Archive for the ‘snorting suboxone’ Category

Better Outcomes with More Services at Opioid Treatment Centers

Opioid treatment centers that are able to offer a wider array of services than just dosing with methadone show better patient retention in treatment and better patient outcomes. This means that just dosing with methadone helps opioid addicts, but not as much as methadone plus addiction counseling. And methadone plus counseling helps, but not as much as when other services are added, like psychiatric care, primary medical care, help with employment, and family counseling services. (1)

The problem is, of course, these extra services cost more to the treatment program. If you want to offer psychiatric services, a psychiatrist must be hired, usually on a contract basis, to be available during dosing hours. If the program’s medical director is a psychiatrist, that doctor has to be paid for the extra time it takes to provide the extra care. More commonly, patients are referred to other places for low-cost psychiatric help.

It’s the same with medical care. In order to offer any level of primary care, you have to hire a doctor, unless patients are asked to pay extra for this. Most patients can barely afford basic treatment, so extra expenses can’t be obtained.

At my program I like to try to treat uncomplicated mental illness like depression and anxiety disorders, and non-chronic, low-intensity primary care illnesses. Of course I refer patients who need ongoing medical or psychiatric care, but I can provide interim care until they get an appointment.  I think this helps patients because I already know their history of addiction and won’t prescribe anything that will interact with methadone. It doesn’t cost the patient anything to see me for these extra services, so it saves patients money. I can usually see them relatively quickly, without an appointment on the two days a week that I work at the clinic. It seems like a good thing all around.

But to do even this low intensity care, accreditation agencies have many guidelines.

Treatment centers usually strive to be certified by the Commission of the Accreditation of Rehabilitation Facilities (CARF). CARF personnel are invited to facilities for a voluntary inspection, hopefully to be given a sort of seal of approval by this agency. They inspect mental health, substance abuse treatment, and physical rehabilitation facilities, as well as youth and family service facilities. Accreditation is important because it demonstrates the facility is providing good care.

The good news is that our CARF survey went very well. We got a one-year accreditation, and the CARF surveyors were professional and knowledgeable. They had good things to say about our clinic regarding our dedication to our mission to help our patients. They said great things about the staff enthusiasm and outlook. The CARF people supported the idea of providing primary care to patients, but they had recommendations about how to implement a few policies and procedures around this care. This is what they recommended, verbatim:

 F.2.a.(1) through F.2.b.(16)It is recommended that ongoing documented training and education on medications be provided to the person served, family members, individuals identified by the person served, the team, and service providers. This ongoing training should include how the medication works; risks associated with each medicine; the intended benefits as related to the behavior or symptom targeted by the medication; side effects, contraindications, and potential implications between medications and diet/exercise; risks associated with pregnancy; the importance of taking medications as prescribed, including, when applicable, the identification of potential obstacles to adherence; the need for laboratory monitoring; the rationale for each medication; early signs of relapse related to medication efficacy; signs of nonadherence to medication prescriptions, including alcohol, tobacco, caffeine, illicit drugs, and alternative medications; instructions on self-administration, when applicable; wellness management and recovery planning; and the availability of financial supports and resources to assist the persons served with handling the cost associated with medications.

 F.a.(1) through F.4.c.(3)It is recommended that, when medications are prescribed for or provided to a person served 9including those self-administered medications), an up-to-date individual record of all medications, including nonprescription and nonpsychoactive medications, include the name of the medication; the dosage; the frequency; instructions for use, including the method/route of administration; and the prescribing professional. The program should provide ready access to the telephone number of a poison control center to the program personnel and the person served. Written procedures that address how the medication will be integrated into the overall plan of the person served should be available. There should be a process for identifying, responding to, documenting, and reporting medication reactions and actions to be followed in case of emergencies related to the use of medication.

 F.5.a.through F.5.n. It is recommended that, as the organization prescribes medications, it implement written procedures that include compliance with all applicable local, state or provincial and federal laws and regulations pertaining to medications and controlled substances, including on-site pharmacy services and dispensing. Written procedures should include the active involvement of the persons served, when able, or their parents or guardians, when appropriate, in making decisions related to the use of medications; the availability of a physician, pharmacist, or qualified professional licensed to prescribe for consultation 24 hours a day, 7 days a week; documentation and reporting of observed and/or reported medication reactions and medication errors; and a review of past medication use, including effectiveness, side effects, and allergies or adverse reactions. Written procedures should include the identification of alcohol, tobacco, and other drug use; use of over-the-counter medications; use of medications by women of childbearing age; use of medications during pregnancy; special dietary needs and restrictions associated with medication use; necessary laboratory studies, tests, or other procedures, when applicable; documented assessment of abnormal involuntary movements at the initiation of treatment and every six months thereafter for persons served receiving typical antipsychotic medications; when possible, coordination with the physician(s) providing primary care needs; and review of medication use activities, including medication errors and drug reactions, as part of the quality monitoring and improvement system.

