Archive for the ‘Uncategorized’ Category

Primary Care Difficult to Find for OTP Patients

This area where I now live is odd in some ways. It’s beautiful country, but odd. Around here, people must “apply” to become patients of local medical practices. This isn’t because of COVID; it was like this before too.

Many of my patients tell me they keep getting turned down when they apply to be patients at local practices. Some of these patients have no insurance, some have Medicaid, and some have private insurance. Sometimes they wonder aloud to me if they were turned down because they truthfully revealed they had opioid use disorder and were being treated with either methadone or buprenorphine.

There’s just no way to know. It would be illegal, of course, for practitioners to turn down a patient for primary care because they have opioid use disorder, whether they are in or out of treatment. But usually these patients aren’t given an exact reason why they are being turned down for care. They are usually told something vague, like, “Our providers don’t have the expertise to treat your medical conditions.”

I’d love to do a little undercover investigation of this situation, but just don’t have the time.

But last week, I saw a new patient seeking treatment for her opioid use disorder. She had other medical issues that had long been neglected. This is not unusual, because active substance use disorders often push other health issues into the background of a patient’s attention. However, this patient told me she had gone to a local medical clinic for help, both for her drug use and for other medical issues. She was turned away without being seen. She was told she had to get help with her drug use first.

She went to an FQHC, an abbreviation for Federally Qualified Health Clinic.

It isn’t easy for a medical clinic to get FQHC designation. These clinics need to meet certain standards, including making medical care easier to obtain by using a sliding scale for payment. That is, the less money a patient has, the less they are charged for care. The benefit of being an FQHC is that they get paid more for Medicaid and Medicare patients, because they are providing affordable care for low-income people.

But my patient got no care.

As she told it, at her first visit she disclosed her regular illicit opioid and methamphetamine use and asked for help with those problems along with other medical problems. She had severe joint pains of her hands and a few other common medical symptoms. She says she was told she could not receive care until she got her addiction under control. The patient sensed this wasn’t right, and asked to talk to the office manager, who told her the provider didn’t feel comfortable treating any of her medical problems because her drug use would interfere. Again, she was told she could return when she got her addiction “under control.”

She says she received no referral for treatment of her addiction.

I asked the patient if she wanted me to call this office to tell them she’s now in treatment, and she said yes, but please wait until she could see if our treatment was going to work. I agreed.

On her seventh day of treatment, she looked and felt much better. She felt stable on her dose of buprenorphine 16mg per day and she had no cravings for opioids or opioid withdrawal. She had not used any heroin since admission, though she did smoke a small amount of methamphetamine on her fifth day of treatment. This is not unusual, and she was talking to her counselor about her triggers for methamphetamine use.

I asked again if she wanted me to call the FQHC, for her to get her needed primary medical care done there. She said yes, she had to go there, since they were the only care available for low-income patients near her home.

So I called them. I was angry for the way she had been treated, and truth be told, spoiling for a verbal fight. Fortunately, I had a pharmacy student shadowing me that day.

As an aside, pharmacy students who rotate through our local hospital for part of their training have asked to come one day a week to shadow me, to learn about opioid use disorder and its treatment with medication. I’ve been delighted to be given a chance to blather on about my favorite topic. I always make sure to have a few willing patients tell the students their stories of recovery, and about how treatment benefitted them. The students are always amazed, and a few have asked if there’s any place for pharmacists at opioid treatment programs. I say yes, some programs do use pharmacists, though currently ours does not. I’ve been happy with their enthusiasm and willingness to learn.

Anyway, a student was with me that day, and I tend to be better behaved when people are watching me. As I made the phone call, I kept repeating to myself, “Be collaborative, be collaborative…”

I got the receptionist, and described who I was, and which patient I was calling about. Immediately I was put on hold and the office manager came on the line. As I remember, our conversation went something like this:

“Hi, I’m Dr. Burson and I’m seeing Mrs. X.  I understand she was seeking medical care at your office and was told she needed to get help with her addiction issues prior to seeing a provider there. I’m calling to let you know she is getting care with us and has made a great deal of progress with…”

“We absolutely did not refuse to provide care for her. I remember her very well. She was hollerin’ in our lobby about us denying her care. We only told her that we couldn’t treat any of her medical problems until she got off the drugs. That’s not unreasonable. That’s all we told her. We did NOT deny her care.”

“Yes, that’s why I’m calling,” I said, smooth and unruffled as silk, “She found help for her opioid use disorder and stimulant use disorder, so I was wondering if I can tell her to make another appointment with your provider. And by the way, anytime you have a patient with opioid use disorder, please refer them to us. We want them. We can help them.”

A bit of a pause ensued. I sensed – or perhaps imagined –  she didn’t really want my patient in that practice but was smart enough to know she’d be breaking the law if she refused.

“Of course. Tell her to call today, we’ll be happy to see her.”

