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Indiana: Discrimination Against Nurses on MOUD

Ukrainian art – Julia Datta

Many medical boards and nursing boards don’t allow their licensees to practice if they are prescribed MOUD (medications for opioid use disorder). It’s something that hasn’t been talked about much. Most of the boards preferred to keep quiet about these decisions, trying to avoid publicity and lawsuits from healthcare professionals who were denied licenses to practice their profession.

As I’ve talked about in other blog posts, things are changing. The Department of Justice has investigated discrimination against people with opioid use disorder who are treated with medications such as methadone or buprenorphine.

In March of this year, the Department of Justice (DOJ) finished investigating Indiana’s state board of nursing, because they have refused to allow nurses on either buprenorphine or methadone to participate in their Nursing Assistance Program.

The medical boards tasked with protecting the public from problematic physicians usually gives the chore of monitoring doctors with mental health and substance use disorders up to an independent organization, usually called Physician Health Programs. Some nursing boards do this monitoring themselves, through some type of nursing assistance program. These programs monitor licensees with substance use disorders through mandating treatment programs, doing random drug screening, and other methods. The licensees who do well in their recovery receive advocacy from the assistance programs and regain their nursing licenses and go back into their professions.

Indiana’s nursing board would not allow nurses on buprenorphine or methadone to participate in their nursing assistance program, leaving these patients with no method to get their licenses re-instated. The treatment providers that the Indiana nursing board contracted with were all abstinence-based, and patients on MOUD couldn’t participate.

The DOJ says this violates those nurses’ civil rights.

Their full report can be read here:

Released in March of this year, the DOJ decision says, in part, that their conclusions of law are:

“The Nursing Board’s prohibition on ISNAP participants’ use of OUD medication in ISNAP (Indian State Nursing Assistance Program) penalized Complainant for her disability and was not justified by any individualized medical assessment.”

Because the DOJ found that the Indiana Nursing Board violated title II of the ADA, they recommended they immediately do the following items:

“1. Adopt or revise written policies to eliminate the ban on ISNAP participants using medication to treat OUD and to explicitly state that the Nursing Board, and its contracted vendors, may not discriminate against, exclude from participation, or deny the benefits of its services, programs, or activities—including ISNAP—to qualified individuals with disabilities because they have OUD.

 2. Appropriately train and educate all Nursing Board staff and the staff of ISNAP vendors about OUD and the nondiscrimination requirements of Title II of the ADA.

3. Pay compensatory damages to the Complainant and other aggrieved individuals for injuries caused by the Nursing Board’s actions described in this letter.

4. Provide the United States with written status reports delineating all steps taken to comply with these requirements, including the date(s) on which each step was taken, and, where applicable, information sufficient to demonstrate compliance.”

I thought this decision was appropriate, and I applaud the DOJ for finding against the abstinence-only version of treatment offered by the Indiana Board of Nursing.

I had the pleasure of working on the North Carolina Board of Nursing’s Advisory Committee from 2010 until 2013. This committee met twice per year and served to advise the NCBON about various aspects of the Board’s job. Considerable time was spent discussing how board Licensees were doing in the recovery programs that were set up under the Board and how that program was administered.

I’m pleased to say that North Carolina was ahead of the times. As far back as 2008, I remember managing the care of nurses who were my patients, on either methadone or buprenorphine products. The Board allowed them to work and participate in the recovery programs, with only a few added precautions.

The Board required periodic updates be sent from the physician prescribing the methadone or buprenorphine. They wanted information about updates in the treatment plan. They also asked for a standard form to be filled out and faxed back to the NCBON after each visit, stating how the patient was doing in treatment. That was simple enough, and I was happy to advocate for my patients with the NCBON.

I saw some of those patients only for a few years, but others I still see today, after over a decade on MOUD. Those patients have done well in their lives and their recovery, rising to the top of their field. They are the kind of nurses that you’d be relieved to have taking care of a loved one.

The NC BON wasn’t enlightened because of me; they already had progressive attitudes before I served on their advisory committee. It was the work of other doctors and personnel who served before I came on the scene. Whatever the reason, I was pleased and surprised with approach towards MOUD.

Around 2013, the Advisory Committee for the Board of Nursing asked me to do an hour-long presentation on opioid use disorder and its treatment with medications. In 2012, there was an article published [1] that claimed medical professionals shouldn’t be considered for buprenorphine therapy, and naturally they were concerned about this report.  In my presentation to the committee, I included my critique of that article. I felt the author was biased and misrepresented the data found in some of the studies she cited.   I was happy to do this, and it seemed well-received. I was grateful the leaders of the Board of Nursing wanted as much information as possible.

Then in 2019, I experienced the highlight of my medical career. I was asked by the North Carolina Medical Board to come and talk to the full board about the same topic: opioid use disorder and its treatment with medication, and how it compares to the usual abstinence-based treatments that physicians usually receive.

What made it the highlight of my career? For one thing, I had some…how shall we call it…experience with the medical board. They saw me at my lowest point – when my own recovery was new and shaky.

During my own substance use disorder, I’d decided the cause of my substance use was my job. Anyone with my job would use drugs, I reasoned, so if I just quit work, I could stop using the drugs and alcohol that I knew were causing me problems. I quit my job and was dismayed when I still couldn’t control my substance use. Convinced I wouldn’t ever want to practice medicine again, I inactivated my license.

It was an impulsive and foolish decision which I later regretted. But people under the influence don’t always make great decisions.

It wasn’t long into recovery before I saw that my addiction was about more than my job. To be sure, there were certain pressures at work that hadn’t helped any, but there were multiple factors. To re-activate my license, I had to complete a form that asked if I had ever had any issues with substance abuse. I answered honestly, and said I was working with the North Carolina’s Physicians Health Program. According to Board regulations, I had to meet with the board to be granted a Consent Order to get an active license and return to work.

I met with the Board three or four times, and it was always scary as hell. These people had the power to revoke my medical license permanently, although they really had no reason to do so.

Because I was doing well in my recovery, the board members who met with me were pleasant and encouraging. They congratulated me on my recovery and granted a consent order with some restrictions on my license for the first year or so. It wasn’t long before I got a full unrestricted license back.

As nice as they were, I was still overwhelmed with shame and felt like a bad doctor & a bad person. As easy as it is for me – now – to tell patients now that they are a sick person trying to get better and not a bad person trying to be good, it didn’t feel that way to me in early recovery. I still felt much guilt for “allowing” addiction to happen to me.

Then for the medical board to ask me to come back twenty years later, to speak to the board as an expert was overwhelming.

