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Congratulations, Spencer Clark!

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This month at the AATOD meeting in Baltimore, Maryland, Spencer Clark won the prestigious Dole-Nyswander award for service to the field. Spencer is the director of North Carolina’s SOTA (State Opioid Treatment Authority).

I’m so pleased he got this award. He’s earned it, for all the hard work he’s done to improve the quality of care given to patients at OTPs in NC.

Being SOTA director can’t be an easy job. He’s had to lead doctors, legislators, OTP owners and managers to a better plan of care for those with opioid addiction.

Spencer has been able to get OTP physicians together, so that we can educate each other about the best standards of care. I don’t know about the other groups, but getting a group of physicians to gather in one place and agree on anything is like trying to herd cats

With the help of the North Carolina Governor’s Institute, Spencer started monthly telephone conferences for all the doctors who work in North Carolina opioid treatment programs. These phone calls, led by a knowledgeable physician moderator, usually start with the presentation of a difficult case, and participants give suggestions for how best to handle the clinical vignette. Then we discuss various timely topics that complicate care to our patients with opioid use disorders.

This sounds like such a simple thing, but it’s had such a beneficial effect for the doctors who participate. This is a very specialized field, and we frequently get difficult cases fraught with medical and ethical issues. Now physicians in North Carolina have access to other doctors with similar specialized knowledge, to discuss difficult and complex cases.

It can be lonely, working as a physician at an opioid treatment program. We don’t usually have a lot of contact with doctors sharing our common vision of how to treat opioid use disorder. More often, OTP doctors are criticized by other community physicians, usually behind our backs, out of ignorance of our work.

SOTA and the Governor’s Institute, along with the North Carolina chapter of ASAM (American Society of Addiction Medicine) also started sponsoring yearly meetings each spring. These several-day conferences have had excellent speakers from around the nation. I’ve learned so much at these meetings, and look forward to it every year.

Spencer Clark set up an unofficial physician mentoring program as well. I help out in the Western part of the state, and another physician is available in the Eastern part of the state. We are available at all times to answer any questions OTP physicians might have. It’s a state-wide version of the national program Providers Clinical Support System (PCSS), run by the American Association of Addiction Psychiatry, which provides guidance for physicians across the nation who treat opioid use disorders with buprenorphine, methadone, or naltrexone.

Since there can be regional variations in drug use problems, a physician in the same region can sometimes add complementary perspective to what a national expert provides.

Spencer Clark came to his office in 2007. At that time, I was pulling my hair out because I’d just become medical director of a large, multi-site opioid treatment program, and we had too many patient deaths. Even one is too many, and I remember we had three patients die in one weekend, over Easter weekend that year.

I analyzed data from all the decedents, and it was obvious we had to change some things about our treatment program. I told the administrators of this program that we had to start being open all days of the week, and that we could not give take homes to brand-new patients. We had to lower starting doses, and start scrutinizing benzodiazepine-using patients to see if they could be started safely in treatment, or needed inpatient detoxification first, to get off benzodiazepines. I had a few other things to recommend, and to their credit, the administrators began to implement some of my ideas.

But later that year, when Spencer Clark came to SOTA, he sent a letter to the president of the opioid treatment program, wanting to know – in essence – what in God’s name was going on with these overdose deaths??

I remember one administrator lamenting that Spencer had taken over as SOTA director. He said of Spencer’s letter, “This will blow over. This isn’t going to amount to much.” I remember thinking, “OK, you’re wrong. Now we appear to have a SOTA director who gives a damn about what’s going on in the methadone clinics.”

Spencer made my job easier. With that pressure from the SOTA, I believe administrators were more willing to implement needed changes. I still wasn’t able to get them to provide buprenorphine in addition to methadone, but other changes reduced our death rate.

Spencer helped the physicians who work at OTP become allies. We set a standard of care, giving individual doctors more clout with the OTP owners. We can now point to what other physicians are doing to improve patients care and safety. And if an OTP owner is intransigent, refusing to make a needed change, that’s information for the physician. She then had to decide what to do – keep working at that program, or look for a greener pasture.

Spencer’s efforts are always focused on making treatment for patients with opioid use disorder better and safer. He may disagree with individuals and agencies about what that looks like in actual practice, but his driving intent is always about the patients. I’ve heard he’s occasionally ruffled some feathers at the quarterly OTP managers meetings. Therefore, it’s a tribute to his tact that this same group nominated him for the Dole-Nyswander award. He’s able feather-ruffle in a way that’s respectful, and clearly motivated by a desire to improve the health of patients with opioid-use disorder.

