Archive for the ‘Uncategorized’ Category

2020 Addiction Medicine Essentials Conference

I just had the pleasure of attending NC’s yearly fall Addiction Medicine Conference, which was held online this year, due to COVID.

My expectations weren’t extremely high; the Essentials conference is intended more for providers new to the field, compared to the yearly Spring conference, plus it was online. However, I’m glad I went because I learned a great deal that I can use, and the speakers were great.

On the first day, Dr. James Finch started with Basic Concepts of Addiction Medicine, but his talk was more than data. He exhorted his listeners to be more thoughtful and compassionate, and to look at the big picture of how and why we want to help our patients. And I was impressed that he gave his talk despite being hospitalized.  That truly is dedication. I pray you have a rapid return to health, Jim!

We had two speakers address racial inequities in Addiction Medicine, and about the explicit and implicit biases that exist in healthcare. Speakers presented some truly depressing data about racial health inequities, but also provided some action steps to address these health inequities. I also learned the new acronym: BIPOC, which stands for Black, Indigenous, and People of Color.

From the speakers, I got some ideas about how to assess our OTP for problem areas, as a prelude to making changes to reduce inequities, at least over issues we can control.

During a lecture on Update in Treating Tobacco Dependence in Mental Health Setting, I was in the “Amen!” corner. As the presenter said, we have data that shows people in recovery who stop smoking have lower rates of return to drug use, as well as better mental and physical health. Nicotine use disorder needs to be addressed in every patient.

At our OTP, about 95% of our patients smoke. Lately I’ve been talking to patients about participating in a free smoking cessation program at our local hospital, and I’ve been surprised at how many patients are receptive. This program offers free samples of patches, nicotine gum and lozenges, as an incentive for participation in group online counseling and support sessions.

At our OTP, we are NOT smoke-free, and we need to be. Our biggest problem may be addressing smoking cessation with our own employees, who often smoke outside on our front porch with the patients. I love our employees and would never hurt their feelings for anything, but I think that’s bad. They are setting a terrible example, besides putting themselves at risk for illness and premature deaths. That last part makes me sad.

We had an interesting session for opioid treatment program medical providers. Our presenter was a cardiologist who talked about the dangers of prolongation of the QT interval in patients treated with methadone. His recommendations about when to obtain an EKG on patients on methadone differed significantly from recommendations given by the American Society of Addiction Medicine. Listening to him speak, I perceived he focused on the dangers of methadone. As Addiction Medicine physicians, we also focus on the dangers of not prescribing methadone. We had good discussion about the topic, though not as many people attended as I would have hoped.

I learned much in a lecture about methamphetamine given by Dr. Richard Rawson of Vermont.

In the past, the methamphetamine found in our area was made by small-town “cooks” from over-the-counter decongestants. After laws were passed that restricted access to these raw materials, that type of manufacture decreased. Now, most of the methamphetamine used by people in our state comes from Mexican labs which make their product from the P2P method. This gives a more potent product which produces more severe complications.

Dr. Rawson said that since 2014, more methamphetamine and cocaine has been contaminated with fentanyl. In fact, in 2020, some areas of the country have found most of their cocaine to contain fentanyl as well.

This contaminated supply of stimulant drugs has caused a “fourth wave” of overdose deaths in the U.S.: first was opioid pain pills, then heroin, then fentanyl, and now stimulants contaminated with fentanyl.

This is not good news.

Dr. Rawson also mentioned a new drug, called “iso” for isotonitazene, a new drug found in overdose victims in the Midwest in June of 2020, who thought they were using cocaine. This was the first time I heard about this drug, which is a designer opioid, slightly more potent than fentanyl. This drug was just put on Schedule 1 by the DEA in the U.S.

The methamphetamine being used now is more potent and more dangerous. Dr. Rawson quoted studies indicating that people who use methamphetamine have more than a six-fold increase of risk of death compared to same-age controls.  Most deaths from methamphetamines are caused by cerebrovascular and cardiovascular disease. Even young patients have strokes, both hemorrhagic and ischemia, due to methamphetamine and other stimulant use.

The more potent methamphetamine being used now is toxic to the brain, causing cell death and brain dysfunction like that seen in patients with degenerative disease of the center nervous system. Even after active use of methamphetamine has ceased, studies show impaired verbal fluency, poor learning and comprehension, and slower processing of information. According to Dr. Rawson, more than two-thirds of users have cognitive impairment. This impairment is worse with intravenous use, older age, and higher quantity used.

As we would expect, patients who are in treatment for opioid use disorder who also use methamphetamine are at higher risk for leaving treatment.

Treatment of methamphetamine use disorder is challenging. Thus far, there are no FDA-approved medications that help with the treatment of methamphetamine use disorder, though there have been some promising trials using bupropion (brand name Wellbutrin) and mirtazapine (brand name Remeron). The mainstay of treatment remains counseling techniques, especially contingency management along with community reinforcement approach. Cognitive behavioral counseling and motivational enhancement counseling also may help.

Anyway, I learned a great deal during Dr. Rawson’s talk as well as others.

If you work in the substance use disorder field in any capacity, I highly recommend the Governor’s Institute’s fall and spring sessions. Our spring session this was truncated by the arrival of COVID 19, but we still had a small online conference.

Either in-person on online, these conferences are always worth the time.

