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Holiday Guide for Families

Last year, who could have predicted that in one year, people would be making life and death decisions to travel to see family on Christmas, versus staying home? Many of us decided to postpone holiday gatherings with loved ones until the COVID situation is safer.

Each year I post a blog about getting along with family. I thought I could post the same thing this year, because while some family get-togethers may be online, the advice is still appropriate. So here it is again:

What to do:

  1. Do invite your loved one in recovery to family functions, and treat her with the same respect you treat the rest of the family. If you have resentments from her past behavior, you can address this privately, not at the holiday dinner table. Perhaps given how holidays can magnify feelings, it’s best to keep things superficial and cheery. Chose another time if you have a grievance to air.
  • Allow your relative some privacy. If the person in recovery wishes to discuss her recovery with the entire family, she will. Let her be the one to bring it up, though. Asking things like, “Are you still on the wagon or have you gone back to shooting drugs?” probably will embarrass her and serve no useful function.
  • Accept her limitations graciously and without comment. Holidays can be trigger for drug use in some people, and your relative may want to go to a 12-step meeting during her visit. Other people in recovery may need some time by themselves, to pray, meditate, or call a recovering friend. Allow them to do this without making it a big deal.
  • Remember there are no black sheep. We are all gray sheep, since we all have our faults. In some families, one person, often the person with substance use disorder, gets unfairly designated as the black sheep. She gets blamed for every misfortune the family has experienced. Don’t slip into this pattern at holiday functions.

What not to do:

  1. Don’t ask the recovering person if she’s relapsed. If you can’t tell, assume all is well with her recovery. If she looks intoxicated, you can express your concern privately, without involving everyone.
  • Don’t use drugs, including alcohol, around a recovering person unless you check with them first. Ask if drug or alcohol use may be a trigger, and if it is, abstain from use yourself. If you must use alcohol or other drugs, go to a separate part of the house or to another location.

Being around drugs including alcohol can be a bigger trigger during the first few years of recovery, but any recovering person can have times when they feel vulnerable, so check with them privately before you break open a bottle of wine.

If your family’s usual way of celebrating holidays is to get “ all liquored up,” then understand why a recovering relative may not wish to come to be with family at this time, and don’t take it personally.

For some of us, remaining in recovery is a serious issue, so please accept we will do what we must to remain in recovery, even if that means making a holiday phone call rather than making a holiday visit.

  • If your recovering loved one is in medication-assisted treatment with methadone or buprenorphine, don’t feel like you have the right to make dosage recommendations. Don’t ask “When are you going to off of that medication (meaning methadone or buprenorphine)?

Your loved one may taper off medication completely at some point, or he may not. Either way, that’s a medical decision best made by the patient and his doctor. Asking when a taper is planned is not your business.

  • Remember your loved one is more than the disease from which they are recovering.

Some people have diabetes and some people have substance use disorders. These diseases are only a small part of who they are.

Refrain from giving hilarious descriptions of your loved one’s past addictive behavior, saying, “But I’m only joking!” This can hurt her feelings, and keep her feeling stuck with an identity as a drug user. She can begin to believe that with her family, being an addict is a life sentence.

I hope this helps.

May all my readers have a Merry Christmas and Happy Holidays!

Deciding COVID Take Home Doses

(I am changing this patient’s description to protect identity)

We have only a few patients who refuse to wear masks. One of these people, an admission from a few months ago, has been dosed in his car since we don’t want him to endanger other patients by his refusal to wear a mask. He’s been dosing with us every day, but after the first three weeks I felt comfortable to give him Sunday and holiday toke homes.

Now he’s asking for the extended COVID take homes, which for a recent patient like him means up to four take home doses per week and coming to dose only the other three day.

But when his counselor first asked me about it, I snapped, “No! He says he doesn’t believe COVID is real and that’s why he refuses to wear a mask. Why should he benefit from COVID take homes?”

Even as I said this, it didn’t feel right.

Decisions about take homes, although ultimately decided by the medical director, shouldn’t be made on emotion. That’s why we have case staffing. So, I asked this counselor to present the issue at our case staffing session the next day.

I was pleasantly surprised at our staff. I heard some mature and considered responses.

One person said something to the effect that the take homes are for the benefit of the patient, whether that individual agrees with us about the risks of COVID or not. And those take-home doses also benefit staff and other patients, by limiting crowd exposure.