“Thank you so much for your help. I’ll tell her.”

The student, having heard the whole conversation, said something to the effect of how is that not denying care? I said I thought it was the same thing too, but didn’t want to argue or offend, since I get more cooperation with politeness and cooperation.

The Americans With Disabilities Act, known as the ADA, makes it illegal to discriminate against someone due to their medical conditions. It is illegal to refuse to provide medical care to a person only because they have substance use disorder.

How should this FQHC have handled my patient? Of course, drug use can influence other medical problems. But the answer isn’t turning the patient away. The answer is to see the patient, form a therapeutic alliance with the patient, and assess her needs. Start treatment of medical problems and include referral for treatment of substance use disorders, while also addressing her other medical problems.

Instead, it feels to me – and her – like they said to her, “You’ll have to take your nasty bad habit somewhere else and stop your bad behavior before you are allowed to see our providers.”

They absolutely bungled it.

Out of curiosity, and to try to see who their medical director was, I went to their web page. Ironically, splashed in large letters over their home page was this statement: “We promise not to deny services based on a person’s race, color, sex, national origin, disability, religion, sexual orientation, or ability to pay.”

Well OK.

One nurse practitioner was listed as a provider, but I didn’t see a medical director listed. I plan to call this nurse practitioner soon, when I am calm and cheerful, in the hopes of doing some gentle education.

I’ll let her know about our opioid treatment program, and that we are happy to receive referrals for patients with opioid use disorder, and that she can refer them any weekday. (Just as COVID hit, we started doing admissions five days per week). I also hope to convince her to refer patients with substance use disorders for treatment, just as she would for any other illness, and to give her my cell number to call if she ever has any questions about what to do for a certain patient with substance abuse, even if they don’t have opioid use disorder.

Treatment of Opioid Use Disorder During Incarceration

Change is coming, but slowly.

In the past, many county jails and state prisons refused to allow patients prescribed methadone or buprenorphine to remain on their medication during incarceration. Most experts felt this was denying medical treatment to inmates, something which – we thought – was not allowed in the United States. But due to the stigma against opioid use disorder and the medications commonly used to treat it, our patients were denied treatment repeatedly.

Now there’s hope on the horizon.

Last month, a patient with opioid use disorder, successfully being treated with methadone, was sentenced to thirty days in jail in DuPage County, Illinois. The Chicago Tribune covered the story, but you can also read pertinent details on the website of the Legal Action Center (LAC). [1]

This patient, instead of resigning herself to a miserable thirty days of methadone withdrawal, decided to petition the court system to allow her to be able to take her prescribed medication as usual. I probably don’t have to point out to my regular readers that methadone treatment for opioid use disorder reduces the risk of death by at least three- fold. Remaining on her usual medication would prevent relapse once she’s released from jail, commonly a time for overdose death. And of course, continuing her medication would prevent agonizing withdrawal syndrome.

This patient had been in treatment for her opioid use disorder since 2019 but got a DUI back in 2016. It took five years for her to be sentenced to jail time for her DUI. In her lawsuit, the patient asked a federal judge to make sure she was allowed to take her usual medication as prescribed. The complaint stated that depriving inmates of needed medical treatment for opioid use disorder is cruel and unusual punishment and violates the Americans with Disabilities Act. The complaint correctly stated that the refusal to continue the patient’s treatment placed her in grave and immediate danger.

She brought her lawsuit with the help of the LAC, working with the American Civil Liberties Union. DuPage County, where she would serve her sentence, was alleged to have an unwritten policy of prohibiting people from dosing with methadone or buprenorphine, even when prescribed by a physician. The county denied this, saying that each patient’s needs were evaluated on a case-by-case basis after a physical exam. However, no non-pregnant inmate was ever allowed to remain on methadone or buprenorphine in the jail’s history.

Based on that last fact, it strains credulity to believe this patient would have received her methadone as usual had she not brought her case.

From what I understand by reading internet reports, the federal judge said this patient had not yet been denied her medication, so she needed to wait until it was denied before she could bring her lawsuit to court.

County jail officials, likely sensing the shitstorm that would descend upon them if they denied this patient her medication after attention her lawsuit had received, finally decided to do the right thing, and give the patient her medication.

County officials made some sort of laughable statement that a “headline-grabbing lawsuit” wasn’t needed for this patient to get proper care, and that they would have done the right thing without a lawsuit…but I doubt that. I am judging DuPage County’s attitudes and actions by the ones I’ve encountered at rural North Carolina’s county jails.

In May of 2019, a federal judge ruled that a patient in Maine, sentenced to forty days in jail, must be allowed to remain on her usual daily dose of Suboxone. She was in recovery on this medication for five years before she was sentenced to this term. The judge said that denial of medication-assisted treatment would cause serious and irreparable harm to the patient, and that denial would violate the Americans with Disabilities Act. The patient asked Maine’s division of the ACLU to assist her attorneys in bringing her suit against the county jail.