Well done, Spencer! You richly deserve this award.

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The Kratom Craze

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Over the last week, I’ve had a handful of patients entering opioid addiction treatment tell me they were taking kratom along with other opioids. For the most part, these patients say they use kratom as a back-up when they can’t find other opioids, in order to ward off opioid withdrawal.

Patients say they buy it online or at head shops. Most say they buy it in a powdered form, to dissolve into hot water and drink as a tea, or take capsules packed with the greenish powder. Some patients say liquid forms of kratom are also available.

I’ve blogged about kratom before, but only in the last few weeks have I seen patients who have used it.

Kratom (also called ketum or kratum) is a tree in the genus Mitrogyna, which is related to the coffee tree, and found in Southeast Asia. Kratom leaves have been used for thousands of years by natives of the area to produce stimulant and opioid effects. Fresh leaves can be chewed, or broken up to make a drink, or steeped in hot water to make a tea, as described above. Dried leaves can be smoked by users, who say low doses of kratom cause a stimulant effect. Higher doses are said to cause sedation.

Kratom’s active ingredient is mitragynine, which activates the mu opioid receptor in the human brain to cause an opioid-like effect. Like other opioids, this compound in the kratom tree relieves pain and causes euphoria. Some rat studies demonstrated more potent analgesia from mitragynine than morphine. It’s structurally different than other opioids, and unlikely to show as an opioid on traditional drug testing.

Rat studies also showed less respiratory depression than other opioids, possibly be due to kratom’s activity at the kappa opioid receptor. This drug also has adrenergic and serotonergic activity, so it has a complicated method of action. The increased adrenergic effect of the drug may give users a feeling of energy, like the other stimulants cocaine and amphetamines. This property has led some people to say kratom could be a treatment for methamphetamine addiction.

Because of its opioid-like effects, kratom can be used recreationally for the high it produces.

If you google “buy kratom,” more than a million websites appear, offering to sell all sorts of varieties of kratom, and extolling its properties of, “Pain relief, Energy, Prolonged Sexual Intimacy, and Mood Support.” The websites attempting to sell kratom say it’s safe because it’s natural, and that it is a treatment for both pain and addiction.

So is it safe?

First of all, just because a substance is found in nature does not mean that it is safe for human consumption. That’s ridiculous. Plenty of plants, herbs, and other substances found in nature are harmful, even lethal. Hemlock, deadly nightshade, castor bean, oleander…those are a few that come to my mind.

Secondly, “natural” does not mean non-addictive In fact, many of our addicting drugs are derived from nature, like opium, cocaine, alcohol, and nicotine. We learned to concentrate the active ingredients over the years to make them even more addictive.

We don’t have safety data on whether kratom is safe or not, because we don’t have studies about this substance. Like so many medications that are derived from plants, it is possible the mitragynine found in this plant could have helpful properties, and I would favor further investigation. But right now, we don’t have information about safety. For further reading, I’d suggest this excellent review article: http://www.hindawi.com/journals/bmri/2015/968786/

As above, there has been some suggestion in animal studies that mitragynine causes less respiratory depression, so it is possible it’s less risky than other mu opioids.

If you go online, you can find testimonials from people saying it helps them with pain and addiction.

Also consider that there’s no quality control of the stuff being sold as kratom. Online or in head shops, what’s labelled as kratom may or not contain kratom.

For the patients I’ve seen, they appear to use kratom as one opioid of many, and I haven’t heard any of them say it’s helped them come off of opioids. (But then, I wouldn’t expect to see people with that experience, would I? If a person was able to stop opioids with kratom, they wouldn’t come to an opioid addiction treatment center.)

To me, kratom seems like another opioid-like substance with the potential to cause addiction, and there’s no way to know what you are really buying, either online or at head shops.

 

 

My Cat is Prescribed Suboxone

This is not Yoshi, but another random Siamese on the internet. Yoshi refused He refused to be photographed today.

This is not Yoshi, but another random Siamese on the internet. Yoshi refused He refused to be photographed today.

 

 

 

 

 

 

We noticed Yoshi, our Siamese cat, peeing in weird places, like into my shoes. This is not like Yoshi. He’s usually fastidious with his grooming, and never has a bowel movement or takes a pee outside of the litter box.