Yep, I thought, that’s the right answer.

Another person said she didn’t think this patient would misuse his take home doses, and he was compliant in all other matters, other than having continued positives for marijuana and not wearing a mask. And wasn’t that the main consideration, whether the patient can consume the take home doses as prescribed?

Right again, I thought.

One of the counselors pointed out that it would make nurses’ jobs easier by giving one less person to car-dose on those days he will get take home doses.

Yep.

Decisions about take homes shouldn’t be made with a punitive mindset. My reflex response to the patient’s counselor hinted of judgementalism, which is why it felt wrong. I was angry with the patient because he didn’t agree with me about COVID. Whether he agrees or not isn’t the point of the extra take homes, as my staff recognized.

So, this patient got his extra COVID take homes even though he doesn’t believe in COVID and I wish him well.

And I’m so proud of this staff of wonderful people I work with.

Injection of Transmucosal Buprenorphine Products

As I’ve said before on this blog, may people find my site by googling phrases like “inject buprenorphine,” so obviously people want information about that topic. I know what I’ve seen in my patients, but that’s anecdotal information, so I searched online for more scientific information.

Morbidity and Mortality Weekly Report, otherwise known as the MMWR, is published by the Centers for Disease Control and Prevention (CDC). In their August 14, 2020 issue, they discussed emergency department visits for complications from injecting buprenorphine products meant to be used sublingually (under the tongue). This formulation is the most frequently prescribed form of buprenorphine. [1]

The authors of the MMWR cited several studies pertinent to the topic. First, a study by Geller et al. looked at emergency department visits resulting from nonmedical use of prescription opioids. Of the 598 cases observed by one health system between 2016 to 2018, around one-third of those emergency department visits were for the treatment of intravenous use of sublingual buprenorphine products.

Of the patients who had complications from injecting buprenorphine products, two-thirds were male, and the average age was 33. Most of these visits (85%) involved the combination product buprenorphine/naloxone. In two thirds of the cases, patients were treated and released from the emergency department or left against medical advice, so most of these patients were not admitted to the hospital.

 In around a third of these patients, other non-pharmaceutical drugs were involved, such as cocaine or heroin.

In another study of one hundred and one emergency department cases of injection of buprenorphine products,  most of those patients had either skin abscess or cellulitis, but around 6% had serious infections such as endocarditis (infected heart valve), sepsis (blood infection) or septic arthritis (bacterial infection of a joint space). These last ailments usually require prolonged hospitalization and treatment with antibiotics.

The MMWR article concluded by saying buprenorphine is an important component of the public health response to opioid use disorders, and that patients may benefit from syringe exchange programs, information about infection prevention practices, and linkage to recovery support services.

I’ve written about the intravenous use of buprenorphine products in past blogs (January 15, 2017 and November 1, 2015). Clearly, medication meant to be used under the tongue is not safe to inject. This medication isn’t sterile, and besides the actual buprenorphine, there are fillers and other substances in the tablets and films that aren’t meant to be injected into veins. These substances can clog the veins, causing clots, or cause infections that can lead to abscesses.

For one thing, buprenorphine mono- and combo- tablets are made with a substance called “amidon” which is a starch that helps the tablet hold its shape. This substance appears to cause specific findings when injected through the skin into veins and may cause the inflammation and irritation we see in patients who inject this product.

So why do people inject buprenorphine? There are several reasons, chief among them being buprenorphine’s poor sublingual bioavailability. Injection of a drug means, by definition, that 100% of the drug makes it to the person’s bloodstream. Sublingual use of buprenorphine, either in the monoproduct or combination product form, has at best around 40% bioavailability. Patients buying buprenorphine on the street often feel that they are wasting money if they use tablets sublingually as the medication was intended and are tempted to inject buprenorphine to make it go farther.

But there are other reasons. Some patients get just as addicted to the “rush” of injecting as they do to the actual drugs. Some people feel a euphoria as soon as they start the act of injecting – preparing the needle, etc. – even before the drug is in their bloodstream. This yearning for intravenous use can be a difficult part of the addiction to defeat. I’ve had many patients in treatment who still feel an obsession to inject their buprenorphine, even though we could increase their sublingual dose to provide a therapeutic blood level.