F.6.a. through F.6.f. If the organization provides prescribing of medications, it is recommended that it implement written procedures that include screening for common medical co-morbidities using evidence- or consensus-based protocols; evaluation of co-existing medical conditions for potential medications impact; identifying potential drug interactions, including the use of over the counter or homeopathic supplements; documentation or confirmation of informed consent for each medication prescribed, when possible; continuing a prescribed medication if a generic medication is not available; and continuity of medication use, when identified as a need in a transition plan for a person served.

F.7.a.through F.7.b.(2) It is recommended that, as an organization that provides prescribing of medications, it demonstrate, to the extent possible, the use of treatment guidelines and protocols to promote state-of-the-art prescribing and ensure the safety of the person served. It is also recommended that a program of medication utilization evaluation include measures of effectiveness and satisfaction of the person served.

 F.8.a. through F.8.e.(2) As an organization that provides prescribing of medications, a documented peer review should be conducted at least annually on a representative sample of records of persons for whom prescriptions were provided in order to assess the appropriateness of each medication as determined by the needs and preferences of each person served and the efficacy of the medication. It should be used to determine if the presence of side effects, unusual effects, and contraindications were identified and addressed and if necessary tests were conducted and used to identify the use of multiple simultaneous medications and medication interactions.

F.9.a. through F.9.c. It is recommended that information collected from the peer review process be reported to applicable staff, used to improve the quality of the services provided, and incorporated into the organization’s performance improvement system.

Whew. I was overwhelmed. Plus, I’m a relatively intelligent person, but I’m still fuzzy on exactly what they mean. Here are some of my concerns:

  • I already record a full history and physical on each patient, and have a record of all medications they’re taking. But apparently the way I’m doing this isn’t adequate, and I’m left to wonder what the specifics of their recommendations would look like..
  • Signed informed consent in order to be written a prescription? This is not generally done in primary care. I’m not sure what the justification for this is in a methadone clinic population.
  • Apparently I need to give each patient a written summary of all side effects of a prescribed medication. I don’t do this in primary care, because the pharmacy does all of that. Each time a prescription is filled, they give a long sheet of possible side effects. What’s the rationale for redundance?
  • These are only a few of my concerns.

When faced with the task of complying with all of these recommendations, many clinics understandably decide it’s just easier to tell patients to see their own doctor for anything they need besides the methadone.

CARF does a needed service, but in many matters I think it’s important to pull back to see the whole picture. It’s similar to the paperwork requirements for Medicaid – most of this paperwork is probably needed in some form or fashion, but surely there’s a better way to do this than to ask counselors to do a mountain of paperwork when they’d rather be doing counseling.        

Regulations are important. But don’t make the regulations so obscure and onerous that most clinics stop providing any extra care.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               

(1)   McLellan AT, Arndt IO, Metzger DS, Woody GE, O’Brien CP. The effects of psychosocial services in substance abuse treatment. JAMA 1993;269(15):1953-59

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Smuggling Suboxone

I was intrigued by an article I saw on my internet homepage. It was titled: “When Children’s Scribbles Hide a Prison Drug”

http://www.nytimes.com/2011/05/27/us/27smuggle.html?_r=1&hpw

 This article describes unique ways Suboxone is being smuggled into jails. Law enforcement officials associated with both state and county jails from Maine and Massachusetts were interviewed. They say prisoners and their accomplices make Suboxone into a paste and smear it over the surfaces of papers sent to prisoners from their families. The article mentions the paste being spread over children’s coloring book pages, and under stamps. Suboxone films have been placed behind stamps or in envelope seams. Correctional officers now have to inspect material coming in the mail to prisoners much more closely.

 I had several thoughts. First, yet again, I’m struck by the creativity and cleverness of addicts. If only they could channel this energy in the right direction, amazingly good things could come to them, instead of the continued hardships brought by addiction.

 Then I felt sad that such actions described in the article would taint the reputation of a medication that has the potential to save lives, when used appropriately. Such illicit use of Suboxone gives ammunition to those who would prefer that office-based treatment with Suboxone didn’t exist.

