Archive for the ‘Uncategorized’ Category

Medicaid’s Limits for Non-compliance

 

The opioid treatment program where I work accepts Medicaid as payment, starting a few years ago. Overall, it’s been so beneficial for hundreds of our patients. However, when Medicaid patients have repeatedly positive drug screens, Medicaid overseers threaten to cut off their funding for treatment.

Our state’s Medicaid system is divided into counties, and these counties contract with agencies to provide oversight for the mental health and substance abuse treatment dollars. I’ve had several conversations with the doctors who do peer review for payment to our program.

We discuss patients’ progress, and whether more Medicaid money will be approved for their treatment. This agency says they have the right to cut off payment for treatment of Medicaid patients who don’t become drug-free within a reasonable period of time. So far, they haven’t cut off payment for any patients, but we have many patients at risk for this. If patients lose Medicaid coverage, they can remain in treatment with us, but have to pay out of their own pocket.

I feel torn about this issue.

On the one hand, I know my patients will do better if they are able to stay in treatment on MAT. If Medicaid quits paying for their treatment, many will leave treatment and go back to illicit drug use. I know from various studies that patients who leave MAT have high relapse rates. Relapses back to illicit opioid use can cost more to the Medicaid system than staying in treatment. Plus, patients who leave treatment are at greater risk of overdose death.

On the other hand, as a taxpayer, I understand why people object to using tax dollars, in the form of Medicaid, to pay for addiction treatment if the patient is still using illicit drugs. Some people may feel this is a government subsidy to continue drug use.

Most people feel we do have an obligation to the disabled and the poor to provide medical care. But should we apply different criteria for payment of substance use disorder compared to other chronic medical illnesses, which also have behavioral components?

The doctors who decide when to stop paying for MAT could use similar criteria to decide when to stop paying for other medical care of chronic illnesses.

Imagine this conversation:

“Hello, this is Dr. X. I am calling regarding approval of payment for the treatment of Mrs. Sweet, the diabetic you are seeing. I’ve authorized ninety days more of payment for her, but if her blood glucose readings and her hemoglobin A1C don’t improve, I will be recommending we stop paying for her treatment. She will have to pay for her diabetic medication and her medical care from her own pocket.”

“I don’t understand. I’ve been treating Mrs. Sweet for years…her diabetes is about as well-controlled now as it has been for years.”

“Our point exactly. She isn’t showing any improvement. You told her to follow a diabetic diet, lose weight, and exercise, and she hasn’t done any of these things. If she’s not willing to follow physician recommendations, Medicaid won’t approve payment for the medical care she needs for diabetes.”

Can you imagine the outrage at such a decision?

Let’s use an example of another chronic illness: heart disease. Let’s say I have a patient who has coronary artery disease. He had one heart attack and had to have a coronary stent placed. He has very high cholesterol, but despite dietary instructions, he continues to eat fatty foods and plenty of red meat. He also isn’t compliant taking his cholesterol medication.

He has another episode of chest pain, goes to the hospital, gets admitted with another heart attack, but the Medicaid overseers say his medical care will not be paid for, since he hasn’t made the changes recommended by his physician.

Are these scenarios starting to hit a little close to home?

Let’s be careful when we start deciding who deserves or doesn’t deserve to have their medical treatment paid for, if we use behavioral change as the yardstick for such decisions. Few of us with chronic illnesses do everything perfectly.

It’s part of human nature.

Mismanagement of Opioid Use Disorder

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I’m going to give an overview of what happened to one patient with opioid use disorder, changing enough details to keep people from recognizing the person. I’ve changed non-essential data, but not the medical facts as I learned them from the patient. The facts were confirmed by medical records that I obtained from two local hospitals, a local cardiologist, and a teaching hospital. I could not get records from the mental health clinic that is mentioned because none were made. All of this happened a few years ago.

This 31 year-old man had years of opioid use disorder which progressed to intravenous use for a little over a year before he started feeling ill. He went to his local hospital and was correctly diagnosed with endocarditis, which is a serious and life-threatening infection of the delicate valves of the heart. He was transferred to a teaching hospital, had a surgical repair of a heart alve, given six weeks of antibiotics, and sent home.