But it was a tough assignment. Physicians in abstinence-based recovery do very well, with 80% abstinence rate at five years. But that’s for all physicians, using a variety of substances. As we know, recovery from opioid use disorder doesn’t always look the same as recovery from other substances. Among physicians in these studies, alcohol was the most used substance, but opioids were in second place.

In my talk, I acknowledged the data showing physicians recover at better rates than the general population with abstinence-based treatments, which may change the decisional balance about using MOUD, particularly if the patient was strongly motivated to have abstinence-based recovery. But I also said medications were the gold standard treatment for opioid use disorder, there was no firm evidence that patients on stable doses are unable to function as physicians, or physician assistants. (The NC Board of Nursing oversees Nurse Practitioners). Patients who want to use MOUD should be allowed to practice in their professions if there are no other safety concerns. If there were specific concerns, the physician could have neuropsychiatric testing for reaction time, dexterity, etc.

I was asked bluntly if I thought the Medical Board could legitimately deny MOUD to one of its licensees seeking recovery. I told them with the data about the increased risk of death for patients denied medication, I didn’t think they could, or should. I said especially if a licensee had a relapse onto opioids after an episode of abstinence-based treatment, methadone or buprenorphine should be presented as an option to the patient, to prevent death.

I said some things that the board probably didn’t want to hear, but I spoke the truth as I knew it, which was what they asked me for.

I was gratified with their response. I think I was one of three speakers, and my understanding was that after my bit, I’d leave, and the next speaker would start. However, the full board called for a break and board members came up to me and thanked me for talking. I was embarrassed by how happy I felt.

At that time, I didn’t know that the law would have considered it a violation of the ADA to deny physicians access to medications for opioid use disorder.

Today, the DOJ appears to have made the decision for all the state licensing boards that to deny licensees the ability to practice is discrimination that can bring legal attention and action onto the boards.

 I think it’s the right decision. In this age of shortages of healthcare personnel, a more flexible approach will allow more recovering people to be able to practice in their profession. It may also reduce deaths from opioid use disorder in this population, as it does for people in general.

  1. Hamza et al., “Buprenorphine Maintenance Therapy in Opioid-addicted Health Care Professionals Returning to Clinical Practice: A Hidden Controversy,” Mayo Clinic Proceedings, 2012 March 87(3): pp. 260-267.

Answering Questions

Ukranian art by Anna Shevel

“Addiction is considered a behavioral mental health disorder, correct?? So what types of diagnostic testing are useful when determining the level of care for someone who’s seeking treatment for an opiate use disorder? Or is the notion of attempting scientific evidence to verify or properly assess patients like these just not practical? surely there’s even one test that a physician should perform besides a standard urine screening (??) Urine test can only verify the presence of an opiate, on one particular day, one occasion, right? In theory I could visit the dentist, take a prescription pain killer one time and then be equally qualified for any MAT program that’s relying on only a urine test! Or maybe I’m just confused… Thank you”

I decided to answer my reader’s question in the form of a whole blog, given the complexities of what the poster is asking.

This is really a two-part question; the first part involves how doctors diagnose opioid use disorder, and the second is how they decide the appropriate level of care.

Let’s take the first question. We use the DSM 5 criteria to confirm a diagnosis of opioid use disorder, and the criteria also help describe the opioid use disorder as mild, moderate, or severe:

My reader is correct: one positive urine drug screen for opioids isn’t diagnostic for opioid use disorder. We need patient histories to confirm the diagnosis. As you can see, all but one (physical withdrawal) of the eleven items are based on patient history, which is why providers who use medications to treat opioid use disorder usually ask new patients to come to arrive in withdrawal. But even when that’s not possible, there are workarounds.

Upon meeting a new patient, I ask her to tell me her story: how she started use, how the use changed over time, what happened in her life. I settle into my chair and listen carefully, trying my best not to interrupt.

I’m listening for common themes, keeping in mind the diagnostic criteria. I’ve talked to thousands of patients over the past twenty-one years, and the histories are similar but not identical. If the patient has an unusual history, I’ll ask questions for clarifications. Some patients are vague with poor memories and other patients recite a straightforward history that I could type word for word. Most are somewhere in between.

Though patient history is a big part of making the diagnosis of opioid use disorder, it’s only one piece of the diagnostic pie, though it is a large piece. We have other factors.

For example, we do point of care (immediate results) drug screens on admission. These results should match the patient’s history and show the opioids the patient has used most recently. If that screen is negative for opioids, we need to know why. Perhaps our test is limited, or it’s been too many days since last use. If the drug screen doesn’t match the history, we need to take a closer look.

We look at prior treatment or lack of it. If I already know the patient from a previous admission, the diagnosis has already been made. We only need to make sure the patient is still appropriate for treatment at our level of care.

I’ll ask for old records. If the patient has had prior treatment elsewhere, I want to see those records, for information not only about diagnosis, but also how the patient did in treatment. It’s nice to get that information before starting treatment but that’s not always possible. Usually, we can get this data within the first 24-48 hours.

I check our state’s prescription monitoring program to look for prior opioid prescriptions and prior buprenorphine product prescriptions. Again, findings should match patient history. If the patient gives a long history of opioid prescriptions from pain clinics, I should be able to see them on our PMP. If I can’t, I need to ask which state the patient filled them in, and when. I might need to double check the patient’s birthdate or spelling of name. Now with so many people using heroin/fentanyl, most patients have limited data on the PMP, which is a big change from five years ago.

I do a physical exam. We ask patients to come for intake in at lease mild withdrawal if possible, so that I can see signs of opioid withdrawal. I look at the size of the pupils, watering of eyes and nose, goosebumps, tremor, and at the blood pressure and heart rate. I look for needle marks on the skin if the patient gave a history of intravenous use. I look for muscle jerks and overall appearance.

While it’s true that other things can cause physical signs that mimic some opioid withdrawal signs (benzodiazepine withdrawal, stimulant intoxication), it’s another way to confirm the patient’s history.

Occasionally I ask for collaterals, with patient permission. Collaterals are family or friends who can confirm the patient history. They aren’t available for every patient but can be helpful. At our opioid treatment program, we often have patients come for admission because they have relatives in treatment with us, and collateral information is easily obtained. Sometimes family will come with the patient and can be a source of information if the patient permits.

But what my reader was really asking was this: What keeps a patient from lying to the physician to meet criteria to start methadone or buprenorphine?

Of course patients can lie. But why would they? Unless they have opioid use disorder, starting medications like methadone and buprenorphine would cause a new problem for them – physical dependency on opioids. If they lied, saying they already had this problem, they would create a new problem for themselves.