Here’s a link to the Governors Institute website: https://governorsinstitute.org/

Writing a Blog: What I’ve Learned

I hereby return from my blog break. This year on my break I contemplated the future of my blog: do I want to continue the blog, or has it run its course? I decided I will continue writing blog posts for now, since people still seem to be reading them, and also because writing posts usually forces me to become better informed about my topics, ultimately benefitting me.

I started this blog ten and a half years ago, only for the purpose of promoting a book about opioid use disorder that I had written, titled “Pain Pill Addiction: Prescription for Hope.”

Against all odds, I was able to get an agent for my book. My agent tried hard to sell my book to publishers, but none were interested in an obscure topic like opioid addiction (in 2010 we were not yet using the term “opioid use disorder”). Eventually, I decided to self-publish.

My book did OK, for a self-published book, selling around 400 copies. I probably sold the majority of those myself, peddling them to independent bookstores to sell on consignment and giving copies to patients. A surprising number sold on Amazon. Then a few years ago, since the book was so out of date, I started sending an electronic copy to anyone who wanted it, for free.

I started the blog only to promote the book, a bit of advice I heard and read from many writers and would-be writers.  I started writing blog posts about opioid use disorder and its treatment with medication-assisted treatment.

The blog did much better than I expected, and I’ve enjoyed writing it more than I thought. I’m still amazed at the number of readers I’ve had over the years, and the variety of readers. I’ve been blessed by attracting the attention of knowledgeable people in this country, with reputations for brilliance. For example, I love every time Dr. Wartenberg writes a comment. He has so much experience and insight.

I’ve had over 1.6 million views of my blog, with over 5600 comments written. My blog traffic peaked a few years ago, when I still had the energy to write a blog each week. Now that I post every few weeks, I get 300-500 views per day. That’s still many more than I expected.

I’ve repeated some blog entries, such as those dealing with a specific topic like drug interactions, or specific drugs like kratom, but for the most part, my blog posts are original. Some posts that I’ve tried to re-cycle from ten years ago had to be re-written because the language has changed – or I have changed. I no longer use the words “addict” or ‘addiction” or at least don’t use them very often, because I’ve become more sensitized to people’s feelings.

Some readers send appalling comments that I won’t approve to appear on my blog, either because they demean people with opioid use disorders or demean people trying to provide care to them. Occasionally I’ll post an offensive comment, to serve as an example of outdated attitudes still held by some people about the nature of substance use disorders and their treatments.

I had one interesting commenter say that I was sinning by having this blog, and that I’d go to hell for it. I’m still not sure what my sin was, aside from dangling a participle or two. Thankfully most commenters are more intelligent and focus on content rather than attacking me as a person.

By far, the most accessed of my blog posts are the ones related to injecting buprenorphine. My site stats tell me that out of the past 408,000 blog views, 151,000 of those views were of my blogs about injecting buprenorphine and complications related to it. I’m not sure what to make of this. It could be a good thing, if people injecting or contemplating injecting buprenorphine are concerned and want to know of possible adverse effects of this practice.

The next most frequently viewed post was about switching from methadone to buprenorphine, at 54,000. The next most popular posts were about overdose with opioids and benzodiazepines, urine drug screening, and getting a commercial drivers license while on buprenorphine.

Often I’ll write a fluffy little post that I regard as a throw away, just something to put on the blog until I get something of substance to post, and I’ll get a big response that I didn’t expect. For example, my post recently about how I got a fever and viral gastroenteritis during COVID and thought I was dying got a lot of responses. Most were in sympathy, acknowledging how jumpy we all are with any sign of illness that could be COVID.

In the blog posts where I complain about difficulties with pharmacies, I get many responses from patients but even more from other medical providers. They tell me their stories of frustration with pharmacy practices and attitudes, and my own frustrations feel validated.

I have intelligent readers who are in treatment for opioid use disorders. They’ve helped me understand more about patients’ feelings, and how they view things. For example, I regarded the reduction of a patient’s take home level for positive urine drug screens as enforcement of state regulations, kind of mechanical and temporary. However, I’ve learned patients take the revocation of take home doses very personally. They take revocation as a slap in the face, like I am telling them I’ve lost faith in them and their recovery.

I don’t write as much about 12-step recovery now as I did ten years ago. Referral to 12-step groups is evidence-based, but most patients aren’t interested in going. I also feel that these 12-step groups have missed opportunities to reach people with opioid use disorder. My patients on medications to treat opioid use disorder aren’t always treated well at meetings.

I know that these groups can work well. In some prior posts, I’ve hinted that I’m in recovery, so today I’ll say it outright – I’ve been blessed with over twenty-two years of recovery mostly through the power of 12-step groups. I’ve gone to two or three thousand meetings over the past few decades. But this form of recovery is not the only way people recover, and some people don’t want to go to such groups.

A few years ago, four of us in recovery founded a Narcotics Anonymous meeting in our little town, with the express purpose of welcoming people in medication-assisted treatment to our NA meeting. We attracted a dozen or so people to come irregularly, but for the most part, only the four founding members regularly attended our meeting. After a few years, COVID hit, and we changed to online meetings for some months. Now, after one member moved away and another had a change in work schedule, we let the meeting close due to lack of interest. I must admit I was relieved.

These days I see how important it is to fact check everything that I write. In these days of misinformation, and dis-information, and outright lies, truth is ever more important. If I write a blog post stating that this or that conclusion is supported by research, I’ll double – check before posting.

