Archive for the ‘Suboxone to get high’ Category

Novel Idea for Buprenorphine Access

 

 

 

 

I still occasionally read medical journals with articles relating to general adult medicine; I consider it a task, not as enjoyable as reading medical journals about Addiction Medicine.

So, imagine my surprise and delight to read a thoughtful opinion piece in the most recent issue of the Journal of the American Medical Association (August 13, 2019, Vol. 322, No. 6, pp 501-502.)

This article, written by Payel Roy M.D. and Michael Stein M.D., both from Boston University School of Medicine, puts forth the idea of increasing access to life-saving buprenorphine by making it available behind the counter at pharmacies with no prescription required.

The article describes the scope of our problem in the U.S: we have around two million people with opioid use disorder, most of whom aren’t getting any treatment. We have around 130 people die from opioid overdose deaths each day. Though we have medication for opioid use disorder available, it’s often hard to access. The authors acknowledge the cumbersome process of prescribing buprenorphine, both for the patient and the provider. The provider must take a special course and get a special DEA license. Patients have difficulty locating and getting appointments with these rare providers, and then must wait for their appointment and be able to pay the provider.

The authors of this viewpoint piece say that having emergency buprenorphine available behind the counter at pharmacies would eliminate some of the problems with access to this life-saving medication.

They say that making buprenorphine available on an emergency basis makes sense, because we’ve done the same thing with other medications that are relatively safe and effective for the conditions they treat. They compared the use of emergency buprenorphine to that of emergency contraception medication, and to pseudoephedrine. The authors feel that a three-day supply of buprenorphine could encourage people with opioid use disorders an opportunity to try buprenorphine legally, and to follow up with a physician provider for long-term treatment.

They also say that uninsured patients could access this emergency treatment more easily than they can at present, since there wouldn’t be provider-based costs. They feel pharmacists could observe the dosing to watch for precipitated withdrawal symptoms.

The authors suggest we define in advance the conditions where emergency buprenorphine could be obtained, perhaps limited to situations where a patient has an upcoming appointment but has severe withdrawal symptoms prior to the appointment. Another indication for emergency use would be if a patient, previously on buprenorphine but tapered off, has a relapse or feels as if she may relapse and wants to get back on buprenorphine to prevent a serious event.

The authors realize this idea is bound to be controversial. They acknowledge that use of buprenorphine with other sedating agents could be harmful but say warning labels are already on buprenorphine medication fills. They also considered accidental pediatric exposure but say that limiting the medication to behind-the-counter would provide monitoring by pharmacists.

They also acknowledge the concerns for buprenorphine becoming a gateway drug. People without physical opioid dependence can experience euphoria with buprenorphine, but the authors say that since it tends to me only a modest euphoria, it’s unlikely to become a drug of choice. They point to literature suggesting that illicit use of buprenorphine is usually seen in people who already have an opioid use disorder, not people just starting to misuse opioids.

They argue that having buprenorphine available behind-the-counter without a prescription might reduce diversion. Rather than having people with opioid use disorder buy buprenorphine from people who already have prescriptions, they can buy their own legally, with the behind-the-counter arrangement.

They point out that having pharmacists monitor use of this emergency buprenorphine would switch some of the burden of safe initiation of treatment from physicians and onto the pharmacists. They say this would require pharmacists to become better education about buprenorphine and improve the counseling that patients receive from pharmacists

They conclude that their idea of emergency buprenorphine could benefit individual and the population overall, by treating withdrawal symptoms and preventing further illicit opioid use. They feel this could reduce health care costs and criminal activity related to obtaining illicit opioids. They also say it would reduce transmission of infectious diseases. They say the risks would be low, given buprenorphine’s safety relative to other illicit opioids, and people could access this medication at night and on weekends, when doctor’s offices are closed.

What do I think of this idea?

I like it.

I think we could define conditions under which buprenorphine could be provided. However, I think the biggest problem could be getting pharmacists to go along.

My patients see plenty of kind, helpful, and well-informed pharmacists, eager to help them with their recovery from opioid use disorder by using buprenorphine products. And other patients have pharmacists that…well…aren’t like that.

Last week, I had a pharmacist call me about a patient of mine who had tapered from 16mg to 8mg over a month. I didn’t recommend she do this; I thought it was a little too fast. But she was optimistic, and asked I write for only #30 films. That’s what I did, but I got a phone call from my patient on day 25 of her month, saying she’d taken more than 8mg per day and she was out of medication, and could I call in a few days of medication until she could see me at her scheduled appointment on day 28?

I didn’t see a problem with this. Yes, she had been overly optimistic about her ability to taper, but I saw no reason to let her go into withdrawal from day 25 to day 28. I called the pharmacist but couldn’t reach a live human. I left a message, saying it was fine with me for them to dispense enough medication for three days, since we had tried to taper, and it hadn’t gone as well as we’d hoped.

The patient called later in the day, crying, saying the pharmacist refused to fill any buprenorphine/naloxone films early, and that she intended to report me, the physician, presumably for careless prescribing.

Sheesh.

I tried again to call the pharmacist, to explain the situation and try to work it out. I was put on hold for eleven minutes, when it occurred to me that this pharmacist had no intention of coming to the phone. I hung up and called my patient back, telling her to go to a different pharmacy and I’d call in three days, which is what I did.