As the information from MMWR shows, people are injecting both the monoproduct and the combination product, though the monoproduct has higher black-market value and is more desirable than the combination product.  As the study showed, 85% of the patients presenting to the emergency department after injecting buprenorphine used the combination product.

I’ve asked patients how they can inject a product that’s supposed to put them into withdrawal. Most of them shrug and say they still get a drug effect, and that if it makes them sick, it’s for a short time only. This puzzles me, since I was sold on the idea that patients could not inject the combination product without serious adverse side effects. Or maybe that’s why the people who injected the combination products went to the emergency department – they felt sick with precipitated withdrawal?

From the MMWR data, I conclude that injection use of buprenorphine occurs frequently. On the one hand, it’s probably safer then injecting heroin, now loaded with either pure fentanyl or various percentages of fentanyl and its analogues. On the other hand, injection of buprenorphine carries increased medical risk seen with any type of intravenous drug use, plus the tablets appear to be particularly caustic to veins and other soft tissues and can cause serious health issues.

At our opioid treatment program, we used to do observed dosing with buprenorphine products just like we do with methadone. Pre-COVID, we asked our patients to sit in a designated area while their dose dissolved. We did this so that patients wouldn’t be tempted to leave our facility with medication in their mouth then spit it out in the parking lot so that they could inject it.

I’ve had a few patients tell me that they were able to do this despite our precautions, and they got substantial infections. This is probably because ordinary human saliva contains some bacteria that causes big problems when injected into the bloodstream

Since COVID, we allow patients to leave our facility as soon as they place medication under their tongues, to reduce the time patients are exposed to other patients. However, if a certain patient has struggled with intravenous buprenorphine use in the past, I’ll ask that patient to stay in the dosing cubicle until he has completed dissolved the medication, so that he won’t be tempted to inject medication. And the patient won’t get take home doses until he makes significant progress in recovery, to the point he’s not at risk of injecting medication.

Upon admission, if a patient admits to past intravenous buprenorphine use, I’ll talk to that patient about starting methadone instead of buprenorphine. Methadone isn’t often injected, at least not for pharmacologic reasons, since it has such good oral bioavailability.

I do not think patients who inject buprenorphine products are appropriate for office-based treatment practices. I think those patients need to be referred to opioid treatment programs, where we have the experience and ability to address this situation. I know some good practitioners who disagree with me about this idea, feeling that any treatment at all is preferable to no treatment. I understand their thinking is based on harm reduction principles, but I also know that with other chronic medical illnesses, we refer the most complicated patients to specialists. The specialists at treating opioid use disorder should be found at opioid treatment programs.

After all, OTPs have been treating opioid use disorders with medication for decades, long before our recent opioid crisis.  I’ve come to realize that even office-based providers of buprenorphine rarely refer patients to OTPs. Incredibly, many office-based providers hold the same stigma towards OTPs as other medical professionals, and this needs to change.

But that’s a topic for a whole other blog.

Webisodes: Resources for Providers Who Work at Opioid Treatment Programs

I’m pleased to announce new resources for providers who work at opioid treatment programs. The Governor’s Institute of North Carolina and our state’s Department of Health and Human Services sponsored this work, which is a series of webinars addressing various topics encountered at opioid treatment programs. These webinars can be found here: https://addiction-medicine.org/training/otp/

Here are the topics:

Webisode 1: Safe Standard Inductions

Webisode 2:  8-Point Take Home Criteria

Webisode 3: Exception Requests

Webisode 4: Split Dosing

Webisode 5: Effective use of the NC CSRS (North Carolina Controlled Substance Reporting System)

Webisode 6:  Benzodiazepines, Alcohol, and Opioids

Webisode 7: Reinstatements

Webisode 8: Drug Testing

Webisode 9:  Standing Orders and Scope of Practice Issues

Webisode 10:  Admission Criteria and Exceptions

Webisode 11: Pain Management for Patients on Methadone or Buprenorphine

Webisode 12: Methadone vs. Buprenorphine

Webisode 13: Duties of an OTP Medical Director

Webisode 14: Interpreting Drug Screens

Webisode 15: Methadone, EKG testing and the QT Interval

Webisode 16: Medical Conditions that may Mimic Opioid Withdrawal

Webisode 17: Hospitalized Patients Returning to an OTP

Webisode 18: Special Dosing Orders for Tapers

Webisode 19: Neurobiology of Opioid Use Disorder

These webisodes were written by Eric Morse, MD, Lisa Wheeler, PA, and…me. We picked topics and wrote brief essays that became the scripts that Dr. Morse read on the Webisodes. Each time after one of us completed an essay, we emailed it to others for critique and adherence to current evidence-based literature.