Of course, blogs are more than recitations of fact. When I state an opinion, I’ll make it clear that it is only an opinion. I have many of these opinions, and they are subject to change, as new information is revealed. When I read posts from ten years ago, some of them embarrass me a little, because I no longer feel exactly the same. But that’s OK, because – hopefully – it means I’m still capable of change and growth as a person.

Having a blog is a fun way to vent. I try not to be grouchy in my real life, but on the blog…I can spew about my frustrations regarding various work irritations. I can give anonymous voice to my patients who are treated badly by this medical system because they are in medication-assisted treatment. I can call out pharmacists who seem to give my patients a hard time only because they have opioid use disorder.

It’s fun.

So for now, I’m going to keep my blog going.

Medication Interactions with Methadone and Buprenorphine

 

 

 

 

 

Patients being treated for opioid use disorder with methadone or buprenorphine often need other medications to treat chronic and acute medical conditions. When our opioid treatment program patients fill other prescriptions at retail pharmacies, the pharmacist might not know that the patient is on methadone or buprenorphine. Due to privacy laws, OTPs don’t report patient data to state prescription monitoring programs. That puts the burden on opioid treatment providers to watch for potential drug interactions.

I take that burden seriously.

Methadone, for various reasons, is more likely to have drug interactions than buprenorphine. Buprenorphine’s various pharmacologic properties reduce the risk of drug interactions. It has a high affinity for the opioid receptor, which means it’s not easily displaced off the receptor. Also, buprenorphine has a ceiling effect, so fluctuations in blood levels are less likely to cause sedation than methadone. Drug interactions can still occur, but not with the frequency or severity as with methadone.

Many medications interact with methadone, too many for me to reliably remember. I use a smart phone app to supplement my aging memory with up-to-date data. And if I can use these smart phone apps, believe me…anyone can. I prefer the Medscape app, though it’s only one of many. Other providers like Epocrates or others. If you work at an opioid treatment program and make dose decisions, I strongly recommend you get one of these apps, because there’s no way to remember or keep up with all new data.

Here are some of the main ways methadone interacts with other medications.

Sedatives

Any sedative medication can have an increased sedative effect when it is administered to a patient on methadone, or any other opioid, for that matter. Sedatives affect that ancient part of our brain that tells us to breath while we sleep. Opioids also affect that brain center, so when opioids and other sedatives are mixed, patients can fall asleep and stop breathing, which is how overdose deaths occur.

By far, the most commonly consumed sedative that my patients use, by prescription or illicitly, are benzodiazepines. However, other sedatives are just as deadly, and alcohol is a sedative drug too. Recently we’ve had more patients prescribe gabapentin (Neurontin) or its mirror-image molecule, pregabalin (Lyrica). These medications are commonly prescribed by primary care providers for just about any complaint of pain, anxiety, or anything else. When misused, or when taken with methadone, it can lead to impairment and even overdose.

I’ve railed against the inappropriate use of benzodiazepines so many times that even I get tired of hearing myself, so I’ll refer to reader to past blog entries. But let me just say that many patients being treated for opioid use disorder with methadone have been harmed by also taking benzos, prescribed or not prescribed. It’s a hazard that should be avoided if possible.

Cardiac Effects: prolonged QT interval

Methadone can prolong the QT interval in the heart. In the interest of not getting overly technical, let’s just say that the QT interval has to do with how the beats are conducted through the electrical system of the heart. If the QT interval lengthens past a critical point, it puts the patient at risk for a potentially fatal heart rhythm.

Many opioids can cause this, but methadone is probably the most well-known. Other opioids, like tramadol and oxycodone, carry some risk of QT prolongation, but usually not to a clinically significant degree. Some sources say buprenorphine can theoretically cause QT prolongation, but most experts don’t feel it’s clinically significant. In fact, if a patient on methadone develops QT prolongation issues, that patient is often recommended to switch to buprenorphine.

While methadone alone infrequently causes clinically significant QT interval prolongation, other factors can increase patient risk. For example, some patients with certain types of underlying heart problems may already be prone to QT prolongation and starting methadone could make this situation worse.

Many other medications also can cause QT prolongation. When these medications are started in a patient on methadone, the combination can cause significant QT interval prolongation.

For a recent list, go here: https://crediblemeds.org/pdftemp/pdf/CombinedList.pdf

As you will see, many common medications are listed. Common antibiotics, like cipro and erythromycin, cause prolonged QT interval and these are often prescribed to our patients. Many commonly prescribed mental health medications can prolong the QT interval.

What should opioid treatment providers do when a patient on methadone gets a new prescription for a medication which could critically prolong the QT interval? I’ve searched the internet and can’t find exact evidence-based solutions. But that’s not uncommon. Physicians often need to weigh decisions of risks and benefits of medications and act based on this.

First, I inform patients if there might be a problem. Next, I decide if the risk presented by the medication is so high that I need to ask the prescriber to change it. Or, if the patient is young and healthy, I might decide to check an EKG to monitor the QT interval. Lowering the dose of methadone can help reduce the QT interval, but at the risk of de-stabilizing the patient, so that’s rarely the best course of action.

Opioid treatment programs vary widely in their abilities to get and interpret ECGs. Thankfully, I’m trained in Internal Medicine and feel comfortable getting my ECG calipers to calculate the QT interval and yes, of course I correct for heart rate too.

Here are two examples of how I handled potential QT situations.

