m going to be somewhat….I’m going to hold on to how powerful residential treatment was for me. But I had failed at methadone treatment. And, there again, it was a different time, the methadone doses weren’t enough at the time.

JB: Did you feel normal on your dose of methadone or did you [still] feel withdrawal?

KS: I was feeling normal, however, I could still feel drug use [other opioids].

JB: So it wasn’t a blocking dose?

It was not a blocking dose. You knew if you got medicated at 7:00 am, at 5:00 pm you could fairly well feel somewhat of a rush and feel the effects of [other opioids].

JB: How did you get started working in the field of addiction treatment?

KS: I came out of treatment, worked for a family business for a couple of years, and always, from day one, I thought, “What a fascinating thing….if I could somehow do this…to get into that line of work [meaning addiction counseling].

 I started, after two years, as an evening counselor at a residential treatment program, and saw that I really wanted to do that. There was an avenue for non-degreed people to come in to a counselor position. You didn’t have to have a degree in substance abuse or anything like that, so I pursued that, and followed the certification process. I didn’t work in residential treatment but nine months, and then moved to methadone counseling. From that point on, I had found what I wanted to do. And I’ve been offered a promotion at the treatment center to another department when I was over the methadone program, and turned it down to stay with that population [meaning opioid addicts in treatment on methadone].

JB: So you obviously enjoy it.

KS: Oh yeah.

JB: What did you like about it?

KS: I think my ability to relate to that population, without having any thought or putting any real effort…I don’t have to think about it. I know I can talk to that population, and I know I can make them feel normal, by just holding a conversation with them….it might not be about drug use. It might not be about anything pertaining to the treatment episode, but I feel like…that I know exactly where they’re coming from, and I can give them some hope that they don’t have to keep living that way. Just an identification with that population.

JB: That’s a precious gift.

KS: I agree.

JB: Do you believe that your background in addiction helps you when you talk to patients?

KS: I do. I believe wholeheartedly that you can’t teach that. I’ve had some people work for me who had a graduate degree, have never personally had an incidence of opioid addiction or any addiction in their family, and they’re absolutely fantastic clinicians. And you know they’re in that line of work for a reason. So [personal experience with addiction] does not need to be a criterion; in my case, it helps. I find it fascinating to watch someone work who has no self-history of addiction. They can be very effective.

JB: What are the biggest challenges you face now at your work?

KS: That would be…documentation. [The demand for] documentation in this field has really overcome the interpersonal relationship. I can’t help but think as time goes on, that’s going to continue. We don’t have twenty or thirty minutes to sit down with a client, and get into one issue after another, or whatever [the client] may have on their plate. And in opioid treatment, a lot of times it’s brief therapy. They [patients] don’t want to talk to you for twenty or thirty minutes. But you don’t have time to do that, because of the documentation. [The counselor has] three people waiting in the lobby, and you’re kind of selling that person short.

The documentation standards continue to rise, and in methadone treatment, I don’t know how that can go hand in hand with a fifty to one case load. Whereas, someone else might have the same documentation required in the mental health field, but they might have sixteen people they’re seeing.

JB: So you’re saying that the state and federal regulations about documentation actually interfere with the amount of counseling the patients get?

KS: Right. Right.

JB: That’s sad.

The clinic where you work has eight different sites. Can you tell me about what sort of interactions you’ve had with the community leaders, local police, and medical community?

KS: Overall, with any opioid treatment program [methadone clinic], there’s going to be a negative stereotype associated with it in the community, as you well know. Local law enforcement has a bias [against] the [methadone] program. What we’ve found is, any interaction we have with them, and the better understanding that they have [of what we do], the better. And I believe we can make a difference in what law enforcement, and other areas of the community [think about methadone programs].  It’s going to have to happen one person at a time.

An example of that would be when I got a call, a couple of weeks ago, to one of the clinics at ten o’clock at night. An alarm is going off. So I meet the police out there, and we go in, make sure nobody’s in the building. I’m trying to give him some information about it [the methadone program].

He says, “Is it true they come in every day and ya’ll shoot ‘em up?” (laughter) So he thinks that’s what happens.

            So, I educated him on what we do and followed that up with, “Why don’t you stop by and get coffee any time you want to and we’ll give you information.” They were very receptive to that. That’s how you’ve got to approach it. Be willing to talk to people and give them information. [Do the] same thing with community leaders. They’re just not educated in outpatient opioid treatment. Once they get some information, they seem to have a different take on it.

JB: Can you tell me what you’ve seen, particularly over the last seven years, about the types of populations that are coming to the clinics, and if that’s changed any?

KS: I started working in methadone treatment seventeen years ago. We used to have statistics on the methadone program. The average age of a person coming on the program was thirty-four years old, at that time. We had eighty or ninety people on the program and that was it. And they were long term users, primarily heroin as drug of choice. We’ve seen what’s happening over the years.

Heroin has decreased somewhat. Prescription medications went wild. I just read information that forty-four percent of patients entering methadone programs in the nation were on prescription opioids. The age of the person coming on the program has dropped from thirty-four into their late twenties. I don’t have that exact number. But we’ve seen them get younger, and we’ve seen prescription drugs take the place of heroin, in driving people into treatment.

JB: What seems to be the main type of prescription drug, or is there one?

KS: OxyContin changed the landscape in our setting. It’s still a driving force, as far as putting people into treatment. We have an increase in heroin here, but the western part of the state…OxyContin and morphine are on the scene….and any painkiller.

JB: Do you have any opinion about why that happened? Why the incidence of pain pill addiction seemed to rise over the last seven to ten years?

KS: If there’s a reason for it….I think it’s generational. It’s passed down. It’s easy. You’ve got doctors giving the mother and the father painkillers for whatever reason, legitimate or not. It gets passed on…obviously there’s a genetic link for some kinds of addiction or alcoholism. I think you know what you’re getting there [meaning a prescription pill]. People addicted to opioid drugs have very few avenues to get quality heroin in those regions of the country. [Pain pills] are a sure bet. Patients say, “I know what I’m getting when I get that pill.”

JB: If you had the ear of policy makers in Washington D.C., what would you tell them? What would you like to see happen in the treatment field for opioid addiction?

KS: I’m going to refer back to what I said earlier. In methadone treatment, there should be some kind of review, as far as what needs to be documented. Obviously, there needs to be accurate documentation, but not to put methadone or opioid treatment into the same mental health arena for documentation requirements. Because you’re dealing with a different environment, a different population, and a different caseload.

JB: Would you like to see buprenorphine play a role [at the methadone clinic]?

KS: Yes, there’s a need for it. You’ve got such a stereotype against methadone facilities, that’s another avenue for people to be in treatment [meaning buprenorphine]….whether it’s administered in the methadone facility or [community] doctor-based, there’s a need for that.

This interview was with one of the many wonderful people I’ve had the honor of working with at methadone clinics. In my years of work in the medical field, I’ve never been surrounded by as many quality people, who had passion for their work, as I have in addiction medicine. I don’t know if I’ve been extremely lucky, or if all addiction treatment centers draw dedicated individuals to work within their systems. Many of these workers try hard to dispel the stigma and social isolation that addicts feel.