Attorneys for the county jail had argued that medical personnel at the jail are able to manage opioid withdrawal symptoms, apparently meaning withdrawal could be managed without Suboxone. But they lost the case, and the patient remained on Suboxone during incarceration.

I was very happy with the outcome of this case, and a few others like it, scattered around the country these last two years.

In my state of North Carolina, there are now around five counties that will allow patients in treatment for opioid use disorder to remain in treatment. These counties are to be congratulated for their progress. However, in my county, patients prescribed methadone or buprenorphine products for opioid use disorder are NOT ALLOWED to dose in our county’s jail while incarcerated. The jail medical personnel have some sort of a detox protocol that involves clonidine (which may help a little) and clonazepam. The latter medication, of course, serves to place inmates at even higher risk of death if they relapse back to opioid use once they leave jail.

Use of clonazepam is not part of any legitimate opioid withdrawal protocol that I’m aware of. Plus, it is a controlled substance. If the jail is willing to dose controlled substances, why not just dose the patient with the evidence-based, life-saving medication that the patient is already on?

I have tried talking to county jail medical personnel. The nurses who work there are sympathetic, for the most part, but medical policy about patients on methadone or buprenorphine seems to be set in stone by someone above them. I once talked via phone to the jail doctor, but it went very badly. He was like other doctors of a certain age, who feel they must talk much, much more than they listen. I had to interrupt to get any time to speak at all, and he then became derisive towards medication-assisted treatment in general and dismissive toward me personally. So much for my attempt at gentle education in the name of cooperation. Not everyone remains teachable throughout life.

I’ve been trying to get patients at our opioid treatment program to reach out to our state’s ACLU branch when it’s obvious they will be sentenced to a jail term and denied their usual medication for opioid use disorder. So far, none have taken this step. I’ve tried to call the ACLU for them, but was told I don’t have standing, and it must be the patient who calls to ask for their help.

Understandably, many patients worry that filing a lawsuit to be able to get their usual medications may backfire. If they don’t win, they fear angering the prosecutor or judge. They worry they may face more severe punishment if they attempt to advocate for themselves.

I understand their fears, and I can’t tell them it’s unfounded. If they bring a suit and lose, perhaps they would be treated more harshly. The law enforcement and judicial system in this county is not as forward-thinking as I would prefer, though it is improving.

Our opioid treatment program participated in a three-year grant that paid for treatment for patients involved with the criminal justice system. This grant just ended last August. Our staff worked with local probation and parole officers, who got to see first-hand the dramatic improvements in patients’ lives when evidence-based treatment with medication for opioid use disorder is available. Some of those officers still refer their clients to us, even after the grant ended. But other officers remain cool towards our treatment program, though at least they have stopped telling our patients they must get off of methadone or buprenorphine to remain on probation. Small victories.

Many jail systems, large and small, say they can’t allow methadone or buprenorphine dosing of inmates already prescribed these medications because of diversion risks. Staff say such medications would be diverted from the patient for whom it is prescribed, presenting overdose risks to other inmates.

That argument suggests that jail personnel are unfamiliar with observed dosing protocols that OTPs use every day. We could teach jail staff these simple techniques. And again, if the jail is already giving out doses of clonazepam, what steps are they now using to make sure the dose goes to the patient for whom it is intended?

And from what I see and hear from patients who have been incarcerated, plenty of drugs are already circulating in some jails and prisons. Availability seems to vary a great deal at different facilities, for whatever reason, but these places don’t allow methadone or buprenorphine through approved channels.

It’s possible to find creative solutions to all the issues that make methadone and buprenorphine administration difficult for incarcerated patients.

Jail systems say they don’t have the manpower to bring each patient to the opioid treatment program to be dosed each day. However, that would not be required in every case.

Most patients could be issued take home doses for whatever time frame the medical director feels in appropriate. For example, a relatively stable patients could be brought to our OTP for observed dosing every two weeks, with daily take -home doses issued for the thirteen days in between visits. These doses could be given, via chain of custody forms, to jail personnel to be taken to the county jail and stored in a locked container. Chain of custody is a method where there is documentation of which personnel are in possession of the medication each step of the way. When a dose if given to the patient, jail personnel watch to make sure it is consumed and can document this.

Or perhaps OTP staff could bring the medication to the local jail and do observed dosing there, then, when appropriate, leave daily doses of medication in the care of medical personnel to be stored in a locked safe until the next dose is due.

For patients on sublingual buprenorphine products prescribed by office-based providers, the methods could be much simpler. The patient could bring in their bottle or box of medication with them when they report for incarceration, and the medication can be stored under lock and key. It can be dosed daily, with jail personnel watching to make sure the medication dissolves and no residue remains under the tongue or in the mouth, to prevent diversion.