The first patient was young and healthy, and dosing with methadone at 95mg per day. He was started on ciprofloxacin for two weeks for an infection. The other prescriber had done a culture of the infectious situation and cipro was one of few antibiotics that the bacteria was sensitive to, so antibiotic choices were limited. I decided to check an ECG after my patient had been taking cipro for a few days, and the QT was fine. He was able to remain on the cipro until the infection cleared, with no problems

The second patient was older, nearly 50, with several chronic medical conditions including severe mental health diagnoses. A new psychiatrist changed his medication and started him on ziprasidone (Geodon), a medication infamous for causing QT prolongation. My patient was dosing at 115mg per day, and extremely fearful about any dose change. I did an ECG as soon as I knew he was on Geodon, and his QT interval was significantly lengthened. I called his new psychiatrist and explained the problem and she immediately switched him to a lower-risk medication. A repeat ECG done a few days after the switch showed his QT was back to normal, and he did well on this second medication, with good resolution of his mental health symptoms.

Drug affected methadone metabolism by the Cytochrome P450 System

Other drugs and substances affect methadone blood concentrations by influencing the rate of methadone metabolism. Methadone is an active opioid, while its first metabolite, 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine (called EDDP for short), is not pharmacologically active. That metabolic process is done in the liver via the cytochrome P450 (CYP450 for short) system. Many other medications affect this system.

Some medications that affect the CYP 450 system slow methadone metabolism and are called inhibitors. They can increase methadone blood levels and the opioid effect it has. Conversely, medications called inducers speed metabolism of methadone into its inactive metabolite, and thus can reduce methadone’s blood level and effect.

Of course, rising or falling methadone blood levels affects patient stability.

To add to the complexity, there are different types of cytochrome P450 enzymes. Several are involved with methadone metabolism, named CYP 3A4, CYP 2D6, CYP2B6, and CYP 2C29. And each enzyme’s activity is further determined by what genes we’ve inherited. Other medications that are metabolized by CYP3A4 are thought to be particularly prone to affect methadone metabolism and regarded with more caution.

So…it’s complicated. But as if that complication weren’tt enough, some scientists now say that though in the past we thought methadone was mainly metabolized by CYP 3A4, that’s old data, and now, we should be looking at drugs metabolized by CYP 2B6. In fact, in a recent article I read, “It has now been unequivocally established that CYP2B6, not CYP3A4, is the principle determinant of methadone metabolism, clearance, elimination, and plasma concentrations in humans.”  [1]

Also, some medications act as inhibitors of inducers of methadone in a test tube but not in real life.

What’s a doctor to do?

Again, I’ve searched the internet for evidence-based recommendations. Should we increase the patient’s methadone dose if he’s started on a medication that induces methadone’s metabolism? Or should we wait to see if the patient has symptoms before we change the dose? Conversely, should we decrease a patient’s methadone dose if she is started on a medication that inhibits methadone’s metabolism, in case her blood levels are going to rise? Or should we just prohibit the use of any medication that can affect methadone blood levels?

That last option, though it would make my life easier, isn’t possible. For example, nearly all mental health medications interact with methadone in some way or another. There’s no way for a patient to get treatment without using medications with the potential to affect methadone metabolism.

Same as with the QT interval problem, the degree of risk must be assessed for each patient. The degree of risk varies with patient medical history,  and the known risk of the inducers or inhibitors. For example, patients newly started on phenytoin nearly always have a clinically significant drop in methadone blood level. For those patients, I’ll make sure I have an order in place to increase their methadone dose with any symptoms of opioid withdrawal.

Most other cases aren’t so clear-cut. I’ll inform patients of potential risks and ask that they communicate with us regularly.

Almost all medications that treat HIV influence methadone metabolism, making it essential for the opioid treatment provider to communicate directly with the provider prescribing HIV medications.

In fact, good communication is essential with other prescribers and I try to cultivate a cooperative attitude with them, so far as it is possible with me.

Our opioid treatment program patients, particularly as they age, will be prescribed medication with possible interactions with their methadone. For their safety, each OTP must have a system in place that: 1. Gets patients to report new prescriptions as soon as possible 2. Gets that information to the program medical provider in order to make decisions about safety and monitoring 3. Informs patients of potential risks 4.  Arranges follow up meeting with medical providers when appropriate 5. Opioid treatment providers must collaborate with other prescribers when necessary

Each OTP needs a system that works for their facility, and methods can differ widely between OTPs. It doesn’t matter how we get the job done, just that it gets done.

Our patients’ safety depends upon this.

  1. Kharasch, “Current Concepts in methadone metabolism and Transport,” Clinical Pharmacology in Drug Devopment, 2019

 

 

The Car Dosing Cart

Nurse Sylvia behind the Car Dose Cart

 

 

 

 

 

 

 

 

 

 

 

 

 

 

At our opioid treatment program, we’ve been dosing some patients in their cars, either because the patients have fragile health and we’re trying to keep them away from crowds, or because they have COVID infections, possible COVID infections, or have been exposed to someone with COVID infection.

In order to give more protection to our nurses while they deliver a dose to a patient in a car, one of our excellent employees, Jerry, created the Car Dosing Cart (Patent is pending.) as pictured above

As you can see, it’s made from a wheeled cart. Plexiglass sheets were attached to the front and sides of the cart, with a cut-out for a window just large enough to push a dose of methadone or buprenorphine toward the patient seated in the car. Just below the top level, there’s a second shelf where the patient can push their lock box onto the cart so that it can be filled with take home doses. The rest of the car is enclosed in plastic which is taped on three sides to the cart.