And at the end of my evaluation, when I’m reviewing the consent form for treatment, I make sure the patient understands that if they start buprenorphine or methadone, they will be physically dependent on the medication.

I tell patients that the medication – mostly methadone – can cause some euphoria in some patients, but it wears off. Anyone starting treatment with methadone only to feel euphoria is making a huge mistake that they will regret.

The most common reason the patients that I see don’t qualify for admission to the opioid treatment program is that they aren’t using opioids. About once a month or so, a patient who wants to stop using methamphetamine will come for admission. For some reason, they believe buprenorphine or methadone will help them stop using methamphetamines. I tell them I’m glad they came for treatment, and we can help them access the right kind of treatment. But starting methadone or buprenorphine isn’t the right thing to do, since they aren’t already using opioids. In fact, there are no evidence-based FDA approved medications to help with methamphetamine use disorders. We’ve had plenty of medications show initial promise, like naltrexone, bupropion, mirtazapine, and others, but none (as of today) have enough evidence to use with confidence they will help.

Once we determine our patient has the diagnosis of opioid use disorder, we need to select the appropriate level of care. This is easier. We use the American Society of Addiction Medicine Criteria:

  • Acute Intoxication and/or Withdrawal Potential.
  • Biomedical Conditions and Complications.
  • Emotional, Behavioral or Cognitive Conditions and Complications.
  • Readiness to Change.
  • Relapse, Continued Use or Continued Problem Potential.
  • Recovery and Living Environment.

In most cases, if the patient has no urgent medical or mental health issues, outpatient treatment with methadone or buprenorphine (or rarely, naltrexone) and counseling will be the appropriate level of care.

There are some exceptions. Federal regulations say patients can’t start on methadone without at least one year of physical dependence.  And if the patient has only mild opioid use disorder using the DSM criteria, patients might be better served with non-medication treatment, though that’s debated by experts.

It’s rare for me to see a patient with less than a year of opioid use and I rarely see a patient with mild opioid use disorder. I can still admit them to the opioid treatment program if I submit a request for an exception to the rules to our state’s SOTA and the federal government too, and the few times I’ve needed to do this, it was quickly approved by both agencies.

I hope this answers my reader’s questions. We do have diagnostic criteria, and we do have placement criteria that we follow for best results.

The Age of Advocacy

Ukranian Art, by Ana Plusk

The medical providers who work at opioid treatment programs in North Carolina have a weekly teleconference to discuss various things: difficult cases, best practices, and advances in treatment for opioid use disorder. We learn from each other.

Lately we’ve been talking more about advocacy efforts.

Especially with the opioid settlement money getting ready to flow out of the state’s financial faucet, we need to remind people that MOUD is the gold- standard, first line treatment for opioid use disorder. We also need to advocate for our patients when they encounter discrimination and are denied their legitimate medication.

Leading this effort is the person who chairs our weekly online meetings: Eric Morse, M.D.

Dr. Morse, owner of a number of opioid treatment programs across the middle of North Carolina,  started sending complaint reports to the Department of Justice when patients are denied their medication while incarcerated or admitted to other facilities.

He told us he sent a complaint about one patient seeking admission to a well-known abstinence-based inpatient rehabilitation facility. This patient was on MOUD but was told he couldn’t take the medication while at the facility. He made another complaint about a patient who was denied the ability to continue MOUD while incarcerated.

The DOJ let him know they decided not to pursue further investigation. That’s disappointing, but not surprising.

Another provider reminded our group that it’s much better to try to educate these facilities and their medical providers rather than make reports to authorities. However, in both above situations, Dr. Morse had exhausted all efforts to contact and educate the medical directors of both facilities prior to sending any complaints.

We now have a website to submit complaints about violations of patients’ rights directly to the Department of Justice:

Anyone can report a violation of a person’s rights experienced at healthcare facilities, jails or prisons, places of employment, schools or educational programs, voting rights, or public facilities. You can print the form, fill it out and mail it in, or you can submit online. The patient can submit the complaint, and so can anyone who witnessed the violation. It can be submitted anonymously, but no reply about outcome could be sent in that case.

This month I’ve been more vocal to our patients who were denied their civil rights. I printed a stack of the complaint forms and have them on my desk. I’ve handed out several to patients who were denied their usual dose of methadone or buprenorphine when incarcerated at our county jail. Maybe one or two complaints won’t matter, but I’m hoping that after fifty or a hundred are submitted, the DOJ may look closer.

I’ve also kept in mind the advice to try to work with other physicians before complaining about them.

In this following example, I changed details to protect the identity of my patient.

A few weeks ago, one of our patients was involuntarily committed to a psychiatric facility in a nearby town. He called his counselor at the opioid treatment program and said the admitting psychiatrist told him that the facility “wasn’t a methadone clinic” and that he would not be getting his usual daily dose of methadone while he was at this facility. My patient was understandably worried he would go into opioid withdrawal. He gave the counselor his psychiatric doctor’s name and asked that I call to advocate for him.

I was happy to do this.

I didn’t have a signed release of information giving me permission to talk to this doctor, but I felt this was an exception to this rule. Medical professionals can communicate without a signed release if there’s a medical emergency. I would call involuntary commitment to a psychiatric hospital an emergency, of course.

When I finally got her psychiatrist of the phone, he was not pleasant.

I introduced myself and thanked him for returning my call, trying to be as polite and friendly and collegial as possible, but my efforts didn’t work. He kept saying, “I can’t talk to you about this patient because I don’t have a release.” I pointed out that under emergency circumstances I felt we could talk even without a release, but he disagreed.

I told him that I appreciated how he felt about this situation, and that he felt he couldn’t talk to me, but perhaps I could give him useful information. I told him the patient’s usual dose of methadone, and said best practice was to continue this dose for the duration of hospitalization. He said that while he couldn’t talk about this patient, in general he didn’t dose patients if he felt they didn’t need it. I then said that the only circumstance I could think of where it would be appropriate to hold the dose would be if the patient was sedated and he was worried about overdose. He then said, “You’ve hit the nail on the head,” over and over.

I can’t say he was lying because I couldn’t see this patient for myself. But I did know he had called his counselor within the hour and sounded very alert and very angry.

This physician was short with me and talked over me to some degree. For a man who said he couldn’t talk to me he interrupted a lot. And, as I pointed out, he could have gotten permission from the patient to talk to me, but he wouldn’t.

What I gleaned from our interaction – and I may be wrong, and prone to overreacting – was that he didn’t think much of me or of our opioid treatment program who were putting people on methadone when they didn’t need it. I felt undertones of hostility and distain from his manner.