Did we agree on everything? No, but we only disagreed on fine points, not on the underlying principles of good patient care. I’m pleased with the final product, as it represents our best efforts.

A few of the webisodes are dated because they were written pre- COVID. We’ve had changes in our state, allowing many more take homes under COVID exception provisions, so Webisode 2 is a little dated.

Dr. Eric Morse did the recorded presentations. I am allergic to video presentations, so I am very grateful he was willing to do these. Dr. Eric Morse is a fellowship- trained addiction psychiatrist, with over eighteen years’ experience working in this field. Dr. Morse did a wonderful job on camera, and the graphics that accompany the verbal information were clear and simple. These are short and concise webisodes, lasting between five to eight minutes.

I wrote about half of the webisodes and was surprised that I still learned much as I was writing.  I would write a paragraph, then wonder if there was newer data available, and I’d go back to do an internet search just to make sure. Sometimes I did find new data to include, improving my essay.

Nearly twenty years ago, when I first started working at an opioid treatment program, I was woefully underprepared. I did get a facility tour and several hours of information from a physician who was medical director at the time, which was great so far as it went. I could have used a manual to help me, and webisodes such as these would have been a godsend.

These days, we have all sorts of informational media: SAMHSA has published books, downloadable for free from their website, containing the basic information needed. TIP 63 is the latest iteration of this data. ASAM (the American Society of Addiction Medicine) has published guidelines for treating opioid use disorder with medications.

There’s the PCSS forum, sponsored by APPP, where providers can get a mentor to help guide them when using medications to treat opioid use disorders.

These webisodes are the latest educational supports available for free to any OTP providers and need to be watched if you are new to the field. Maybe they need to be watched even if you are “old” to the field like me. Sometimes I think I know something, but what I remember turns out not to be quite accurate

I am grateful to the Governor’s Institute and the NC DHHS for identifying this educational need and their support to fill the need. I especially appreciate Dr. Morse’s willingness to do the on-camera work.

Check out these webisodes and let me know what you think!

Book Review: “Drug Dealer, MD” by Anna Lembke, MD

I hated the title but loved the book.

I imagine some marketing hack told the author she needed a title that would grab people, and this is what they came up with. The book doesn’t talk much about the few doctors who turned out to be drug dealers. Rather, the book tells the story of pain pill addiction in our country, about how it happened and the contributing factors. Most importantly, it discusses how to prevent opioid use disorder and how to treat the patients who developed opioid use disorder.

I like this book because it’s concise. The author succinctly presents data without getting wordy or going off on too many tangents. Even with so many other competing books on the market, this one stands out. Published by Johns Hopkins University Press, it only runs to 152 pages. But since it was published in 2016, it missed the last few years of our opioid epidemic and how patients have switched to heroin, now that pain pills are scarce.

The author uses some patients’ stories to underline points of information in the book but doesn’t overdo this. Her first chapter is about the nature of addiction, with descriptions of risk factors for initiation of substance use, and risk factors for the development of substance use disorders.

In Chapter Two, the author told about the overprescribing we saw in this country, beginning at the end of the twentieth century. She described how the internet functioned as a supplier, though most other experts say the internet wasn’t a prominent driver of the opioid epidemic in its early years.

By Chapter Three, the author, a well-known and respected Addiction Medicine specialist, expressed interesting ideas about the role of “illness narratives” in some patients. By this term, she means some people with physical and psychiatric differences get labelled as having an illness, rather than being accepted as normal human variations. She uses the example of back pain, which she says in the past might have been looked at as a normal part of human existence, which now is termed a chronic pain disorder. The implications of the illness narrative are that pain should be viewed as something dangerous that must be got rid of, rather than endured, exposing the afflicted person to the dangers of opioids and opioid use disorder.

As an example of psychiatric differences, she uses the normal human tendency to become distracted, which in an extreme form is now labeled as an illness: Attention Deficit Disorder. This label of illness, she says, implies the need to medicate the condition. This illness becomes part of the person’s identity and thus their “personal illness narrative.” She says it’s tempting for people to blame their illness as the cause for life’s failures and disappointments.