It’s genius.

The nurses feel protected while using it, and there’s enough surface area for everything they need. It’s wheeled, so it can be pushed easily out of the pharmacy, out our front door and to the curb outside. It’s the next best thing to a take-out window.

Per protocol, nurses never go by themselves to the parking lot to administer a dose. For security, another staff member accompanies him or her, both to discourage theft, and to provide a second set of eyes to vouch that the dose was given to the patient for whom it was intended. All of this is documented in the patient’s chart.

The idea for the Car Dosing Cart was born after a case staffing, when the staff asked me to allow car dosing for all our patients who work at a local poultry plant, after they had a large outbreak of COVID 19 infections.

I balked at this idea, feeling there were too many patients involved. I also worried the nurses would be more exposed to patients when dosing them in their cars. But as the number of cases at the poultry plant soared, I had second thoughts. I asked other doctors working at opioid treatment programs for advice. They recommended car dosing all poultry plant employees, who could unintentionally spread COVID infection. I backtracked my initial decision and we started to car dose many more patients.

That’s when Jerry invented the Car Dosing Cart.

Thus far, the cart is working very well. It’s stocked with everything the nurses might need, like cups, tissues, gloves, etc.

We will car dose patients for as long as the state allows, for as long as we have consistently elevated number of new cases of COVID 19 in our county and state.

I’m so grateful for the courage, compassion, and creativity of all our staff at our opioid treatment program.

COVID Scare

Cartoon style illustration of a sign or symbol that says ban, stop coronoavirus or COVID-19 being stamp out and prohibited on isolated white background.

 

 

 

I’ve had a rough week.

I’ve been so careful. I’ve worn an N95 mask every day at work, removing it only briefly when I need to eat or drink. I’ve wiped my office multiple times per day with cleaning wipes, not forgetting my cell phone, computer keyboard or door handles.

I haven’t gone anywhere, except once to the pharmacy for my blood pressure pills, and even then I used their drive- through. And I made several short trips for groceries, wearing my mask while inside.

That’s why I was so surprised when, shortly after going to bed one night early last week, I got a shaking chill more suitable to being on an icy Tibetan mountaintop rather than my snug bed.

It grew worse. I ached in every part of my body. I was too cold to get out of bed for more covers but eventually had to do so. While I was up, I went to the bathroom and ratted around trying to find a thermometer.

When I found one, my temp was 98.8. I laughed at myself. I am such a silly goose, imagining I’m ill when I’m not. But my symptoms continued with my chills and when I checked again a half hour later, the thermometer read 101.2.

My beloved fiancé was asleep in the bed next to me. I had to get some distance between us and moved to the upstairs guest room. I didn’t want to make him sick. I took some Tylenol and tried to get some sleep. But then the dry cough started, and later, some diarrhea.

As I lie in bed, feeling like I was wearing a jumpsuit of muscle aches, I thought, “This is it. I’ve got The COVID.” (That’s the way we say it here, “The COVID,” not COVID 19 or Coronavirus.)

I didn’t sleep any that night, and the next morning told my fiancé to stay away, I was sick. I sent emails to work supervisors telling them of my condition and that I could not come to work. My fiancé arranged COVID testing for the next day.

My fever jumped between 100.4 and 101.9 even with generous amounts of Tylenol and Advil.

But then the diarrhea got worse. My sweetie said, “Maybe you just have one of those 24 hour stomach flus.” I pooh-poohed him. I felt too bad for this to be a mere GI virus. Besides, the fever was lasting much too long for that and I had no nausea.

Then, about 48 hours after it started, I felt better. My fever started to come down, though the diarrhea grew ferocious. The cough never developed into anything. I took my COVID test and two days later, got the results: NEGATIVE

All I suffered from was  probably viral enteritis and a vivid imagination.

It’s easy to get carried away with any illness in the middle of the COVID 19 pandemic, especially if it’s accompanied by fever. At one point, I wrote my last will and testament. I laugh about it now, but I felt so bad, and my pessimism seemed to rise with my fever.

At least I got a chance to see what wonderful people are in my life.  At work, I was told not to worry about anything, and arrangements were made for another physician to do admissions for our OTP. I still handled the minor things by phone. My co-workers sent me encouraging emails and prayed for my wellness. My fiancé took great care of me – at a distance of course – and friends and family brought food and sent funny emails.

Right now, I feel very, very grateful. I’m now in my usual state of good health, which is wonderful. I’ll be able to get back to work this week, at a job I enjoy, with people I love. I have fantastic friends and family, and my life partner, the love of my life, didn’t get sick because of me.

And I don’t have The COVID.

Update on COVID 19 at an Opioid Treatment Program

 

 

 

This pandemic hasn’t struck all places in the U.S. at the same time. Back when I was watching the horrors faced by New York City, I felt relief things weren’t like that in my rural community, but also worried we would eventually face something similar.

Now COVID 19 has come to town. For now, it hasn’t been as awful as I saw on the news in the cities, but we’ve had many more people testing positive.

Part of this could be that testing has really ramped up. Early in the pandemic, not much testing was being done, either because there weren’t many test kits or because local health department officials were following the CDC’s relatively restrictive testing guidelines. As I’ve posted before, we had a few patients hospitalized with respiratory failure who weren’t tested for COVID 19. I read their hospital records. They were tested for influenza and when those tests were negative, were told to assume that they had COVID and isolate for two weeks.