After the patient was allowed to leave, 72 hours later, he signed a release so we could get his hospital records. It was thin and short on information. It contained only his discharge diagnoses and not much else. The patient wasn’t on any new medications and there was no admission history and physical, no doctor’s note, and no mention of methadone anywhere in this record. There was no documentation of the conversation with me, and no reason why he allowed this patient to go into opioid withdrawal for three days.

I gave my patient a form to report this to the Department of Justice, as I feel my patient was treated inappropriately and was discriminated against by this doctor who refused to dose my patient as usual while he was being held in a psychiatric hospital against his will.

I will send a complaint report this as well, and I’ll let you know if I get any follow up.

This needs to end.

Review: Hulu’s “Dopesick”

I’ve already reviewed Beth Macy’s excellent book by the same name in my blog on 10/30/2018. This Hulu series was based on her book. I feared the series would be a let-down, as so often happens when books try to travel to television. But several of my patients saw it and told me it was very well done, so last week my husband and I started watching the series. We just finished several days ago.

My review for the series in a word is “Powerful.”

The series shows it all.

This series humanized the people who developed addiction to OxyContin and showed that good people became addicted to this medication. It showed the devastation of their lives and the suffering of family and loved ones. Some of the main characters were composites of the real people involved, such as Dr. Finnix, a physician who initially prescribed OxyContin after he’s influenced by a feckless OxyContin drug representative. He develops his own problems (I won’t spoil the story by giving too much detail). His character was based on several physicians that the author knew, and some of the other main characters were also composites. All the actors gave brilliant performances.

I thought the series gave devastating depictions of the ruthless greed of the Sackler family. Their ability to rationalize and ignore any publicized suffering caused by their drug is mind-blowing. They had the audacity to try to blame the rising tide of addiction and death on the very people who were prescribed their drug. The Sacklers tried to make a distinction between “bad” addicts and “good” patients who used the drug for pain, when reality is a whole lot messier.

The Sacklers probably weren’t happy with how they were portrayed, especially Richard Sackler.  He was portrayed as a difficult man who wasn’t satisfied with any degree of success. He was driven to make ever more money for Purdue Pharma and the Sackler family with no concern about damages being done to patients, their families, or their communities.

He was savvy about keeping himself out of trouble, too. When he saw legal problems on the horizon, he stepped down as president of Purdue Pharma. He promoted another executive, Michael Friedman, who was one of the three executives who pled guilty to criminal misbranding of medication in 2007. The series implies that Sackler got himself out of a position of power before the Department of Justice presented charges and things got bad for Purdue.

The FDA (Food and Drug Administration) got a deserved black eye in the series. The series showed how an FDA official helped Purdue Pharma get their unusual labeling approval and how he ended up working for Purdue several years later. That official was representative of what was wrong with the weakened FDA at that time.

It’s not only the FDA employees who jump from government to the private industries they may have formerly been tasked with overseeing. Government workers jump to private industry all the time. For example, the head of CSAT division of SAMHSA left that job to work for Reckitt Benckiser, the drug company who sold Suboxone and Subutex.

There are heroes in this story, and at the top I’d put the indefatigable investigators, the assistant U.S. attorneys Randy Ramseyer and Rick Mountcastle. They are the lawyers who painstakingly went through mountains of evidence and gradually realized the extent of Purdue Pharma’s wrongdoing. They assembled the case for John Brownlee, the attorney general for Virginia’s Western District. These diligent public servants not only investigated Purdue Pharma for wrongdoing, but also had to fend off efforts to sabotage their investigation from the inside of the DOJ.

One episode depicted a meeting of all three lawyers, Ramseyer, Mountcastle, and Brownlee, with the then-deputy attorney general James Comey. Comey commanded their presence and then asked what their problem was with the “chicken guy.” Apparently, Comey thought the lawyers were gathering evidence against Perdue Farms, not Purdue Pharma. But when the confusion cleared, Comey told them to proceed with their case, giving his approval.

The three lawyers faced incredible pressure from government insiders and from Purdue Pharma. One scene in the series shows Richard Sackler talking with an associate, wondering how he should deal with these lawyers. The associate tells him that these men don’t care about money and can’t be bought. They are present-day “untouchables,” people whose moral code can’t be corrupted.

What a tribute. They are heroes.

In the end, they had a tremendous victory with the Purdue settlement: the drug company settled for a fine of $600 million, and the top three executives settled for $34.5 million and a misdemeanor conviction for misbranding a drug.

In retrospect… it was small potatoes compared to what the company was making and continued to make. Purdue didn’t re-formulate their OxyContin until 2010, when their patent was set to expire.

I have a few minor complaints about the series.

First, I heard no mention of Barry Meier, investigative journalist who used to write for the New York Times. He wrote his extraordinary book, “Pain Killer: A Wonder Drug’s Trail of Addiction and Death,” in 2003, amazingly early in the opioid epidemic. “Dopesick” by Beth Macy, wasn’t published until 2018, fifteen years after Meier’s powerful groundbreaking book. He deserves credit for putting together facts on which further investigations were built.

Second, I don’t like how the series skips around. Of course, it’s a complicated story, and difficult to tell in a sequential manner. But I don’t like this new trend of books and movies where the beginning is in the middle and the end at the beginning, and so on. What happened to the traditional beginning, middle, and end? I predict this jumping around during storytelling is a fad that will pass.

Third, the series represented physicians in recovery can’t keep or regain their medical license if they are prescribed Suboxone or methadone. I don’t think that’s accurate in all states, thankfully. In North Carolina, I know the Board of Nursing allows nurses to work while on MOUD, and I think the medical board does the same for physicians and extenders, under some provisions. However, if the state in question is Tennessee…probably not.

Lastly, I didn’t like the scene when one of the main characters goes to an Alcoholic Anonymous meeting, and she gets offered OxyContin for sale by a woman in the AA meeting. That gives an unfairly negative image about what happens at 12-step meetings. I’ve attended over three thousand 12-step meetings and have never once been offered drugs. I’m not saying it doesn’t ever happen, just that it’s rare. I hate when people at12-step meetings tear down the benefits of MOUD (medications for opioid use disorder), but I equally hate when people not in 12-step recovery paint a negative picture about what they think happens at meetings. In a perfect world, all forms of recovery would support each other.

Other than these minor criticisms, I loved the series. I loved that the characters talked about how helpful Suboxone was to them, but a little sad at how methadone was portrayed.

Beth Macy has a new book coming out in August titled: “Raising Lazarus: The Search for Hope and Justice, and the Future of America’s Overdose Crisis.” I’ve already pre-ordered it on Amazon and look forward to reading it.