Later in the book, in Chapter Six, she describes the dilemma of people who have adapted an identity of an ill patient, calling them “professional patients.” She makes a case that people who have been granted disability benefits have a financial incentive to stay sick, in order to maintain their benefits. They may become so psychologically attached to their role as a sick person that the thought of recovery and wellness is frightening.

Most of all I enjoyed reading Chapter Four, titled, “Big Pharma Joins Big Medicine.” She did an excellent job of skewering Big Pharma’s great deception: marketing which masqueraded as education. Big Pharma identified physicians they could influence to parrot Pharma’s lies and coronated them “thought leaders.” These professionals were paid speakers’ fees to give talks to other prescribers, extolling the benefits and lack of risks of opioids.

What hard-working and underappreciated doctor wouldn’t be flattered to be called a “thought leader?” Along with hefty speaking fees, I can see how pharmaceutical companies seduced some physicians, encouraging them to present Big Pharma’s message about how safe opioids were for chronic pain treatment, even though there wasn’t data to support those claims.

In a few paragraphs, the author succinctly describes how the FDA failed to prevent drug companies from marketing opioids for the treatment of chronic pain, despite the lack of studies about safety. She also deftly describes a new study technique that’s bound to skew data about opioids, called “enriched enrollment.”

Then in Chapter Five, the author describes stereotypic behaviors of patients who try to manipulate doctors into prescribing the medications that they want. The author prefaces these behaviors with a sentence saying the terms aren’t meant to denigrate drug seeking patients, but that’s exactly what she proceeds to do.

For example, she describes patients who try to filibuster and talk past the allotted time for the appointment as “Senators.” She describes patients who flatter doctors by telling they are so much wiser/compassionate/competent than any other doctors as “Sycophants.” Other patients are described as “Exhibitionists,” who display dramatic emotions and physical scars to underscore dire need for opioid medication.

I recognize all these behaviors, both in patients I see with substance use disorders and in primary care patients; however, to place labels on the behaviors of people caught up in the desperation of active addiction is unseemly. The book would have been better if this section was omitted. However, in that same chapter, the author neatly summarizes the basic principles underlying the treatment of opioid use disorder with methadone and buprenorphine.

Chapter Eight was the most interesting. This chapter is titled, “Pill Mills and the Toyota-ization of Medicine.” In this chapter, the author talks about physicians who work at pill mills, who have long ago given up the illusion of working to help people. They are in a business to give pain pills to people who want them, no matter if it’s in the patients’ best interest, in order to make a lot of money for themselves.

But then she starts talking about how medicine has become a business, and that pill mills are only extreme examples of how medicine has changed into an industrial business. Physicians have less autonomy as their practices are bought by hospital corporations. Treatment options for all illnesses are more often determined by hospital administrators, insurance companies, and treatment guidelines promulgated by agencies like the Joint Commission (used to be called JCHCO).

Doctors are expected to meet productivity quotas and see ever more patients in a day. I’ve heard practice administrators use the euphemisms “practice maximization,” and “increased patient throughput.” The author of this book describes how she was given monthly feedback about whether she was hitting the billing targets that had been set for her. If she wasn’t meeting these targets, set by her employers, she had more to worry about than caring for her patients.

Giving patients what they want is the quickest way to get on to the next patient, further exacerbating overprescribing. It takes much less time to write a prescription than to talk to the patients about non-opioid ways to treat pain, and about the emotional issues that make pain worse. And this applies not only to opioids, but other medications. What physician hasn’t buckled at least once to the demands of a patient insisting that a Z-pack always gets rid of her viral illness? It’s easier to write the damned prescription than it is to have a conversation about how antibiotics don’t work for viral illness, and how inappropriate use of antibiotics causes antibiotic resistance.

I commiserate with the time pressures she describes.

On my 40th birthday, nearly two decades ago, I was told by a practice administrator that I was too slow. I was “only” averaging six patients per hour, and I’d have to pick up the pace if I wanted to keep working there.

Driving home that evening, I was shaking with anger and fear. I knew I couldn’t deliver quality care seeing more than thirty-six patients per day. I felt defective, like there must be something wrong with me because I couldn’t (or wouldn’t) keep up the pace of my colleagues.