Fearing he was sick with an acute bladder infection, I took Yoshi to the emergency 24-hour vet over the weekend. His urine sample had crystals in it, and was very concentrated, but had no white or red blood cells. This means it’s unlikely he has an infection or kidney stone, but the vet sent a urine sample for culture, just to be sure.

The vet says he probably has feline lower urinary tract disease, which turns out to be very similar to interstitial cystitis in humans. It’s a syndrome of painful and frequent urination without a specific cause. It’s more common in younger male cats like Yoshi, and tends to diminish with ago. It’s also caused by stress, and the vet questioned me closely about my cat’s living conditions.

Yoshi is an only cat, but lives inside, with two dog siblings, both large weimaraners, a male and female. They all get along very well, aside from an occasional spat over sleeping areas. In these fights, Yoshi is the aggressor, not the dogs. They have been trained to respect the cat, and turn the other cheek if he’s a bit cranky.

The only change in routine was that I’d been on a five-day vacation over the holiday, and spent it at home. I hate to think that my presence stresses out my cat.

Anyway, Yoshi was prescribed  twice-daily antibiotics, at least until the culture of the urine is complete, and pain medication. Since the pain and irritation at the cat’s urethra can lead to increased licking and “overgrooming” of the urethra, treatment with pain medication reduces the cat’s discomfort and the frequency of licking, which in turn allows the urethra to heal.

The vet gave me a packet of anti-inflammatory pills, and then started to explain about the opioid pain medication she was prescribing called buprenorphine. I laughed a little, and told her I was very familiar with buprenorphine, but she continued. She told me it could be absorbed from the thin lining of the underside of the tongue, and also the mucosa on the cheek. I started to tell her I know this, since I’ve prescribed it for my human patients over the past ten years, but she interrupted me to tell me it was a long-acting pain medication, and Yoshi might only need one or two doses per day, and to be careful not to overmedicate him.

Then she started to tell me signs of a feline opioid overdose. At this point it was obvious she was not to be interrupted, so I listened politely, inwardly amused.

She did not give me a naloxone kit for Yoshi.

He has done well with buprenorphine. After his first dose, I worried he didn’t get good absorption, since his cat pupils remained largely dilated. But gradually, he developed a sway and seemed much calmer. The frantic licking stopped, and I put him in our basement with food, water, his litter box, and a pile of rugs and blankets. He didn’t go to sleep, but he started “sitting on the brisket.” This is an old-timey term for when a cat sits with both front paws curled under in front of him. Gradually, his head became lower until his nose was on the floor, supporting his head.

I was happy he looked comfortable, so I eased out of the room to let him sleep.

Now it’s been several days, and I’ve given him one dose per day. I think he’s improving, since today he walked by one of my shoes without attempting to pee in it.

So here you have it – another use of buprenorphine, for interstitial cystitis in cats!

5 Year Blog Anniversary

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I never imagined my blog would be going strong after five years. Initially, I started it to promote I book that a wrote. The book did OK, but the blog has been so much more interesting and rewarding. I hope I’ve helped educate my readers, because they surely have educated me. I have a much better idea what’s going on out there in “addiction land.” My patients educate me about local trends, but blog commenters give a more universal view.

Thanks for reading and let’s continue our education of each other.

Goblins of Addiction

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Time for some whimsy…

Misery and Deceit, two goblins who worked for the Emperor of Wretchedness, were talking in a dark alley. Hopeless, another goblin, had just left them and was shuffling down the street, trailing the stench of sulfur.

“Idiot,” said Misery, speaking about Hopeless. “He couldn’t stop his human from getting help for addiction. What an incompetent. Doesn’t he realize that addiction must continue so we can make these humans miserable? Addiction is a key method to keep people in our Kingdom of Wretchedness”

The other goblin, Deceit, fancied himself a guru to the younger and less experienced dark spirits like Misery, Despair, and Hopeless. He smiled as he thought about how much wiser he was than the others. After all, he had been the original dark spirit to help lead most humans to addiction. He promised these humans that drugs would allow them feel good all of the time. He promised freedom from the usual ups and downs of a normal human life. Many times, they believed him.

“Well, now, Misery, when you’ve been around as long as I have…” Deceit started.

“Yeah yeah. Whatever. But what advice can we give the poor fellow?” Misery really didn’t feel like listening to the bombastic Deceit blather on again, and cut him off with a question.