He says no one mentioned any sort of addiction treatment, but he admits he probably would not have agreed to treatment anyway. He also admits it’s possible he just doesn’t remember and treatment was discussed. His records contain no mention of substance use treatment referral upon his discharge from the hospital.

About a year later, he was re-admitted to our local hospital with fever and suspected endocarditis. His attending physician in the hospital started treatment with appropriate antibiotics but correctly identified he needed to be seen by a specialist too. As his medical record reveals, two teaching hospitals refused to accept this patient in transfer because he had no insurance, no money, and because he didn’t quit using drugs after the first illness. The physicians that could have accepted the patient in transfer said they don’t want to waste resources treating him again.

His admitting physician explained all of this to the patient. Since it appeared he would die without surgery, Hospice care was arranged to ease his remaining days. He was sent home to die. Somehow, qualifying for Hospice care also got him approved for Medicaid.

After his Medicaid came through and he’d been on antibiotics waiting to die for some weeks, he started wondering what would happen if he arranged an appointment with a cardiologist on his own. Since he now had Medicaid, he was able to make an appointment with a local cardiologist. Though he hadn’t died yet, he was very sick, with fluid building in his lungs and backing up into his feet and legs.

I got the cardiologists’ records, and between the lines I could sense he had been as puzzled as I was now– why was this man turned down for medical care? The cardiologist correctly suspected the patient didn’t have a severe endocarditis, since he probably wouldn’t still be alive at that point. He arranged a referral to a cardiologist friend of his at the local teaching hospital, and a more sophisticated evaluation was done. It showed a hole in the patient’s heart. Blood was flowing in the wrong direction, causing heart failure and severe shortness of breath.

The patient was admitted to the hospital and had a procedure to patch this hole. As it turned out, this procedure could be done without open-heart surgery.

All is well, right? Nope. The original problem, opioid use disorder, has still not been comprehensively treated, although this teaching hospital did at least give this patient a few days of buprenorphine during his short hospitalization. He was told to follow up with a Suboxone doctor in his area.

He tried. He called several office-based buprenorphine physicians in his area. But he had Medicaid, and couldn’t find a doctor to accept this form of payment, or else the few that did accept Medicaid didn’t have appointments for many weeks.

He relapsed to intravenous opioid use, and became sick with fever, had trouble breathing, and went to his local hospital’s emergency department. He was given some fluids, some antibiotics for “pneumonia,” and told to go home.

Before he left, he asked if he could be referred for treatment of his addiction, and was told he would have to go to the local mental health provider that contracts with Medicaid in his county.

He went in person to that facility the next day, and asked the receptionist if he could be referred to the local methadone clinic. He was told they didn’t make referrals to the methadone clinic, so he left, discouraged. He never imagined it could be so hard to get treatment for his addiction.

He continued to feel very bad, with fevers, cough, and then developed severe back pain. He went to another local hospital’s emergency department, was again told he had pneumonia, and that he needed different antibiotics. He was sent home from the emergency department, but went back a few days later, when his back pain worsened.

He says he got the feeling the hospital personnel felt he was drug seeking for pain medication. He admits he did want pain medication, but mainly because of severe back pain. He was told to be patient, and give the antibiotics time to work.

The day before he came to our opioid treatment center, he went back to the first local hospital with fever, back pain, and trouble breathing. He was told for a fourth time that he had pneumonia, and was sent home with new antibiotics.

He got the address of our opioid treatment program from one of his friends, and came in person to see if we could help him. Since I wasn’t there that day, we set him up with an intake appointment for the next day, and he arrived bright and early to start the intake process.

When I first laid eyes on this patient, my impression was that he was seriously ill and not stable enough to start treatment with us that day. He looked bad. However, I listened with fascination to his entire story, which he told in short bursts of conversation between gasping breaths.

I didn’t want to start treatment. I wanted to get him to a teaching hospital as quickly as possible. He was sweaty, breathless, wincing in pain and clutching his back, and running a low-grade fever. He did have sounds in his lungs consistent with pneumonia, but at this point he’d been on antibiotics for over a week. Clearly something more than pneumonia was going on.