Sublocade could be an excellent option for buprenorphine patients. This is an injection that can be given once monthly, so that the jail personnel would only need to bring that patient from the jail to the provider once per month for their injection, instead of worrying about daily dosing. And with the injection, diversion of medication would not be an issue. Soon, we may have weekly injections available, also eliminating fears of medication diversion.

My point is that I believe we can work together to find solutions to every possible problem raised by continuing patients on life-saving methadone and buprenorphine, if only we have the will to do so.

These half-assed, county jail “detox protocols” must stop. They are insufficient to prevent withdrawal, not evidence-based, and they place patients at unnecessary risk of overdose death once the patient is released. They interrupt a legitimate medical treatment that has more evidence to support it than nearly anything else we do in the field of medicine.

Medically fragile patients can die from improperly treated opioid withdrawal during incarceration. I’ve blogged about this before. Who can forget the case of David Stojcevski, who died from benzodiazepine and methadone withdrawal, sixteen days into his incarceration? He lost forty-four pounds and suffered from hallucinations and seizures during his time in this county jail. The family brought lawsuits against the county jail, which still has not been resolved. The county jail employees pointed their fingers to Correct Care Solutions, a company that was supposed to have provided medical care to their inmates. Of course, Correct Care Solutions pointed their fingers at county jail employees. Since all this happened, Correct Care Solutions was bought by another company and merged into Wellpath LLC. This new company is also plagued with lawsuits alleging improper care of inmates. [2]

I’m going to continue to tell my patients facing incarceration about recent lawsuits, and I’m going to continue to point them towards the Legal Action Center in New York, and our state’s chapter of the ACLU. I’d love for one of my patients to make a little history in the cause of patients’ rights.

And I’ll testify for my patients for free, with pleasure, if I am asked.

  1. https://www.lac.org/news/dupage-county-sheriff-sued-for-access-to-life-saving-medication-to-treat-opioid-use-disorder
  2. https://www.metrotimes.com/news-hits/archives/2020/03/12/lawsuit-targets-billion-dollar-company-making-life-and-death-medical-decisions-in-michigan-jails

The Future of COVID Take Home Doses

This may be a controversial blog post. I’ve been mulling over the ideas I’m presenting in this blog for many weeks and have changed my mind several times. So don’t get too upset with what you read, because I may have changed my mind again by the time you read it.

The events of this past year have given us experiences and information, and it seems prudent to learn what we can from them.

In the spring of last year, state and federal authorities moved quickly to allow patients enrolled in opioid treatment programs to receive more take homes doses than usual. They did this to reduce the risk of patients’ exposure to the COVID virus. Most opioid treatment programs were able to give many more take home doses of buprenorphine or methadone than ever before. This cut down the number of patients physically present at OTPs at any one time, thus creating more social distancing than ever before.

Now patients – and providers – are wondering what will happen after our country no longer has a high risk of COVID transmission in crowds. Will the previous regulations snap back into place? Will patients receiving extended take home doses now be asked to come more frequently and give up the convenience of extra take home doses?

In my state of North Carolina, as I understand it, once the state is no longer under a “state of emergency” declaration, the permission to give extra take homes to patients will no longer exist.

I’m not sure what state and federal authorities will advise, but I have some thoughts.

As I see it, we have two sets of questions. The first is what to do about patients presently receiving extra take homes. The second is deciding if information from events of the past year should cause us to change regulations about methadone take home doses.

At my opioid treatment program, we have about half our patients dosing of buprenorphine and half on methadone. Because of its better safety profile, buprenorphine patients already get take homes more quickly than methadone patients. So, my next paragraphs will be about patients being prescribed methadone at opioid treatment programs.

Let’s take the first question: what shall we do about patients who are getting extra take homes now? This has been an unusual time in history – I hope – and we have a cohort of patients who were suddenly given many more take homes than they were accustomed to getting.

Some patients had problems with those extra take homes. They came back to the opioid treatment program early, saying they didn’t know what had happened to the extra doses, or that the nurse hadn’t given them extra doses, or that some other person stole their medication. These problems almost always came to light within the first few months. Those patients were not ready – at that time – for extended take homes, though they may be able to do so in the future.

However, most patients with extra methadone take home doses did well. We’ve done bottle recalls (like pill counts done at pain management clinics) and most patients brought their bottles back in with the correct number of bottles untouched, with the appropriate amount of medication contained in them. This reassures us that these patients can take only one dose per day and are able to store it safely where it won’t be stolen or tampered with. Most of these patients have been reachable by their counselors for weekly in-person or telehealth meetings, showing further evidence of stability.

For patients who have proven their ability to manage their take home doses, it seems counterproductive to reduce the number of take- home doses again after the COVID emergency passes. Why would we want to do this? So long as patients have been making appropriate contact with their counselors at their programs and are doing well, I will advocate for them to stay at their advanced take homes. I might have to submit an exception to get permission for this from state and federal authorities, but that’s easy to do, and would seem a reasonable request.