This opioid epidemic won’t be over for a very long time.

Book Review: “The Weight of Air: A Story of the Lies about Addiction and the Truth about Recovery,” by David Poses

I just found out this author is deceased – he passed away earlier this year. Out of respect for his family, I deleted my original post reviewing the book.

The conclusion of my review was that I hoped he could write a follow up book on his life in recovery on buprenorphine. It saddens me that he passed away before he could do more writing.

My condolences to his family and friends.

Research News

Art by Ukranian artist Ohla – purchased off ETSY

I missed both the annual spring national ASAM (American Society of Addiction Medicine) meeting and our annual spring state NC SAM meeting over the past two weeks. I hated to miss them, but it was for a good reason. I took time to visit family I hadn’t seen in years, including aging relatives who won’t be around forever.

To make up for missing these fantastic educational opportunities, I’ve been reading recent journals and I found some gems I readers might find interesting. 

In the March/April 2022 edition of the Journal of Addiction Medicine, I read an informative review article of various states’ laws which have been passed to regulate office-based buprenorphine treatment of opioid use disorder. The lead author was Dr. Barbara Andraka-Christou.

As we know, the DATA 2000 law made it legal to treatment opioid use disorder in an office-based setting using buprenorphine products. This Act did require prescribers to complete a training and obtain a special “X” DEA number, and it also limited the number of patients who could be treated at any one time. Other than these two things, there were few added regulations, because the purpose of DATA 2000 was to make it easier for patients to get treatment, without the tradition regulations that are placed on opioid treatment programs (OTPs).

But some state legislatures felt DATA 2000 was too loosey-goosey and got busy passing more restrictive laws. The authors of this article grouped these restrictive laws under a few themes:

-Provider credentials and continuing medical education requirements

-Objective symptoms that new patients must exhibit before initiating buprenorphine prescriptions

-Educational requirements for new patients

-Counseling requirements, setting minimums on counselor credentials, or frequency or type of counseling necessary

-Patient monitoring including prescription medication program monitoring, mandatory minimum frequency for drug screening, and other things

-Enhanced clinical monitoring, mandating the minimum contact frequency or health assessment requirements or treatment planning requirements

-Patient safety requirements including mandating the co-prescribing of Narcan, use of the combination product versus monoproduct, and other things.

The authors voiced concern that these more restrictive laws might interfere with patient access to treatment, at a time when access is needed to prevent more opioid overdose deaths. The ten states that passed laws were West Virginia (which has the unfortunate distinction of being number one in opioid overdose deaths), Ohio, Kentucky, Vermont, North Carolina, Tennessee, Indiana, Florida, Virginia, and Alabama.

The authors of this article say that their study of these states’ laws raise three concerns.

First, they point out that some laws aren’t based on strong evidence. As an example, they cite laws passed that require some minimum counseling frequency. Literature reviews about this issue show mixed results about the effectiveness of adding counseling to buprenorphine treatment. Patients who are unable or unwilling to participate in counseling could be excluded from treatment with these regulations. For example, West Virginia dictates that weekly counseling must be done for the first ninety days of treatment, and at least twice per month for the rest of the first year. Patients who can’t or won’t meet those minimum requirements can’t get treatment at office-based programs. I’m sure intentions were good, but result is that the state which leads the nation in opioid overdose deaths placed an extra burden on patients seeking treatment which may or may not benefit them.

Don’t misunderstand me. I advocate for quality counseling in all patients, but I don’t advocate excluding patients who can’t or won’t participate.

Second, these state regulations resemble those placed on Opioid Treatment Programs, though DATA 2000 was passed purposely to give easier access than that seen with OTPs. Not to brag, but I said this back in my blog post of February 11, 2018, when I pointed out that Tennessee’s office-based buprenorphine laws were nearly as burdensome as the laws around opioid treatment programs (OTPs), defeating the whole purpose of DATA 2000.

Other examples of regulations include West Virginia’s law for a mandatory call-back plan to control diversion of medication, reminiscent of the diversion control plans OTPs must follow. Also, going a bit further than the regulations on OTPs, Kentucky’s law demands that before prescribing buprenorphine products to a pregnant patient with opioid use disorder, the physician needs to get a written concurring opinion from a board-certified Addiction Medicine physician.

 I don’t know how many board-certified physicians in Addiction Medicine Kentucky has, (maybe fewer now, after that weird law was passed), so that requirement seems restrictive. What’s a pregnant patient to do? In the rest of the healthcare world, these patients are given the highest priority access to treatment

 And third, some of the laws resemble those placed on pain clinics, which are meant to limit unsafe prescribing. But buprenorphine treatment is safer and has much more evidence of benefit than the treatment of chronic pain with opioids. Tennessee’s law limiting a patient’s daily dose to 16mg or less is one example of these types of laws. We have data that indicates patient retention in treatment is better with higher doses, so most practitioners have abandoned the once-popular idea the less buprenorphine is better.

Reminiscent of requirements around pain clinics, some of these ten states have asked providers who prescribe buprenorphine products to register with their state officials. Thankfully, North Carolina repealed this regulation several years ago.

Why did the states with the worst problems with opioid use disorder pass laws that limit treatment access? The authors don’t offer answers, be we can guess.

I think that states with legislators who are less aware of the science around substance-use disorders in general, and of evidence-based treatments for opioid use disorder in specific, are more likely to pass laws that inadvertently make the situation worse. It’s important for all workers in the Addiction Medicine field to makes efforts to educate their legislators.

I’m grateful I live in North Carolina, where legislators sought information and input from Addiction Medicine specialists. They’ve made great efforts to make wise decisions and continue to do so when considering how to spend the opioid settlement money, as you can read about in blogs from January 6 and January 20 of this year.

In North Carolina, our state’s Department of Health and Human Services formed a committee called the North Carolina Opioid and Prescription Drug Advisory Committee, or OPDAAC for short. The purpose of this committee was to plan implementation of the state’s Opioid Action Plan, but the meetings expanded to include anyone with an interest in working on the state’s problem with opioid use disorder. They invite experts and stakeholders to speak at their meetings, giving a diversity of opinions and a chance from committee members to learn from each other.

I think these efforts have helped form better public policy in our state. It may not be perfect, but it’s improving, leading to more patients getting the help they need.

There’s a lesson for other states.

OTP Greets County Commissioners for Lunch & Learn

Art by Ukranian artist Yulia Parabina (purchased on ETSY)

As I wrote about in past blogs, government officials in North Carolina have decided to allow each county’s commissioners to decide how to spend the opioid settlement money. They set a framework of priorities for this money, but the commissioners will have final control of how it’s spent. Also in past blogs, I wrote about how other physicians have tried to educate their county commissioners about evidence-based treatments for opioid use disorder.