After people who work at the meat processing plant in our county tested positive for COVID, suddenly there’s been extensive testing for people who work there.

According to our local paper, the total number of COVID 19 cases remained at four known cases from April 5 until April 21. During the last weeks of April, the number of people testing positive rose slowly, then more quickly. As of today, with businesses re-opening under Phase 1, we have two hundred and sixty-one people in our county testing positive for COVID 19, out of a population of around sixty-eight thousand people.

Our opioid treatment program had to decide how to respond to this new information. Last week, the staff petitioned me dose all our patients who work at this facility in their cars. They wanted potentially infected people to be kept out of our facility. I balked, thinking the risks of car dosing those people outweighed the benefits. Now, after talking to some other doctors about the situation, I’ve changed my mind. We intend to car dose all patients who work in high-risk environments with multiple people testing positive, like the meat packing plant.

It’s not as bad as it sounds. Many of these patients have been stable for months or years and were already on advanced take home levels. Under the blanket exception allowed by federal and state authorities, a significant minority of the only come once per month. Others need to come daily, with most patients coming to the OTP a few times per week.

Our facility got some N95 masks from our parent company. I’ve worn mine for the last three weeks. It still works, though the elastic is getting frayed. We also got a few hundred paper masks that are somewhat helpful. We’ve asked patients to wear masks or other face coverings while at our opioid treatment program. Nearly all patients have supported our request, but a few grumbled about it. We won’t refuse to dose patients who don’t wear masks, but we encourage them to do so. I still bring my Breath Buddy respirator mask to work with me each day, in case I need to see a patient sick with acute COVID 19 symptoms.

Every few hours, there’s an announcement over our intercom to ask for help wiping down our waiting room. Any staff member who isn’t busy with patients comes to pitch in and wipe down chairs, keypads, door handles, bathrooms, etc, with antibacterial liquid meant to murder Coronavirus. It doesn’t take long with many people helping. It’s become part of the daily routine. Patients have voiced repeated appreciation for our actions, which makes me feel good.

I’ve been dealing with patients who appear to have mismanaged their extra take home doses. Around nine patients have had some problem with their take homes. Some patients returned early, when they should still have take home doses, and can’t explain what happened. Some have had bottles missing, lost, spilled, or damaged in some fashion. No one has died from extra take homes, and so far as I know, there have been no close calls with overdoses among our patients from extra take homes.

In most cases, I can’t be sure what happened. The situations came to light either when patients returned early, or when they had drug screens that didn’t contain the medication we are prescribing. In one case, the patient said she was doing fine with weekly take homes, but when she suddenly got 27 take homes under the blanket exception for our COVID 19 situation, she was unable to take them as prescribed. She took extra medication compulsively, even though it didn’t make her feel any different. She ran out of medication a week early. I was happy she told us what happened, and we dropped her back to weekly take homes. Thankfully, she was on buprenorphine and not methadone.

I’m sure these nine cases are the tip of an iceberg. Most patients likely won’t tell us if they’ve mismanaged their extra take home doses.

Patients are at risk both ways: if we decrease the number of take home doses, their risk of contracting COVID 19 increases; however, extra take home doses (especially methadone) can de-stabilize patients accustomed to more accountability with their dosing. We try our best to balance the risks.

We’re still doing intakes for patients, both to methadone and buprenorphine. These patients must dose daily during their induction onto medication, as do patients who aren’t doing well, who have continued alcohol or benzodiazepines drug use.

I feel uneasy about the Phase 1 opening of businesses this week, because we are only now seeing the number of cases increase. I know this could be from accelerated testing recently, and that we must live with some degree of risk.

No matter what happens, our OTP plans to continue to be open for admissions and established patients. We want out patients to know we aren’t closing, that we will be here to provide care for our patients.

We plan to keep doing all we can to keep our patients healthy, both from opioid use disorder and from COVID 19.

COVID19 and Medication-assisted Treatment of Opioid Use Disorder

Pretty But Dangerous

 

 

 

As the COVID19 debacle drags on, treatment for patients with opioid use disorder continues to evolve in some ways.

Last week, I saw my office-based patients via telemedicine rather than in my private office. It went well, for the most part, but out of the fifteen people I saw, two had such bad connections that I could barely communicate. The picture blurred, the voice distorted, and I felt frustrated.

I think patients with poor connectivity may not have the bandwidth to do telemedicine. I don’t know if this is a problem that’s easily fixable. I may have to resort to phone calls only in these cases. In fact, phone calls would have been much better than the telemedicine on these two patients.

However, I also gained some insights into my patients’ lives. I got a small peek into their everyday lives, in some cases. I saw how they dress while at home and saw a few details about their home in the background of the picture. Several seems much more relaxed than when I see them in my office. Others were more tense, struggling with the technology.

Overall, patients appreciated the convenience of telemedicine and appreciated not having to expose themselves to the outside world, with possible Coronavirus floating around. I know I did.

At the opioid treatment program where I work, I came to the facility on my usual days, but things have been slow. I didn’t have any patients wanting to do intake this week and saw only a handful of patients each day for other reasons, mostly dose adjustments.