Then comes the question of what to do with these patients if they have drug screens positive for illicit drugs. Should these patients move back to daily dosing? What if the only illicit drug they use is THC? Before the extra COVID take homes, our state said patients who remained positive for THC couldn’t advance past a level 1, which means they had to come every day but Sundays. In the past, I agreed with this policy. I reasoned that people using THC weren’t as stable as those not using it.

Now I have changed my mind.

Don’t misunderstand. I am no fan of marijuana. I think it can hold patients back in some insidious ways. It’s not harmless, as some people think, but neither is it a toxic substance, like alcohol is. Some day we may have beneficial medications derived from the marijuana plant, but at present, lighting the plant on fire to inhale the smoke isn’t a medically safe way to ingest those chemicals. We know marijuana use affects adolescent brains adversely, but even in adults, it can shave off IQ points, and may interfere with motivation to make life changes.

However, regular marijuana doesn’t cause the chaos that other illicit drugs cause.

 Since COVID, I’ve seen many patients, long-term smokers of marijuana, managing their additional take-home doses quite well. They appear as stable as non-smokers of THC. I don’t see that it would help anyone to revoke those take-home doses, and it may benefit some of these patients to be able to give even more take homes. At present I am more open to such ideas than I ever have been in the past.

Patients using alcohol and other sedatives are not getting extra take homes at the opioid treatment program where I work, due to the dangers of mixing methadone with sedatives. I have not changed my mind about that.

What about stimulant use? We’ve seen an uptick in methamphetamine use over the past several years, and some of those patients are getting extra take homes now. Some are not, depending on an assessment of each patient’s overall stability. I have not been consistent with decisions about take home doses for such patients, because stimulant-using patients can differ widely.

For example, one patient has tested positive for methamphetamines for about a year, but she has a job, a stable relationship, and no apparent clinical decline, at least thus far. But another patient tested positive for methamphetamines for two months. Since then, his family committed him once to a mental institution for a few days, for auditory hallucinations related to drug use. He’s lost twenty pounds in two months and is twitchy and easily distracted when I try to talk to him.

I was generous with take homes for the first patient and denied take homes to the second one. Of course, the second patient feels like this is unfair towards him. After the COVID take-home exceptions end, should both patients be moved back to daily dosing?

Let’s move on to the idea of changing existing take home regulations. There are eight criteria that patients ordinarily need to meet to get take home doses of medication. In an abbreviated form, these are:

  1. No ongoing drug or alcohol use
  2. Regular attendance
  3. No serious behavioral problems at the OTP
  4. No recent criminal activity
  5. Stable home environment
  6. Ability to store medication safely
  7. Benefits of take homes outweigh risks of diversion
  8. Time in treatment

I agree with all these requirements, except perhaps the last one, which I feel is the most restrictive. Federal and state authorities have firm regulations about how soon a patient, doing very well otherwise, can be granted take home doses, based only on how long that patient has been in treatment. New patients can receive up to one take home dose per week for the first three month, then if all is going well, can get three take home doses per week for the next three months, then four doses per week for three months, etc. At the one-year mark, even an extremely stable patient will need to come once per week for a year.

That’s a long time, and perhaps unduly restrictive for many patients.

Before readers criticize me for risking lives due to putting methadone at risk for diversion, let me explain that I do know how much harm methadone take homes can cause in the wrong hands. I can tell you horror stories about diverted methadone, but I won’t do that now.

But on the other side, more patients thrive with extra take- home doses, able to feel less stress about getting to their OTP in time to get dosed and get to work on time. They can spend more time with their families in the morning hours. That’s worth quite a lot.

If we decide to revisit our present methadone take home schedule regulations and ultimately relax them a bit, it will fall to treatment center staff and ultimately the medical director to decide if a given patient is stable enough for take homes. That means the medical director will need to know her patients well. This requires time at the opioid treatment program and involvement with the patients. That should already be happening, but I know that’s not always the case.

Here are a few of the warning signs we’ve seen that can indicate problems forming: coming in a day or two early to dose, even when the patient should already have take-home doses; being unable or unwilling to give urine drug screens; giving falsified urine drug screens; counselors being unable to reach the patient for telehealth counseling sessions; poor attendance or repeatedly coming at the last minute to dose; new mental health issues or new physical health issues, and unexplained change in appearance or affect.

Since the medical director is ultimately responsible for the consequences of methadone take-home doses, the medical director needs to be made aware of any warning signs seen in patients, aside from positive urine drug screens. The medical director needs to know the patients well, and have input from counselors, nursing, and even front office staff when making these important decisions. Therefore, time for case staffing, sometimes also called treatment team meetings, is so important.