I talked to my opioid treatment program’s program director about how we could have a discussion with our county’s commissioners. She thought we could invite them to come for lunch, a tour of our facility, and maybe a short education presentation by me about opioid use disorder and evidence-based treatment.

I thought this was an excellent idea. Food always helps.

She invited them, we worked out a date that worked for everyone, and it happened just last week.

It went very well.

We invited all five county commissioners, but three of them are rotating off service this year. The two active commissioners came to our event. We also invited other people in our area with whom we work: the head of Project Lazarus, a local non-profit agency that offers a variety of help and services to our patients and other people; the head of the county’s Health Coalition; and the leader of R3 Recovery Services, which also assists our patients – and others – with a variety of needs such as needle exchange, housing, peer support, and other things. We had a few other city officials, so in addition to our twenty or so staff members, it was a good-sized group.

I’ve given presentations about medications for opioid use disorder dozens of times. I’ve presented at Addiction Medicine conferences, at conferences for social workers, for nurses, and even for federal probation and parole officers. I’ve given this presentation to our county probation officers and to our county’s EMS works. I’ve given this presentation to hospital labor and delivery nurses, and probably a few other places that I don’t recall.

As always, I spent time updating my presentation, then pruned it to make it lean but full of information. In my presentation I described what opioid use disorder is, and how its course is like other chronic illnesses. I defined “evidence-based treatment” and how it differs from treatment fads. I commiserated about how they have been handed a large responsibility: deciding how to spend the opioid settlement money in a way that benefits the most people with the illness. I went on to tell them which treatments are ineffective, such as ultra-rapid detox and short-term detox- only treatments, which both increase patients’ risk of death.

Then I spent the bulk of the time describing treatment with methadone at an opioid treatment program, and treatment with buprenorphine products at both office-based programs and opioid treatment programs. I ended by giving them information about depot naltrexone injection as a treatment option.

I felt anxious before I started because I was so eager to make myself understood. I don’t enjoy public speaking, but I do it when asked because I need to do my part. I’m not a great speaker; I stammer and often phrase things awkwardly. But when I forget about myself and focus on the material, the words flow more easily and that’s what I did. My audience listened in respective silence, and one county commissioner took notes during my presentation.

I was thrilled.

Then we had a brief time for questions. I could tell by the questions they asked that they understood the information and were trying to understand how the settlement money could be spent effectively. I sensed they were intent on making good decisions. I was glad other recovery resource people were in the room, because we talked about patients’ biggest needs after treatment fees. We talked about the importance of housing and transportation, to name the biggest barriers to staying in treatment, along with childcare options and employment.

I was delighted. I felt like this short session was a big hit, and I felt like I had a chance to say what I needed to.

If you are a counselor, nurse, patients, doctor, or therapist, please consider reaching out to your county commissioners and give them information. Tell them what you see or what your experiences have been. Help them get the information they need to spend this opioid settlement money wisely.

Increased Take Home Doses for Patients at Opioid Treatment Programs: What’s the Risk?

Digital art downloaded from ETSY – by Ukranian artist Julia

The pandemic led to loosening of regulations on take home medications for patients being treated at opioid treatment programs, dosing on either methadone or buprenorphine. As I blogged about in my 12/1/21 post, SAMHSA has proposed guidelines for continuing extended take homes. Now there’s more evidence to support benefits of this approach.

Last week there was an article in the Journal of the American Medical Association (March 1, 2022, pp. 791-886), by Gomes et al., outlining results of the looser restrictions.

The authors concluded, after examining the study data, that increased take home dose schedules were associated with significantly lower rates of patients dropping out of treatment, without any increase of opioid-related overdoses, during the six months of follow up.

This is great news and supports the current popular viewpoint that more take home doses for patients at opioid treatment programs (OTPs) can be given without a reduction in safety.

This study was done in Ontario, Canada. Of course, I was concerned that Canadian take home schedules were already different from the U.S., but the authors say that both countries have similar take home schedules pre-pandemic. However, in Canada, patients can get some doses from pharmacies as well as OTPs. Treatment in Canada tends to be less centralized in the U.S

This study was large, including a total of over twenty-one thousand patients enrolled in opioid use disorder treatment programs.

The study divided these patients into four groups, depending on the number of take-home doses they were receiving pre-pandemic. Group one consisted of patients who dosed on methadone with no more than one take home dose per week. Similarly, Group Two dosed with buprenorphine/naloxone with no more than one take home per week. Group Three patients dosed with methadone and had up to a week of take-home doses just before COVID hit, and Group Four dosed on buprenorphine/naloxone and got five or six take homes per week pre-COVID.

To be included in the study, every subject had to have had at least one physician visit between 3/22/2020 and 4/21/2020.

Then the study divided each of the four groups of patients into “exposed” or “non-exposed” based on whether they received extra take home doses. For example, in the first group of patients, dosing daily on methadone, some of these patients received up to a week of take-home doses and some remained daily dosers, depending on decisions made by their physicians. For the patients in groups 3 and 4, which were made up of patients getting 5 or 6 take homes per week, they were either “exposed” to approximately two weeks’ of take homes or they were “non-exposed” to the extra take homes and remained on weekly schedules.

The study wanted to see if the patients who received the extra take homes in the four groups had worse outcomes than the ones who didn’t get the extra take homes. The primary outcomes that were observed were fatal or non-fatal opioid overdoses, interruption in treatment for opioid use disorder, and discontinuation of treatment. The interruption of treatment was defined as a gap in treatment of 5 to 14 days, and termination was defined as a gap of more than 14 days.

The study subjects were followed for 180 days.

The data is surprising and supports the use of more take home doses for patients.

 In group one, the group of patients dosing daily on methadone, the patients who were given extra take home doses had significantly lower risk of opioid overdose. They were also less likely to have an interruption or termination of their methadone treatment than the patients who remained on daily dosing schedule.

So…getting extra take home doses decreased the risk of having an opioid overdose. I would not have expected this. I wasn’t surprised that those patients were less likely to have disruption of treatment.

Buprenorphine/naloxone patients who were dosed daily prior to COVID but received extra take homes with the new guidelines were not significantly more likely to have opioid overdose. They  were less likely to have interrupted or terminated treatment, compared to those patients who remained at daily dosing.

Similarly, when they looked at groups 3 and 4, composed of patients already getting a week of take-home medication, the patients who were “exposed” to two weeks of take homes were less likely to have interruption of treatment.