But I knew I could not turn him away without doing something for him. More as a gesture than as a real treatment, I gave him an induction dose of buprenorphine and sent him to the teaching hospital, located about an hour from us.

I got a call back later that day from the resident physician who admitted this patient. The severe back pain that my patient had reported at four hospital emergency department visits turned out to be osteomyelitis, which is a bacterial bone infection needing antibiotic treatment for several months. He also had an abscess on the spine nearby the infected bone. The bacteria they finally cultured was methicillin-resistant Staph aureus, also known as MRSA.

He spent months in several hospitals. He had to undergo a debridement of the bone to get rid of infected and dead material, and had to be on very heavy intravenous antibiotics for a prolonged time.

Because he had been started on buprenorphine at our opioid treatment program, I convince the residents they could continue that medication, and gave some suggestions for increasing it a little bit.

Finally, he was healthy enough to leave the acute care hospital to go to a physical rehabilitation hospital, where he stayed for about six weeks. Thankfully, since he had already been started on buprenorphine, these providers were also willing to continue his medication. He was re-admitted to our opioid treatment program the day after he was discharged from the physical rehab hospital so that we could continue his treatment.

He had to have strong opioids early in his hospitalization but by the time he came back to our OTP, he was only on buprenorphine 8mg sublingually per day. I did have to increase his dose a little for fine-tuning, and he’s been healthy ever since, with no positive UDS, no illicit drug use.

He looks fantastic. He’s healthy, energetic, and works every day. He’s usually smiling, and he makes me smile too. I don’t think he’s using any illicit opioids for many months.

He asked me a difficult question. He wanted to know how his medical treatment could have been better. I told him that I had the luxury of hindsight and the pile of his medical records, but I did see some mismanagement of his care. I told him these were the things that bothered me about his treatment:

  1. He was turned down for medical care when he came to his local hospital for what they thought was endocarditis. It turned out to be something different, but the small hospital didn’t have the technology to diagnose and manage the problem. They did the right thing by attempting to transfer him to another hospital, but were refused. I don’t know what recourse a physician at a small hospital has if teaching hospitals refuse to accept a patient, and I’m sure this patient was refused because he had drug addiction, and judged as a person not worthy of care.
  2. There was an appalling lack of attention to his underlying medical disease that fueled all of his medical problems. He should have been told about buprenorphine and methadone as treatments for his problem, and referrals should have been made. Ideally, he should have been referred after his endocarditis infection, or by any of the half-dozen doctors who saw him after that. Then even when he specifically asked for referral for that sort of treatment, the mental health facility missed an opportunity to help this man, saying they didn’t refer to the methadone clinic.

Believe me, we notified people who supervise this mental health facility about their failure to act, and what we thought of this failure. We have been assured this will never happen again.

3.This patient sensed an attitude of distain in his caregivers, and I also sensed it in the wording of the documents from the hospital. The emergency department records are sketchy, with little documentation of the medical reasoning of the attending physician. I worry that the physician saw the patient as a bad person seeking drugs, rather than a sick person with a treatable illness. I know I’m sensitized to this issue, so it’s possible I’m jumping to the wrong conclusion.

I’ve tried my best to talk to local physicians. In a few enjoyable exceptions, I’ve had great responses and cooperation. In other cases, I’ve had rude responses. Most responses are neutral, neither rude nor friendly, and I sense a disinterest in the topic.

I wish all of the doctors who treated this patient when he was sick with opioid use disorder could see him now. He’s a happy and productive member of society, and yes, he does plan to stay on buprenorphine indefinitely. I support that decision.

This patient, and hundreds like him, are why I love my job.

Mandated Training?


 

 

 

 

It looks like 2017 is going to be the year of governmental solutions to the opioid use disorder problem.

I blogged last week about the regulation passed by the Virginia Board of Medicine. Now there’s a proposed bill making its way through the NC legislature, advocating new laws to help solve the addiction problem. Legislators certainly have their hearts in the right place. I agree with many parts of the proposed bill.

But now, I’d like to suggest a new regulation: ask all doctors to take an eight-hour course on opioid use disorder and its treatment with medication-assisted treatments, as a prerequisite to renewing their licenses.