At the OTP where I work, we usually have case staffing twice per week, and it includes medical and counseling staff. We make decisions about take home doses at these meetings. Sometimes we disagree, and that’s good. It means differing opinions are being voiced. Sometimes emotions run high, a reflection of the importance of our decisions to patients. It’s often a difficult process.

But because of the importance to patients, perhaps take-home regulations should be re-evaluated at national and state levels, in the light shed by our recent experiences with the extra COVID 19 take home doses.

Never mind….

You know that blog I posted a few weeks ago, about DHHS’s decision to allow any physician with a DEA license to prescribe buprenorphine products for their patients with opioid use disorder? That idea has been nixed. SAMHSA said HHS’s decision to announce the change of regulations to have been “premature.”

I have no idea what political machinations were behind all of this, but Medscape’s webpage said loosening the restrictions was an idea put forward by Trump’s administration, and Biden’s administration cancelled that plan.

Many addiction medicine specialists were wary about the idea of loosening restrictions, fearful of the consequences if any physician could prescribe buprenorphine without the mandatory training course. That eight-hour course teaches providers about opioid use disorder in general and specifically about how to prescribe buprenorphine products from an office-based practice to treat that disorder. They say prescribers need this education, since for decades it was illegal to treat opioid use disorder from an office setting. Consequently, most physicians don’t know much about treating addiction, and may mistakenly think it’s the same thing as treating pain.

On the other hand, eliminating the need to take this course could encourage more doctors to prescribe buprenorphine products to treat opioid use disorders, thus expanding access to treatment.

I’m not sure what I think.

 On the one hand, I’ve seen providers with no training or “X” number prescribing all sorts of buprenorphine products for years, and not always with the diligence I would hope for.

For example, several months ago I reviewed a new patient’s data from the North Carolina prescription monitoring program. I saw the local pain clinic had been prescribing an extended- release full opioid agonist, along with a short-acting full agonist for breakthrough pain for many months. Then I saw the Butrans patch (contains buprenorphine) was added to this regime of medication.

I asked the patient what happened when they started the Butrans patch.

“Oh I found out I was allergic to it. It made me very sick. I felt like I was back in withdrawal. I can’t take that medication.”

Of course, that was no allergic reaction. That was precipitated withdrawal, predictable to providers familiar to the pharmacology of buprenorphine. But now this patient is convinced that buprenorphine in any form will make her sick under any circumstance. She was started on methadone and has done very well, but it is a shame she had to be put through that nightmare.

However, another prescriber, this one who took the eight-hour course and who has a DEA “X” number, starts all patients at a dose of buprenorphine/naloxone 32/8mg per day (four of the 8/2mg tablets) and tapers down over a period of several months until the patient is off the medication completely. Apparently this prescriber wasn’t paying attention to instructions given at the 8-hour training course about how to do induction. Or how to do maintenance. Or that most patients need much longer than several months on the medication to remain in recovery, and few need any higher dose than 16 to 24mg per day.

Then there’s another prescriber in town, also with her DEA “X” number, who accepts methadone patients from our opioid treatment program and starts them on buprenorphine without asking for any data from us. We only find out about the patient’s medical misadventures when their counselor calls them, to find out why they’ve missed days of treatment with us. The patient says he told the prescriber what dose of methadone he was currently on, and but prescriber asked the patient to miss one or two days of methadone before she started a sublingual buprenorphine product.

If they patient was on a dose of 40mg or less for at least a week, everything will go well. But if the patient’s been dosing at 110mg per day, per example, and missed a few days…things usually don’t go well. The patient ends up in precipitated withdrawal, which is completely predictable. If we are lucky, we can get them back into treatment right away.

At our opioid treatment program, we switch patients all of the time, though much more slowly. My usual “recipe” for switching involves tapering by 5mg per week, down to 40mg, where they dose for at least a week. Then the patient misses two days and sees me on the third day. If they are in sufficient withdrawal, with a COWS greater than 12, I feel safe starting them on buprenorphine. I usually end up dosing them with between 4 to 8mg on that first day.

Anyway, my point is that most of these prescribers, who took the eight- hour course, don’t necessarily do things as I would hope they learned in the course. But perhaps it would be worse if buprenorphine prescribers took no course.

My opinion about this issue rockets from one side to the other faster than a tennis ball at Wimbledon.

I can’t decide what I think. I read opinions from leaders in the field that say untrained prescribers could lead to disasters, and I know they are correct. Then I read from other leaders in the field that increasing access will save lives and I know that’s right, too.

I have no conclusion for this blog post. I’m just acknowledging uncertainty.

My Quest to Get the COVID 19 Vaccine

In North Carolina, hospital systems are immunizing their staffs for COVID. These systems also own many doctors’ offices and immunize their personnel at those offices too. But local county health departments have been assigned the chore of providing vaccines to the public.