I made up my mind that I needed to look for some other type of work in the medical field. I told my physician friends I was open to new ideas, and a few months later I was asked to fill in for a friend who was going on vacation. He was the medical director of an opioid treatment program. Deeply skeptical at first, I eventually found this to be my niche. It’s intensely satisfying to work with patients and see the tremendous life changes that I never saw while practicing primary care.

I feel sorry for doctors who never found their way out of the production line. I’m not saying opioid treatment programs never push providers to see more patients in less time, but I haven’t experienced near the pressure in OTPs that I have working in primary care.

The author then talks about another driver of the opioid epidemic: patient satisfaction scores. Many medical practices conduct surveys of patients after visits, to get feedback on what patients like and what they don’t like. They are asked about their physicians.

 Initially, these surveys were said to help providers pivot to a more patient-centered frame of mind, to sensitize them to patient concerns. Now, patient satisfaction scores are considered a “quality measure.” Providers with higher patient satisfaction scores are assumed to have provided better care, despite some evidence to the contrary. Physician pay is often linked to these satisfaction scores, giving doctors another reason to prescribe what the patient wants rather than take the time to have a difficult discussion about substance use disorders. Providers know giving patients what they want gives better satisfaction scores, and indirectly, better pay for themselves.

Then there’s the whole internet “Grade your doctor” websites. The author describes her trauma of reading a bad review online that was found by her son, and her angst in wondering who it could be who left such unkind remarks about her as a physician.

Back when there were one or two sites for physician grading, the internet could have been a factor that had an impact, but now there are at least twenty sites for this. I think this dilutes the effect of any one site, reducing the influence they have.

In Chapter Nine, titled, “Addiction, the Disease that Insurance Companies Still Won’t Pay Doctors to Treat,” the author describes the problem that persists in the U.S., despite passage of the Parity Law in 2008. The Parity Act, which said substance use disorders and mental health disorders must be covered by insurance companies to the same extent as other medical illnesses, has not assured equal coverage. This is a frustration that most providers of care to patients with substance use disorders face daily.

Though coverage for medical care of substance use disorders isn’t great, coverage for the medical complications of those disorders is much better. The complications of intravenous drug use, for example – endocarditis, osteomyelitis, cellulitis – are usually covered if the patient has medical insurance. Yet most medical insurers still don’t cover care delivered at opioid treatment programs or cover it poorly.

In the last chapter of the book, the author gives reasons to hope that our nation’s opioid problem may improve at some point. She points to better education of medical students, residents, and practicing providers about prescribing skills. More providers in training are being taught addiction medicine basics, and addiction medicine fellowship training programs have been started.

She hopes substance use disorders will be viewed as the chronic illness that it is, rather than a moral issue or a short-term medical problem. She says providers need to be allowed to spend more time with patients to give better care. She describes new models of care for patients with chronic pain, using both non-opioid medications and non-medication treatments, which have been successful.

I really wish she would have re-iterated the benefits of medications in the treatment of opioid use disorders in that last chapter. But at least this author did write three pages about the benefits of medications like methadone and buprenorphine in the middle of the book, and that’s more than most of the recent popular books about opioid use disorder have done. I thank her for that.

But then…she is an addiction medicine specialist, so maybe I’m justified to be a bit disappointed by this.

But this book is succinct, the data is accurate, the patient stories typical for many patients, and she does a wonderful job of documenting factors that merged to cause our present opioid problem.

For any person interested in opioid use disorders, I strongly recommend this book.

2020 Addiction Medicine Essentials Conference

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

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

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

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

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

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

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

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

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

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

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

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

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

This is not good news.

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

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

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

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

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

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

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

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

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

Writing a Blog: What I’ve Learned

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

It’s fun.

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

Medication Interactions with Methadone and Buprenorphine

 

 

 

 

 

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

I take that burden seriously.

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

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

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

Sedatives

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

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

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

Cardiac Effects: prolonged QT interval

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

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

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

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

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

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

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

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

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

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

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

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

Drug affected methadone metabolism by the Cytochrome P450 System

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

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

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

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

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

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

What’s a doctor to do?

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

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

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

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

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

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

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

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

Our patients’ safety depends upon this.

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

 

 

The Car Dosing Cart

Nurse Sylvia behind the Car Dose Cart

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

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

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

It’s genius.

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

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

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

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

That’s when Jerry invented the Car Dosing Cart.

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

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

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