I can hear my colleagues already howling with indignation. I’d feel the same way if I were them. It’s hard to admit you don’t have the education you need in an area of medicine. But this specialized area of medicine powerfully influences nearly all other subspecialties of medicine, so the consequences of neglecting the disease of addiction can be enormous.

Before I listen to my fellow physicians’ protests, I’d like to give examples, from my own community, of some things medical providers have done with patients prescribed opioids, and with patients who have opioid use disorder. I believe they all could have been handled better. Patient details have been changed to protect identities.

Example number one:

One of my patients needed to have surgery on his lumbar spine. He went to see the orthopedic specialist and was told he had to taper off methadone before the procedure could be done. I asked my patient why the doctor told him this, and the patient said he didn’t know. The patient said he was also told he couldn’t be “allowed” to have any pain medicine after he left the hospital after this surgery.

I’ve had other doctors in my area tell patients the same thing. One local weight loss surgeon tells patients they have to come off their evidence-based treatments (methadone or buprenorphine) for their potentially fatal medical illness (opioid use disorder) before he will agree to do any sort of gastric bypass weight loss surgery.

I was eager to have a discussion with my patient’s orthopedic surgeon, but my patient told me not to bother. He said he wasn’t going back to that surgeon anyway, and planned to get a second opinion at a nearby teaching hospital. I told him I thought this was a very good idea, though I was disappointed I couldn’t talk to the orthopedic surgeon. I was actually looking forward to that conversation. Probably the maniacal gleam in my eye made my patient tell me not to call.

Example number two:

Several weeks ago, I saw a new patient who was seeking admission to our opioid treatment program after being kicked out of a pain clinic. “Tim” (not his real name) had been going to several different pain clinics for years, and had been misusing his medication for at least two years. He was snorting oxycodone, around 150mg per day, and failed a pill count done by his pain medicine physician. His pain management doctor dismissed him from the practice, citing a “zero tolerance,” with no referral or further help. His friends told him about our treatment program, so he came for admission.

Tim was offered a choice between methadone and buprenorphine as treatment medications. He was so vehemently opposed to buprenorphine that it made me curious. He said that buprenorphine made him so sick, he nearly died.

I had already looked at his information on the prescription monitoring program, and saw that a few months ago, the physician assistant at his pain clinic prescribed Belbuca, along with relatively high doses of the usual immediate and extended release hydromorphone. This had piqued my interest.

Belbuca is a form of buprenorphine that’s approved for the treatment of pain. We don’t use it to treat addiction because it doesn’t have FDA approval for that purpose, and therefore isn’t covered by the DATA 2000 law.

Obviously this physician’s assistant who prescribed Belbucca failed to realize it would precipitate withdrawal in this patient who had been on full opioids for months.

I asked him to describe what happened after he took the first Belbucca. He said he felt like he had immediate onset of intense nausea and repeated vomiting so bad that he called EMS to take him to the hospital. He said he thought he was dying.

It doesn’t sound like anyone who saw the patient at the hospital told my patient his reaction was completely predictable.

I tried to explain to my patient that he may not get sick with buprenorphine if it were prescribed properly, but he was having none of it. That was OK, because methadone is still a great treatment for his opioid use disorder.

Example number three:

Some patients at our opioid treatment program stabilize on buprenorphine and then transfer to an office-based setting for care in a less restrictive setting. These patients have done well for months, so we wish them well, send their requested records, and encourage them to continue getting counseling in some form.

However, for some reason, some pain clinics take these patients off buprenorphine and start short-acting opioids. I’ve blogged about this problem before, dismayed at the predictable return of their opioid use disorder. They fail pill counts, and then get kicked out of treatment, having been set up to fail by their provider.

Now, things are getting weirder.

One patient, who did well for seven months at our opioid treatment program, transferred to a local office-based buprenorphine program. She did well for a few months, until she was switched to immediate and extended-release hydromorphone, which had been her drug of choice when she was in active addiction.

This patient predictably lost control of how she was taking this hydromorphone, started injecting it, and failed a pill count. Her doctor then told her she must go for an assessment at a substance abuse treatment facility in order to continue being prescribed hydromorphone.

Ummm…here’s the thing…she was started on buprenorphine in the first place because she had an opioid use disorder.