“There are things to be done. After all, his human, Joe, entered treatment at a methadone clinic. As you know, in his part of the country, many people have bad opinions about that kind of treatment. Especially if they know nothing about it.” Deceit began laughing, but the laugh ended with a phlegm-producing cough. Ironically, Deceit was strongly addicted to cigarettes, though he kept saying he could quit when he wanted.

“I’ll call on poor Hopeless, and give him some advice. That would be gracious of me.” Deceit said. In his mind, Deceit finished the sentence with, “And he would owe me a big favor.” The dark spirits kept careful tallies of who owed a favor to whom, and often fought bitterly about this.

“All right, great. I’ve gotta go.” Misery was sick of this conversation, and wanted to get away. Misery was never happy with where he was, and always wanted to be somewhere else, which made it difficult to have a conversation with him.

Later that week, Deceit knocked on Hopeless’s door. It was smudged with some dirty substance. Hopeless believed cleaning house was hopeless, as it only got dirty again. Deceit’s knuckles were black with the stuff. As he was wiping the filth off his hand, Hopeless answered the door. It looked as if he’d been crying, as his eyes were red and there was mucus sliding from his nose. “Hello Deceit. Come on it. I’ve been feeling down this week after my failure with my human, Joe. Sometimes I feel like I’ll never get anything right. And of course I’ll be blamed for it all.” Hopeless sighed dramatically as he said this last part, feeling very sorry for himself.

“I’ve come to help you. I have much sound advice to give you, so let’s sit and talk for a while.”

“OK. But I doubt it will work.”

Deceit ground his teeth at Hopeless’s predictable self-pity. Of all the dark spirits, Deceit thought Hopeless was the least pleasant to be around.

“It will work,” Deceit said more emphatically than he felt. “The key is to use the people around your human to discourage him in his recovery.”

“For example, Joe’s wife is happy that Joe is no longer spending $100 a day for pain pills off the street, and she’s happy he’s no longer snorting them. But she won’t be happy if you can convince her that methadone is a dangerous drug. Suggest she look on the internet. She’s sure to find negative and untrue information. But keep her off legitimate websites. You don’t want her to learn any of the benefits of methadone. Keep her on the more emotional sites, where people write about their beliefs, and not actual facts. And be careful she doesn’t understand the distinction between methadone bought on the street and methadone dosed each day as prescribed by a doctor. Try to get her to hysterically demand of Joe that he “get off that stuff.”

“Or you can use his friends. Have them call him a weakling for wanting to quit drugs, and
how foolish he is to go to the clinic. Tell him that the clinic only wants his money. Be careful not to remind Joe that all medical treatments cost money. Convince him his addiction treatment should be free. After all, he is giving up drugs. Maybe you can even get him to thinking people should pay him to give up his drugs.”

Hopeless began to mewl about the impossibility of such things, but Deceit cut him off again.

“You can get an addict to believe all kinds of outrageous nonsense. Oh, and keep him from remembering that some of these same so-called friends have sold him pain pills. We don’t want Joe to perceive that these people want to keep a good customer.”

“Get him to go to a family doctor who’s uneducated about methadone treatment. Even if he’s seen for an unrelated medical problem, these docs sometimes will give deadly advice to such patients. Some of these doctors tell their patients to get off methadone as soon as possible.”

“What, his doctor wants him dead? Surely not.”

“Oh no, but many of them aren’t well-educated about the treatment of addiction. So if you can get Joe in with one of these doctors, we have the delight of watching a medical professional, who should know better, give bad advice to one of our humans. If Joe follows that advice, it will be easier for us to steer him back into addiction again. And then if Joe relapses, and tells his doctor about it, the doc is likely to shame him for relapsing. You see how funny it gets to be? He wouldn’t have relapsed but for the doctor’s bad advice….” Deceit trailed off, smiling at fond memories of previously amusing times.

“I don’t know. Joe doesn’t seem to be listening to me, or his old friends. He used to be easy to lead with a suggestion or two. Now he wants to stand up for himself. He says he feels good and isn’t using drugs for the first time in years. It feels hopeless to try to convince him he’s doing a bad thing.” Hopeless shook his head and squinted at the floor.