Most opioid treatment programs (OTPs) are not part of health systems. During our weekly state-wide opioid treatment provider teleconferences, we’ve discussed how and when OTP staff can get COVID 19 vaccines.

The medical staff, including nurses, physicians, and physician extenders, are categorized as 1a priority for vaccine, and for counselors and OTP office staff, consensus seemed to be they were also 1a, or 1b according to some county health departments.

Like my co-workers, I got notification that the opioid treatment program where I work, owned by Acadia Healthcare, will not be offering vaccinations to patients or their healthcare workers at the programs. However, they do encourage providers to obtain the vaccine.

So, I was left to find the vaccine on my own.

Our local hospital immunized most of their workers near the end of December. Beginning in late December, our local health department started giving the vaccine to other community members, as they received doses from the government.

I went to our county’s health department website and was pleased to find a form to fill out with my name and data. I was under the mistaken impression that submitting the form meant I was requesting the vaccine. That was not the case. The form was a survey regarding potential interest in getting the vaccine. I got a polite email from the health department telling me to be sure and call if I needed the vaccine.

So I did. Our OTP works with our health department, so we had some contacts there. I called them but could not get through to our contact person or any other human, so I left a message. I was called back by a pleasant woman who told me to call the next week, since they were already out of vaccine, and perhaps some would be available the next week.

Many of my colleagues at other OTPs in other counties already got their vaccines, usually by appointment at their health departments.  I was feeling a bit left out of things.

Last week, I called their number again and got a general message: more vaccine had been received and “appointments were not necessary.” The vaccine would be available on a first come, first serve basis, starting at 10am at a drive-through site, only for people in the 1a and 1b categories. On previous vaccine drive-through days, they have run out of vaccine rather quickly.

I’m usually at work on weekdays, so I had to ask to leave work at 9:30 that morning, to get in line at our health department.

My fiancée, whose schedule is less structured than mine, reconnoitered for me that morning. He went to the old airport where the vaccines were being given at around 8:30am, only to be turned away by a policeman who told him that the vaccines were already all gone, and that people had been camping out there at 2 am to be first in line for the vaccine. Disappointed, he let me know there was no reason for me to leave work that day.

So, I stayed and worked as usual, thinking I wasn’t going to be able to get a vaccine that week. But then at around 11:30 one of the employees told me two of her elderly relatives had just received the vaccine after waiting in line for two hours. They got to the site at 9:30.

This made no sense, since my fiancé had seen many cars being sent back home at 8:30am. I put it out of my mind until after we finished up case staff at around 1pm.

Later, we discovered local police, helping manage crowds, mistakenly sent people back home because they thought the vaccine was already gone when it was not.

As I was leaving work around 1pm, I thought I’d drive the extra ten minutes out of my way home, just to see for myself what was happening – or not happening.

I kept thinking how silly I was to think there would be any vaccine left this late in the day, but I pushed on. I passed a flashing sign giving directions to the vaccine site. That was promising. Surely the sign would be off if everyone was gone. I turned the corner and saw a squadron of flashing police lights and lines of cars.

I pulled up behind one line and after several minutes a helper came to my window and asked if I had the correct forms. I told her I had the forms I downloaded off the Health Department’s website. She took them from me and peevishly told me they weren’t the correct forms. She took my temperature and asked about recent illness including cough and fevers. I answered no to all, and she gave me a card with a number on it.

I was in line to get my vaccine!

Hurriedly, I called my fiancé to let him know to return for the vaccine, since he’s also in the 1a risk group. I also texted other co-workers also wanted to get the vaccine. Thankfully, two other co-workers made it in time to get vaccinated.

The health department nurses couldn’t have been nicer, and the shot was a breeze. I remained in my car the whole time and got a card with the vaccine name and other information with a reminder of when my second dose was due. This whole process took maybe twenty minutes.

Then after the injection, people waited in a line of cars, because we had to wait 20 minutes to see if we were going to have a reaction.

And if you think anyone was leaving that parking area one minute early, you are mistaken. At the eighteen- minute mark, an EMS worker asked me how I was feeling, I said fine, and she said something I mistakenly thought meant I could drive away. Nope. A stout policeman literally jumped in front of my car to block my exit. He shook a finger at me. I obediently stayed four more minutes until I was permitted to leave.

My arm was sore at the injection site for two days, about the same feeling that I get with the yearly influenza vaccine. I did have body aches the day after the vaccine but was able to work as usual, though I took a few Tylenol to ease the aches. I’ve felt fine since.

These county health departments have been poorly funded for years. With relatively small budgets, the health departments have been trying to provide medical care for the many uninsured patients of the county. Now we’ve asked these health departments to perform the most daunting task of the century: get a COVID vaccine to any person who wants one. I admire their resolve to get the job done and I’ll happily overlook any inconveniences presented.