Patients have not had to wait to dose at all, except for Monday. That day we had many people with extra take homes coming back to dose with us and to get more take homes. Our nurse manager is fine-tuning the schedule, to even out the number of people dosing on site as much as possible. I told him he has a very hard job, trying to juggle nearly 600 patients so that everyone has the least amount of wait time. Other than Monday, we had negligible wait times.

We renewed our blanket exception requests for extra take homes with the state, and I think this is something we will renew every two weeks until the COVID19 mess is over with.

Our rural county, population of a little over 68,000 people, has two confirmed COVID cases. However, few tests have been done. According to an article in our local paper, our Health Department has done 28 tests, with 24 negatives and four pending. This number didn’t count any testing done at the local hospital, though, where the two positive tests were done.

I’ve read the hospital records of a few of our OTP patients who went to the hospital over the last two weeks with acute respiratory failure, cough and fever. It appears they were given COVID precautions but were not tested. They were told to quarantine, though. We’ve dosed those patients in their cars and given take homes to keep them away from the OTP. Initially we decided we would do this only for confirmed cases, but that idea appears unworkable, both because not many patients are being tested, and because of the delay in results of a week or more. We must act as if those patients have COVID 19.

I find the reluctance to test patients with symptoms to be odd.

I’ve heard that local testing policies are based on CDC recommendations: people with symptoms who have traveled to areas with active COVID infections are being tested, and people who have been in close contact with known COVID patients are being tested. Perhaps reluctance to test any patient with symptoms is based on a lack of test kits. I don’t know, but I’m repeatedly struck by this reluctance to test. Even nurses with symptoms have not been tested for COVID.

We continue to wear what masks we have – paper disposable ones that we re-use day after day, or hand-sewn cloth masks that can be laundered frequently. We have sanitizing wipes and take turns wiping down doorknobs, chairs, reception counters, etc. We practice social distancing among staff and patients. We use our homemade hand sanitizers and wash our hands with soap and water too.

Patients can have either in-person sessions, sitting at least six feet from their counselors, or have phone sessions. Counselors are trying to call patients with extended take home doses weekly. That can be a problem, given than many of our patients have the disposable phones and they change numbers frequently. If they can’t be reached, counselors document that they tried to call, and we try to get a working phone number the next time the patient comes to dose on site.

We are doing all we know to do to keep our patients and ourselves safe.

We have weekly teleconferences for program directors and medical directors of OTPs. There’s been much debate around telemedicine capabilities. Under federal regulations, physicians (or other providers) can’t admit methadone patients to an OTP unless they have an onsite admission process. However, OTPs can admit patients to buprenorphine via telemedicine. I think regulators feel buprenorphine is much safer, and office-based providers even do home inductions, so an on-site interaction isn’t needed. But with methadone, which is more dangerous to start, particularly in the first two weeks, the provider needs to see the patient in person, face-to-face. That’s the way the federal regulation reads at present.

There’s a petition floating around OTP circles, asking SAMHSA to re-consider their block on methadone admissions via telemedicine. If this petition succeeds in changing federal regulations, prescribers still must obey their state laws on this topic.

I am not in favor of telemedicine admissions to methadone. I’m aware this isn’t a popular opinion at present, and I understand the benefit of making admission to OTPs as easy as possible and eliminating barriers.

However, I’ve been working at OTPs for nineteen years, and I’ve had methadone patients die during induction under the best of circumstances. Methadone is a different breed of cat than buprenorphine, and even though induction overdose deaths are still rare, they are devastating when they do happen. I think I could miss subtle signs of sedative intoxication via telehealth, which could make a big difference in my decision to start treatment. It may be difficult to discern subtle withdrawal signs. If there’s another medical professional on site to do the exam, that could fill in some information gaps, but will this professional be an RN? It would be (in my state) outside the scope of practice for an LPN, and certainly could not be done by a counselor.

We talked about the prohibition of telehealth admissions for methadone on our OTP phone call today, and most providers voiced the opinion that it would be perfectly safe to do this, so I’m clearly in the minority with my opinion. Fortunately for now, I’m able to work on site at my OTP, so it’s not an issue.

On our phone call, there were some interesting ideas about what OTPs are doing around the country. One state apparently asked agencies to agree to share staff. That is, if one OTP has all their nurses out sick and unable to work, a nurse or two could be brought in from another OTP that has all of its staff able to work. That would be great, and such a policy would be in the best interest for all patients… but would require a great deal of cooperation between organizations that are accustomed to competition.

We talked about financial hardship policies; in other words, what to do about patients who, suddenly out of work, can’t pay for treatment. Some programs said they would work with such patients and try to help them make a budget or agree to a financial contract. Some programs agreed to allow patients to charge part of their daily fee, to be paid back later. Our OTP is allowing patients to charge for take home doses, hoping they will be able to pay again at some point. It sounds as if other programs are doing similar.

Unfortunately, state funding for patients unable to pay, under the SORs grant, was set to run out of money in early May, at the worst possible time for our patients who’ve just been laid off from work due to COVID 19 shutdowns. It now appears that some extra money may be found, but there’s much uncertainty now. I pray it works out, because we have many patients who are doing well in treatment, at risk for relapse if their grant for treatment runs out.

 

Twined leather rug

My most recent rug

Coping in the Days of COVID19

My homemade masks

When I rolled into our opioid treatment program parking lot at 7 this morning, there was only one vehicle in the patient parking lot. When I got inside, the waiting room was empty.