Why were these results so good? Was it because the physicians were exceptionally wise when they decided which patients were safe to get extra take homes and who weren’t? That might be one explanation, and the explanation that would made me happy, but I can’t tell that from the data.

I looked at the article to see if there were specific factors that were associated with extra take home. I looked to see if some factors were associated with NOT getting extra take homes. The article says physicians making the decisions did have guidance from a document from the Canadian Centre for Addiction and Mental Health: “COVID 19 Opioid Agonist Treatment Guidance.” It discouraged advanced take homes for patients with recent overdose, unstable psychiatric illness, or use of illicit substances in ways that were considered high risk. This article says that it appears physicians used this guidance when deciding about take-home status. Patients who didn’t get advanced take homes tended to have higher rates of mental illness and medical problems related to alcohol use disorders

The authors say their study should be interpreted with caution, since there are some factors that may not have been captured by this clinical data. They say that the decision to allow more take homes was affected by complex characteristics that could confound the outcome of the study. They also say that overdoses may have been under-counted if they occurred out in the community and if the victims weren’t transferred to a hospital.

Even with its possible limitations, this study presents good news about the extra methadone doses and buprenorphine/naloxone doses that were given in Canada during the first months of COVID. More patients were maintained in treatment with no increase in overdoses. This study’s conclusions are supported by other articles in scientific literature that support the safety of extending take home doses for patients on both methadone and buprenorphine/naloxone. (Amram et al., 2021; Levander et al., 2021.

I do wish there was additional information about the physicians’ decision- making process regarding extra take home doses.

An Example of Lowering Barriers to Treatment

I’m lucky to work with many wonderful and caring people at the opioid treatment program. Usually counselors and nurses (and medical providers) do the visible work to help patients, but in this blog, I wanted to relate an inspiring example of how our receptionist lowered a barrier to treatment for a desperate patient seeking help.

Our opioid treatment program opens at 5am, but I don’t get there until 7am, which allows time for new patients to see a counselor and a nurse.

That morning, I settled into my office and went to the front office to see which patients were ready for me. One of our receptionists, named Trish, pointed at the patient list and said, “You’ve got to take of this one. He’s special.”

A little taken aback, I said, “I take care of all of them. They’re all special. But how is he special?”

She told me that he really was anxious to get into treatment and that she’d done some work to get him ready. I asked her to explain.

All new patients must have state-issued photo ID. I think this is mandated so we can make sure the patient isn’t enrolled in another opioid treatment program, and of course to make sure we are treating who we think we are treating. This requirement isn’t usually an obstacle. Most people have photo IDs, such as driver’s license or other documents. But once in a great while, a prospective patient doesn’t have such an ID, as was the case with this patient.

When the patient arrived at 5am, Trish discovered the patient didn’t have any ID. She sent him home to bring back all the ID that he possessed. Unfortunately, none of them were state-issued picture identification. It looked like he was going to have to make a trip to the DMV to get a photo ID before he could be admitted and start treatment.

But Trish’s heart went out to this patient, who was feeling bad from withdrawal. He wanted help and didn’t feel like taking a detour to the DMV. This is where Trish got creative. She asked if he’d ever been arrested because inmates get photo identifications made. He said yes, but it was in another county. With the patient’s permission, Trish called that county jail but quickly discovered they didn’t have photo ID available for him.

So then Trish asked the patient if he was sure he hadn’t spent any time in our county jail, and he said yes, he did stay one night in our county jail. Again, with the patient’s permission, Trish called our county jail and asked if they had a photo ID of him. They said no, it had been too long ago, and they didn’t have it in their system, but she might get it from the sheriff’s office.

So she called the sheriff’s office. They put her on hold and eventually told her she’d have to talk to a supervisor.

By this time, Trish was losing hope. She didn’t expect great cooperation from a law enforcement supervisor at six in the morning. But she was forwarded to him, and he told her he would look to see if they had such a document and call her back.

Trish didn’t expect much from this so she was pleasantly surprised when he called her back after about 20 minutes, saying he had a photo ID that the patient could come pick up. Pushing her luck, Trish asked if it would be possible for the supervisor to fax that copy to our office, to eliminate further wait time, and the supervisor agreed.

Several minutes later the patient had a photo ID in his chart and was ready to see me.

The patient was effusive with his gratitude for Trish’s actions. He told me, “I can’t believe how nice she was. She didn’t have to do any of that. She could have just sent me on my way and told me to come back when I had a photo ID.”

I agreed with him. I told him yes, she really wanted to see him get help as soon as possible, and I was also thankful she went the extra distance to help him. We did his intake and he entered treatment that morning and has come every day since.

This is a little example but such a big illustration of how a spirit of compassion can lead workers in the addiction treatment field to provide that something extra.

Trish didn’t have to do all of what she did, which took well over an hour of her time. Thankfully there was a second receptionist who cheerfully took over the daily chores of greeting patients, checking them in, taking payment, and everything else that the front office does. Thankfully our OTP adequately staffed the front office to be able to handle complicated intakes along with the daily routines.

I’m thankful Trish saw our prospective patient with eyes focused on helping him rather than turning him away. That day, she reminded me what a servant’s spirit is and what it looks like in real life. She reminded me how much benefit we can see when we go the extra mile to help another person.

She sets a great example. She inspires me to keep a willing and helpful attitude towards patients and all other people.

This patient may not stay in treatment. He may not have used his last illicit opioid. However, he will always remember the special effort and care that our receptionist put forth to get him into treatment. Maybe that will help him continue to work on making the life changes he seeks.

What is “Low Barrier” Treatment?

Also called “low threshold” treatment, these terms refer to the idea that getting into treatment for opioid use disorder should be as easy as possible. Since only around 20% of the people in the U.S. with opioid use disorder are getting help, we need to improve treatment accessibility.

DATA 2000 was passed to make treatment more accessible. Before that piece of legislation, opioid use disorder was only treated with methadone which was only available at opioid treatment programs. DATA 2000 made it possible to get treatment at doctors’ offices.

Or at least that was the idea. Primary care physicians and other providers haven’t rushed to fill the treatment void as quickly as we might have hoped, but progress is being made.

So now experts are talking about other barriers to treatment and how to eliminate them.

Jakubowski et al., in their article “Defining Low-threshold Buprenorphine Treatment,” (Journal of Addiction Medicine, 2020, Mar-Apr 14(2), pp95-98.) published ideas about this concept.

First, they advocate for same day admission into treatment. The hope and desire for change can be fleeting, so getting people into treatment the same day they are ready is essential. Many people fear the unknown, and when they work up the courage to ask for help we need to make it available as soon as possible. It’s too easy to drop back into old behaviors if people meet with discouragement. Same day admission into treatment is the ideal.