 Then I wondered, how many of these prisoners have a legitimate prescription for Suboxone, but are denied their medication by prison officials? How many are legitimate patients of methadone clinics, also denied their medication while imprisoned, who know that Suboxone will alleviate some of the opioid withdrawal they are feeling? How many of these people are addicted to opioids, not in any kind of treatment, but who know Suboxone will treat their withdrawals?

At least one study supports the idea that many people use Suboxone illicitly not to get high, but to prevent withdrawal. Dr. Schuman-Olivier studied 78 opioid addicts entering treatment. Nearly half said they had used Suboxone illicitly prior to entering treatment. Of these people, 90% said they used to prevent withdrawal symptoms. These addicts also said they used Suboxone illicitly to treat pain and to ease depression.

Many law enforcement personnel and members of the legal community have strong biases against medication-assisted treatments. They don’t understand that addiction is a disease, and that methadone and buprenorphine are legitimate, evidence-based treatments. They have difficulty letting go of their idea that addiction is a choice that deserves blame, and have a punitive stance towards addicts. They have low opinions of addicts who are using drugs, but often have no better opinion of a recovering addict who has sought treatment and is doing well on replacement medications, like methadone or buprenorphine.

 But no matter what law enforcement personnel think they know, when they deny prescribed, life-saving medications, I believe they’re practicing medicine without a license.

The article mentions one woman who, with the aid of the Maine Civil Liberties Union, sued because her Suboxone treatment had not been continued while she was in jailed for a traffic violation. She settled out of court, but her lawyer made the excellent point that if inmates are denied their medications, they will try unlawful means to get it.

Other patients and their families have brought successful lawsuits against the jail facilities. In at least two cases, in the same Orange County, Florida jail, patient/prisoners were allowed to go through withdrawal for so long that they died. The estate of one person won a three million dollar judgment against the county. (1, 2)

I’m glad to see these lawsuits. I’ve heard appalling stories from many methadone patients, who were denied their medication while incarcerated. I’ve heard tales of jailers taunting these prisoners, when they became sick. There is no defense for such cruelty.

Orange County now works with local methadone clinics. If a prisoner is a current patient of a clinic, his clinic will send a week’s worth of medication in a locked box via courier. Nurses at the jail have the key to the box, and administer each day’s dose. The jail doctor consults with the medical director at the methadone clinic. Prisoners still have to pay out of pocket to get the medication, so the only cost to the jail is the time required for personnel to administer the medication. It’s certainly much cheaper than paying three million to the estate of a dead prisoner, not to mention much more humane.

I wish the county jails around the methadone clinic where I work would approach the problem of opioid addiction and treatment in a collaborative way. Sadly, only seven state prison systems offer medication-assisted treatment with methadone or buprenorphine.

Rikers Island, in New York City, gives us another example of how such a system could work. There, opioid-addicted prisoners charged with misdemeanors or low grade felonies can be enrolled in a program known as KEEP (Key Extended Entry Program). This program treats opioid addicts with methadone and counseling. Upon release from Rikers Island, these patients are referred to methadone treatment centers in the community. Seventy-six percent have followed through with their treatment, post-release. The results of this program show significant reduction in reincarceration and significant reduction in criminal activity. (3)

Drug courts trying to save money would be well-advised to look at the Rikers Island program. Studies have shown a cost savings of at least four dollars for every one dollar spent on methadone treatment. This money is saved because methadone patients require fewer days of hospitalization and other healthcare costs, and also because of reduction in criminal activity and incarceration costs. (3, 4)

I know from comments written to this blog that there are many more people abusing Suboxone than I previously imagined. For sure, some of the prisoners getting smuggled Suboxone are misusing it. But I don’t think the majority are using for anything other than prevention of withdrawal, since they are usually not offered any other effective treatment for this medical condition.

  1. “Outrageous: the death of Susan Bennett raises serious questions about the competence and quality of the jail’s nursing staff” Orlando Sentinel, editorial, March 27, 1998.
  2. Doris Bloodsworth, “Inmate begged for methadone” Orlando Sentinel July 12, 2001.
  3. Par`rino, Mark, “Methadone Treatment in Jail,” American Jails, Vol: 14, 2000, issue 2, pp 9-12.
  4. California Department of Drug and Alcohol Programs, 2004, California drug and alcohol treatment assessment (CALDATA) California Department of Alcohol and Drug Programs. California Drug and Alcohol Treatment Assessment (CALDATA), 1991-1993 [Computer File]. ICPSR02295-v2. Ann Arbor, MI: Inter-university Consortium for Political and Social Research [distributor], 2008-10-07. doi:10.3886/ICPSR02295