It’s quiet at the opioid treatment program these days. We’ve already implemented accelerated take homes for most patients, which drastically reduced traffic through our lobby. Patients new to treatment on methadone are still coming daily, as are unstable patients, but many patients got anywhere from six to twenty-seven take homes, under the blanket exceptions we submitted to our state officials.

Our nurses wear protective gear and dose potentially infected patients in their cars, if they aren’t stable enough for take home doses. Our patients with severe immunosuppression or other conditions that place them at higher risk of death if they contract COVID19 are also dosed in their cars.

We have another group of patients, mostly older people with COPD, whom we dose in an expedited fashion, moving them to the front of the line to shorten their time of exposure to other people. That created resentment when we had wait times, but now that there’s practically no wait time (except for the last fifteen minutes of the day, because that’s always the busiest time), everyone gets dosed in an expedited way.

We are open for business as usual. I haven’t seen as many people seeking admission as usual, but there have been a handful this week. In accordance with SAMHSA (Substance Abuse and Mental Health Services Administration) and state guidelines for treatment in the age of COVID19, I’ve been trying to get new patients to agree to start on buprenorphine so that they can get take homes sooner. However, not all patients do well on buprenorphine, and some can’t tolerate it. A few patients, miserable on buprenorphine, wanted to switch to methadone this last week, and we did this. As good as buprenorphine products are when they work, they don’t work for everyone.

I’ve seen a handful of patients each day for various reasons but mainly for dose adjustments. I’ve helped the staff by wiping down doorknobs, computers, dosing counters and the like, taking turns with other staff.  I’ve had extra time to look at patients on our state’s prescription monitoring program. So far, no unpleasant surprises.

We made a bunch of decisions about take home doses very quickly, to try to prevent COVID19 spread in our community. I pray I’ve had the right decisions, and patients will be able to take their extra doses as prescribed.

Counselors are doing phone sessions to provide support for patients but are available to do in- person sessions as well, at six feet apart. We cancelled group sessions until the age of the COVID passes. I hate that, but we want everyone to be safe.

So, for now, at the opioid treatment program, I’m going to work each day. The time may come when I will need to telecommute, and that will be fine, too. I’m ready.

I see patients in my private office on Fridays, and most are people for whom I prescribe buprenorphine products. Tomorrow, instead of driving to my office, an hour away from my home, we are using telemedicine. Regular readers will remember I’m a bit of a dunce with technology, but my fiancé is a whiz. He has a computer program set up and showed me how to use it. I think I will like it. The sound and picture look great, and I’m hopeful it will work very well.

We’ve called all my patients to explain what they need to do to see me from the comfort of their home, via the computer. Most are younger than me and computer savvy.

We have one older gentleman, well over seventy, who doesn’t have the capability of getting on a computer. I completely understand. I plan to talk to him on the phone, see how he’s doing, and then send in his electronic prescription. Given his situation and that he’s been stable in his recovery for twelve years, I feel it’s reasonable to do phone sessions until COVID19 goes away.

The advantage to me is that I could go to work in my pajamas. I won’t, of course. But I could.

My home life hasn’t changed much. When I’m not working, there’s no place I’d rather be than home, so I’m an expert at “sheltering in place.” Since my fiancé, my dogs, and the cat are there with me, I’m happy. I have my hobbies: writing, weaving rugs, reading, and carving our backyard quartz into interesting shapes. We have several weeks of food at home, so we are more fortunate than most.

However, routine decisions can have big consequences. Over the weekend, I needed some little thing for cooking, and my fiancé was going to Lowes, so I asked him to stop by Walmart, which is nearby. While he was gone, I thought, “What have I done? There will be crowds at Walmart, and he could get infected and get sick.” I felt so guilty and worried. He laughed it off when he got home, but little decisions like that matter now.

To combat the feelings of unease, last weekend I did one of the most hopeful things I could think of: I planted a garden. I realize I might be pushing the season, and that we may get another frost, but I felt like I wanted to do something optimistic. I planted tomato seeds in little compartments, to grow into seedlings that I’ll plant later. Then I planted green and yellow squash, cucumbers, carrots, lettuce, and spinach into the ground. I do this every year, but usually not until mid-April.

Last weekend, I made cloth surgical masks for our nursing staff. I took tightly woven cotton cloth, cut it up and constructed the masks, then ran them through the high-temperature cycle with Clorox. Of course, being 100% cotton, they came out wrinkly as hell. I ironed them flat with a steam iron, perhaps further killing the little viral/bacterial bugs. I reasoned that most masks aren’t sterile, outside the operating room, so these may be of some help.  I’m not very fast at it, though. It took me three hours to make seven masks. Staff were very appreciative.

Twelve-step recovery continues to flourish. Though some groups have ceased to hold meetings for now, online meetings have opened. On a recent Narcotics Anonymous meeting held on Zoom, over forty recovering people shared their experience, strength and hope in the traditional manner. Participants shared one at a time, sharing their fears and challenges, and how they were coping with difficulties without using drugs to mask their fears. There was a real sense of comradery, every bit as real as in face-to-face meetings.

People who want to attend these meetings should contact Narcotics Anonymous or Alcoholics Anonymous in their area, to get times and meeting codes. These meetings can be excellent support during these difficult times.

Even though the evening news is a horror show, I plan to carry on with life as best I can, like everyone else. I’ll do the best I can to protect me and the people I love from COVID19. In my free time, I’ll continue making the arts & crafts that relax me. I’m going to try my best to have as normal a life as possible, and enjoy every moment.