Again, Deceit felt a great surge of annoyance at Hopeless’s attitude. “Then you must undermine his confidence. Have you had no training in that sort of interference? Tell lies, and plenty of them, before he gains even more confidence. His mind must be turned against him. I’ll get one of my friends to come and help you. His name is Denial, and he’s an expert at convincing such humans that their lives in addiction really weren’t that bad. How about I send him over here later today so you two can make a plan?”

“You can send your friend Denial, but I doubt there’s much that can be done…”

Shortly after this somewhat unsatisfying end of their conversation, Deceit waddled home. (He was very fat, having fed on the misery of humans for millennia). He knew this was not a hopeless situation, because he’d seen many recovering addicts, patients of methadone clinics, who had been shamed into stopping their treatment. It was entertaining to watch a person, leading a normal life but for dosing each day with methadone, slide back down into the darkness of active addiction once he left treatment. Quite often, goblins of the underworld used the twisted fears and inaccurate beliefs of the people who said they loved the addict to aid in the addict’s downfall.

Entertainment in the underworld didn’t get any better than this!

(…inspired by The Screwtape Letters by C.S. Lewis)

Harm Reduction

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In the interest of harm reduction, I’m going to describe precautions that addicts, still in active addiction, can take to reduce the risk of overdose death. This information can be accessed at: http://harmreduction.org/wp-content/uploads/2011/12/getting-off-right.pdf

1. Don’t use alone. Use a buddy system, to have someone who can call 911 in case you stop breathing. Do the same for another addict. Obviously you shouldn’t inject at the same time. Stagger your injection times.
Many states now have Good Samaritan laws that protect the overdose victim and the person calling 911 for help, so that police don’t give criminal charges to people who do the right thing by calling for help for an overdose.
Take a class on how to give CPR so that you can revive a friend or acquaintance with an overdose while you wait on EMS to arrive.

2. Get a naloxone kit. I’ve blogged about how one patient saved his sister with a naloxone kit. These are easy to use and very effective. You can read more about these kits at the Project Lazarus website: http://projectlazarus.org/

3. Use new equipment. Many pharmacies sell needles and syringes without asking questions. Your addict friends probably can tell you which pharmacies are the most understanding.
Don’t use a needle and syringe more than once. Repeated use dulls the needle’s point and causes more damage to the vein and surrounding tissue. Don’t try to re-sharpen on a matchbook – frequently this can cause burrs on the needle point which can cause even more tissue damage.

4. Don’t share any equipment. Many people who wouldn’t think of sharing a needle still share cottons, cookers, or spoons, but hepatitis C and HIV can be transmitted by sharing any of this other equipment. If you have to share or re-use equipment, wash needle and syringe with cold water several times, then do the same again with bleach. Finally, wash out the bleach with cold water. This reduces the risk of transmitting HIV and Hepatitis C, but isn’t foolproof.

5. Use a tester shot. Since heroin varies widely in its potency, use small amount of the drug to assess its potency. You can always use more, but once it’s been injected you can’t use less. The New England overdose deaths described by SAMHSA may have been avoided if the addicts had used smaller tester shots instead of shooting up the usual amount.

6. Use clean cotton to filter the drug. Use cotton from a Q-tip or cotton ball; cigarette filters are not as safe because they contain glass particles.

7. Wash your hands thoroughly before preparing your shot, and clean the injection site with an alcohol wipe if possible. Don’t use lemon juice to help dissolve heroin, as it carries a contaminant that can cause a serous fungal infection.

8. Opioid overdoses are much more likely to occur in an addict who hasn’t used or has used less than usual for a few days, weeks, or longer. Overdose risks are much higher in people just getting out of jail and just getting out of a detox. Patients who have recently stopped using Suboxone or Subutex may be more likely to overdose if they resume their usual amount of IV opioids.

9. Don’t mix drugs. Many opioid overdoses occur with combinations of opioids and alcohol or benzodiazepines, though overdose can certainly occur with opioids alone.

10. Don’t inject an overdosed person with salt water, ice water, or a stimulant such as cocaine or crystal methamphetamine – these don’t work and may cause harm. Don’t put the person in an ice bath and don’t leave them alone. Call for help, and give mouth-to-mouth resuscitation if you can.

To people who believe I’m giving addicts permission to use, I’d like to remind them that addicts don’t care if someone gives them permission or not. If an addict wants to use, what other people think matters little. But giving people information about how to inject more safely may help keep the addict alive until she wants to get help.

The Harm Reduction Coalition has excellent information on its website: http://harmreduction.org