I’m not saying every patient with opioid use disorder immediately loses control of their medication if they’re prescribed opioids. But after less than a year of recovery from severe, intravenous opioid use disorder, you don’t have to be psychic to predict this would happen. Handing this patient a bottle of her drug of choice with a thirty-day supply triggered a relapse back to intravenous drug use.

Example number four:

I’ve saved the craziest for last. This example is tragic, both because of the bad patient outcome, and because so many doctors dropped the ball on this patient.

The patient, who developed opioid use disorder during treatment of chronic pain syndrome, developed severe mid-back pain. He told the emergency room doctor that he had been injecting the pain pills prescribed to him by a local pain medicine practice, and the emergency department physician noted track marks on his arms.

The patient had a limited work up and was sent home with a diagnosis of non-specific back pain and referred back to his pain clinic. The patient, miserable with intense and severe pain very unlike his chronic pain, returned to that hospital’s emergency department three more times. On the next to the last time, he says he was told that the doctor would not see him because he was a pain medication seeker.

Several days later, on his last visit to the emergency department, the patient was nearly comatose, with a high fever and labs indicating sepsis, and overwhelming blood infection. The patient was immediately admitted to the hospital and started on a range on antibiotics, but failed to improve. His relative demanded transfer to the local teaching hospital, an hour away.

Upon arrival at the teaching hospital, this 44 year -old man was diagnosed with a spinal abscess that extended from the neck all the way to the end of the spinal cord. This infection had obviously started at the area of his intense back pain. His spinal cord was being bathed in pus rather than spinal fluid.

He was not expected to live.

He was taken to the operating room, where the infection was drained and washed away, and dead tissue removed. Against all odds, the patient survived, though he was a quadriplegic when he woke up after surgery.

After being treated with antibiotics for many weeks, he was sent to a physical rehabilitation hospital for months. Eventually, he regained some strength in his arms and legs, and against all odds, improved to the point he could feed himself, and could walk with great difficulty, with two canes. He was eventually released from the physical rehabilitation hospital.

Eight months since his last appointment, he went back to his pain clinic. The doctor resumed prescribing the same medications that the patient had been misusing.

Wait a minute, you will say. Surely that doctor wasn’t told about the whole IV use, spinal abscess, quadriplegia thing, right? Wrong. Records show he did know.

The patient, after trying very hard not to inject these medications, finally came to our opioid treatment program, and asked for help. He was referred to us not by our local hospital’s physicians, not by anyone at the teaching hospital, not by social workers at that hospital, not by the physical rehabilitation hospital, and not by his pain management doctor.

His friends, in treatment at our OTP for their opioid use disorder, and told him to come to us for help.

He was started on sublingual buprenorphine and has done beautifully.

One day, after he’d been on a stable dose of buprenorphine for a few weeks, I asked him what he thought when his pain management doctor offered to put her back on hydromorphone. He said, “I was surprised. I didn’t think it was a good idea, but I was in pain and in withdrawal, so I just took the prescription.”

I understood. After all his time in the hospital, this patient hadn’t had any treatment for the disease of opioid use disorder. He’d only had treatment of the sequellae of opioid use disorder.

At that time, saving his life was the most important thing. But later, why not address the original disease that caused this million-dollar hospital treatment admission? Why not direct the patient to treatment of his opioid use disorder when released from the hospital and/or physical rehab facility? Why not pause for more than a moment before writing a prescription for the same drug that caused the whole mess?

 

All physicians make mistakes, usually out of ignorance, and I’m no different. But now, the opioid addiction problem is so bad that each state is passing laws to fix the problem. Isn’t it worth passing a law that makes sure all physicians are part of the solution?

At a minimum, let’s teach all doctors that substance use disorders are diseases, and that we do have treatments available. Some treatments work better than others, and medication-assisted treatment of opioid use disorder works very well. In fact, there’s more evidence to support MAT than anything they are doing in their practices. Why not refer patients with problems rather than shaming and ignoring them?

Let’s teach physicians that failure to diagnose and refer patients with substance use disorder for appropriate treatment is malpractice, just as it is for all other medical problems.

 

 

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.

 

 

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.