Second, the article’s authors advocate for a harm reduction approach to treatment. At the most basic level, the article’s authors state this means improving patients’ quality of life and reducing overdose risk. What this looks like in a practice setting can include many things.

For example, it includes trying to keep people in treatment once they have started. It means we don’t kick patients out of drug use disorder treatment for drug use. If treatment is benefitting patients in some way, keep them involved, even if they are using other drugs. Harm reduction can also mean encouraging patients who still use drugs intravenously to use new needles and safer injection practices.

Harm reduction also means – and this should go without saying but I’m saying it anyway – treating people with warmth and empathy. Patients with opioid and other substance use disorders deserve kindness just like patients with any other illness. We shouldn’t minimize our patients’ complexities by seeing only their addiction. We always need to remember they are more than just their addiction.

Hopefully all treatment environments make patients feel comfortable and supported with no judgment.

I don’t understand treatment facilities that tolerate bad attitudes by employees charged with helping patients. Our patients can sense attitudes of judgment or distain even when they are transmitting non-verbally. A tone of voice or a sour expression can do as much damage as outright hostility. Providers must be vigilant for these problems in every employee from the receptionist to the physicians.

Third, the authors talk about the importance of flexibility in meeting the patients’ needs. Treatment shouldn’t be an obstacle to life’s other obligations like work and family. Hopefully office-based buprenorphine practices can offer a variety of appointment times.

The study authors recommend against making intensive counseling mandatory. They aren’t saying counseling isn’t needed or that it is not part of a recovery program. They are saying we shouldn’t let the ideal counseling program be the enemy of what the patient is willing or able to do. If the patient can’t or won’t make daily counseling appointments, be satisfied with weekly or monthly sessions.

The authors also say that monthly appointments with providers are adequate for many patients, and that patients should be offered which ever buprenorphine preparation appeals to them: sublingual tablets, films, or depot monthly injections.

Fourth, the authors advocate to make treatment available close to where patients live and work. The authors talk about non-traditional settings which might include mobile vans, homeless shelters, and other places. Of course, as mentioned above, primary care offices can be an ideal place to offer treatment since many people access medical care there.

I was talking to people in the opioid use disorder treatment sphere about how I felt opioid treatment programs can also be low-threshold, or at least low-ish threshold. I was met with some doubt, which I understand. After all, the nature of federal and state regulations on treatment are limiting.

However, since COVID, we’ve seen some positive changes. We’ve also seen much better funding available for patients who need help.

The Jakubowski article didn’t mention the cost of treatment, which is the biggest barrier among the patients I see. Private insurance does better at covering treatment costs than they did ten years ago, but it can still be challenging to get them to pay. Thankfully Medicaid covers treatment at opioid treatment program.

What about the vast numbers of people who have no insurance and don’t qualify for Medicaid? These working poor don’t get insurance where they work, which are often blue-collar jobs. For the past few years, the state has been able to pay for treatment, first under what was called the CURES grant and now under the SOR (State opioid response) grant.

Our opioid treatment program has more than two hundred and fifty people who get free treatment under these grants. The grants removed their biggest barrier to treatment.

Do office-based buprenorphine programs offer anything similar? Not the ones in my area, because we often get patients transfer to our program when their ability to pay for treatment runs out at an office-based practice.

So it appears OTPs have lower financial barriers then OBOTs, at least in our area.

Let’s look again at some of the Jakubowski criteria above.

The same day admission into treatment is important, and at the opioid treatment program where I work, we do same day admitting four days per week. I don’t do intakes on Fridays or the weekend. But Mondays through Thursdays, patient can walk in and ask for admission from 5am until around 10 am and we will do their admission. We also make appointments for intakes, so patients have their choice.

I don’t do same day admissions at my office-based practice, and I don’t think most OBOT practices are able to do same-day admissions, at least in my area. I’m only in my own office one day per week, and my schedule is tight.

So again, some opioid treatment programs do better with same day admissions than many office-based programs, including my own.

What about using harm reduction policies?

In North Carolina, we have a weekly teleconference open to all providers who work at opioid treatment programs in our state, moderated by a fellowship-trained addiction medicine physician and supported by our Governor’s Institute. Over the past few years, consensus of this group has changed a great deal. After heroin with fentanyl became the most used opioid statewide, most of the providers no longer kick patients out of treatment for using stimulants like cocaine and methamphetamine. Most of us try every option we can think of to get patients using alcohol or benzos (dangerous with methadone) into more intensive treatment while continuing to treat with methadone (or buprenorphine). We don’t kick patients out of treatment for using THC.

However, we get many patients transfer from local office-based buprenorphine programs who have been discharged because they had repeatedly positive drug screens for other drugs besides opioids. We are happy to have these patients, and I don’t fault these providers. Usually, the providers were worried they weren’t doing a good job by “allowing” patients to use other drugs. They dismiss the patient because they think that’s what they think a good physician would do.

Many office-based buprenorphine providers aren’t familiar with harm reduction principles, and our OTP is happy to have these patients until providers become more comfortable with harm reduction ideas.

 However, it would be much better if they did a warm handoff to us rather than dismiss the patient.

Some regulations make full adherence to harm-reduction policies impossible, of course. OTPs must get at least eight observed drug screens per year, and there’s mandated minimum of individual counseling sessions that must be done at the opioid treatment program. Particularly with methadone, we have state and federal rules about take home doses.

Even so, I can’t think of any patient – over the last twenty-one years I’ve worked at assorted opioid treatment programs – who has been dismissed from treatment because they refused counseling. OTPs usually try to meet people where they are.

There are outliers – opioid treatment programs who insist their patients get intensive outpatient group treatment as a condition of also getting medication to treat opioid use disorder – but they are in the minority.

The ideal is to offer intense treatment to those who want it, but not to withhold medication if they decline.

Federal and state rules about daily dosing at opioid treatment programs has been a barrier to patients in the past. However, those rules have been relaxed since COVID. The response of patients has been so positive that changes are proposed to allow take home doses much more quickly. I just blogged about these positive changes in my blog posted December 1, 2021.

As far as Jakubowski’s urging to get treatment where the patients are, I’m not sure how OTPs can meet that recommendation, unless they take advantage of newer regulation changes around mobile vans. I’ve also blogged about this (see May 23, 2021).

Anyway, both OBOT and OTP treatment programs can do more to lower the barriers for patients to enter treatment and to stay in treatment. Providers need to examine current protocols and habits around admissions and treatment.

I’d love to see an era where treatment is as easy to get as drugs.