This emergency buprenorphine could be a wonderful thing, but some pharmacists in my area are extremely cautious about buprenorphine products. I think it’s weird that after practically throwing OxyContin and Xanax and Opana medications at patients for fifteen years, now pharmacists are worried about an established buprenorphine patient filling a prescription three days early.

Swallow a camel, strain at a gnat, as the biblical saying goes.

So yes, I’d like to see some pilot programs try this novel idea, but you’d better make sure the pharmacists are all on board first. Perhaps in Massachusetts, it would be easier than in rural North Carolina.

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Complications of Intravenous Buprenorphine (Suboxone, Subutex) Abuse

Endophthalmitis from IV drug use

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Since I started this blog, some of my readers have educated me about how frequently addicts use Suboxone and Subutex intravenously. I think some of these addicts have become blasé about the reality of complications that can occur from injecting a medication that’s not meant to be injected.

Like oral opioids, Suboxone and Subutex tablets and films aren’t sterile. Bacteria live everywhere, including inside an on oral medication. Since the medication is meant to be taken by mouth, these bacteria don’t harm the user when swallowed or used sublingually as intended. But when injected, these bacteria have the potential to cause catastrophic illness, depending on the nature of the bacteria.

Skin and bloodstream infections, endocarditis

Most commonly, we see cellulitis, a soft tissue infection, around the site of the injection. Sometimes the infection walls off and forms an abscess that usually must be drained. The infection can spread to the walls of the vein, causing angiitis. These infections can spread to the rest of the body, and can lodge in special areas that cause big problems. For example, endocarditis, an infection of one of the heart valves, occurs more commonly in IV drug users. It’s difficult to treat endocarditis, and requires lengthy antibiotic treatments. Sometimes this infection can destroy the heart valve and the patient may require surgical replacement of the valve. People can die from this serious infection.

Some of Singapore’s large population of intravenous heroin users switched to buprenorphine when it became available, but with that availability came an increase in complications from addicts who injected buprenorphine rather than use it as intended.

Researchers studied a series of one-hundred and thirty intravenous buprenorphine addicts that came to a Singapore hospital for treatment for infections. Of those, 31% had cellulitis. In nearly half of those patients, skin and blood cultures were positive for bacteria, most for Staph aureus. Twenty-four percent of the patients with skin infections eventually required surgical procedures, and the average length of stay in the hospital was eight days. (1)

A different study, also done in Singapore, looked at twelve consecutive patients admitted to the hospital with infective endocarditis from using buprenorphine intravenously. Eleven of the twelve patients had Staph aureus in their bloodstream, and five of them died. The average length of stay was 48 days, and multiple medical complications were noted. Three patients required open heart surgery. (2)

Fungal Endophthalmitis

Bacteria aren’t the only unwelcome travelers hitching a ride on a buprenorphine tablet. Fungal endophthalmitis is rare in people who have not had eye surgery, yet it is seen in intravenous addicts in general, and now specifically in addicts injecting sublingual tablets. At least four cases of endophthalmitis in intravenous users of buprenorphine tablets occurred within a year at one Australian hospital. These serious inner eye infections developed due to a type of Candida fungus usually found in the mouth. One of the patients admitted injecting a tablet that had been in her friend’s mouth for a short time, prior to diversion of the tablet to the patient. The oral candida species likely contaminated the buprenorphine tablet through this method.

In the 1980’s, a series of cases of candida endophthalmitis was seen in users of brown heroin. At that time, scientists thought the Candida came from lemon juice used to break down the heroin for injection. However, none of these four intravenous buprenorphine abusers used lemon juice. (3)

It is possible we will see more cases of fungal infections in patients who inject buprenorphine that has partially dissolved in another person’s mouth, due to the oral contamination of the pill.

Talc Granulomatosis

Tablets meant to be taken by mouth or sublingually (under the tongue) often contain talc as a filler. Heroin is sometimes cut with talc, to make more product to sell on the street. When these substances are injected, they can cause talc granulomatosis. Many addicts don’t get regular check-ups and most are reluctant to tell doctors about their IV drug use, even during serious medical problems. This condition is likely under-recognized because on the chest X-ray, talc granulomatosis looks like other interstitial lung diseases. The talc crystals lodge in the lungs, and cause an immunologic response. This in turn causes trouble breathing, dry cough, and low oxygen levels. Respiratory failure and death can occur in the worst cases, since there are no definite effective treatments. In some studies, patients with talc granulomatosis have improved when given corticosteroids, but tend to get worse again as soon as the medication is stopped.

Tablets meant to be used under the tongue aren’t sterile and aren’t suitable to be injected. Tablets diverted from patients who partially dissolve them in their mouths may be particularly hazardous due to contamination with mouth bacteria.  Addicts who inject tablets meant for orally use risk catastrophic health problems beyond overdose.

If you are an intravenous drug user, don’t fool yourself into thinking you’re safe because you use new needles and “works” each time. New needles do reduce the risk of contracting hepatitis and HIV, but oral pills still contain substances that were never meant to be injected.

  1. Ho et al., “Cutaneous complications among i.v. buprenorphine users,” Journal of Dermatology, 2009, Jan;36(1) pp22-
  2. Chong et.al., “Infective Endocarditis due to intravenous Subutex abuse,” Singapore Medical Journal, 2009 Jan;50(1):34-42.
  3. Alboltins et. al., letter to the editor, Medical Journal of Australia, April 18, 2005, Vol 182(8) p.427.

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