I was happy to see local police and EMS services on the site to help with the task. I thought that was a great idea. They held this drive-through vaccine program on an old airport runway, which was perfect for the purpose

I was thrilled to get this vaccine. I was thrilled the wait was very brief and I didn’t have to miss any work. I was especially happy that my sweet fiancé was also able to get vaccinated. I hope it can be quickly distributed to any person who wants one.

I was surprised that at the opioid treatment program where I work, out of around twenty-five employees, only five of us wanted to get the vaccine. I think that may change with time, as more people are vaccinated.

I still wear a mask to work and to the grocery, the only two places I need to go. I know I can still spread COVID, and it’s still possible to get sick with COVID between the two vaccines in the series, though I’m less likely to get severe illness.

Early on, I wasn’t sure about the vaccine, and told people that I didn’t want to be the first person in line to get it and I didn’t want to be the last one either.

One of my patients helped me adjust my thinking. She participated in the Pfizer vaccine trial, and we talked about this last fall. I told her I admired her courage. She said courage had nothing to do with it. She entered the initial clinical trial because she wanted to be able to tell her grandchildren that she did something to help mankind overcome this threat to us all. Even if the vaccine wasn’t successful, she was willing to take a risk to help other people.

I admire her generosity of spirit. Her outlook is more like, “What can I do to help others?” rather than, “What will be best for me?”

As always, my patients continue to teach me.

Health and Human Services Seeks to Expand Buprenorphine Services

Last week, the U.S. government’s Department of Health and Human Services announced new guidelines intended to expand access to treatment for patients with opioid use disorder. [1]

 My reading of this announcement is that HSS is exempting prescribers from obtaining a waiver to prescribe buprenorphine products from office-based practices. It appears to mean that physicians no long must take the eight-hour training course that is necessary to get a DEA “X” number waiver. Physicians only need a valid DEA license that covers prescribing Schedule III controlled substances. Physician extenders such as nurse practitioners and physician assistants must still go through the extra training already in place, however.

Non-waivered physicians can start prescribing buprenorphine products to up to thirty patients at any one time. The thirty-patient cap doesn’t apply to hospital-based physicians like those working in emergency departments.

This change applies only to buprenorphine products and does NOT apply to the prescribing of methadone for opioid use disorder. That medication must be prescribed from an opioid treatment program, as it has been.

HHS says that physicians can only prescribe buprenorphine products to patients residing in states where the physician is licensed and must keep separate charts for these patients. I think both things are already required. If they want to prescribe for more than thirty patients at a time, they will need to get the usual DEA “X” number. Prescribers must also put an “X” on the prescription to indicate it is being prescribed for opioid use disorder and not for pain.

HSS also says an interagency group will be formed to monitor implementation of these services.

For the past twenty-one years, we’ve tried to convince medical providers that instead of viewing opioid use disorder as a crime, we need to treat it as the chronic medical problem that science shows that it is. Trying to reverse a near-century of bad policy (the time from passage of the Harrison Act until the DATA 2000 Act) has not been easy.

Then our present epidemic of opioid use disorder with its corresponding epidemic of death started at the end of the 20th century and it grew like cancer into this century.

This has been a tough year for more than just COVID deaths. A record number of people – around 83,000 – died from opioid overdoses over the twelve months ending in June of 2020 in the U.S.

 We know prescribing buprenorphine products (or methadone, by the way) to patients with opioid use disorder is life -saving. Mortality is reduced at least three-fold by the most conservative estimates. I challenge anyone to name any other medical intervention that has such an impact and reduction of mortality. Yet medical providers haven’t been enthusiastic about providing this treatment. Old ways of thinking have been hard to challenge.

The new guidelines intend to loosen restrictions on prescribing buprenorphine products. People in the government fear that the eight-hour course to get a special DEA number is keeping physicians from prescribing buprenorphine products. Many patients with opioid use disorder have a hard time finding prescribers with the waiver to treat, and the Department of Human Services wants to make it easier for these patients.

Both the American Medical Association and the American College of Emergency Physicians praised the change in policy.

Not surprisingly, I have some thoughts about this change in HSS policy.

Weirdly, my first thought was, “Wow, someone is going to have to tell all the CVS pharmacists because they are going to lose their minds about this.” Readers of my blog may recall the comical insistence of CVS pharmacies that providers to include a “NADEAN” number in a specific format before they will fill any buprenorphine product.

Overall, I agree that dropping training requirements may make providers more willing to prescribe buprenorphine products. Providers may not be as educated about buprenorphine before starting to use it, but other than causing precipitated withdrawal, it’s hard to kill anyone with it.

We experts may not like to admit it, but just providing the medication saves lives. Even with no psychosocial counseling and very little provider interaction, lives are saved if patients just take the medication. Ideally, the medication should be provided in concert with counseling, but some patients aren’t interested in counseling, for whatever reasons.

There may be diversion if physicians with little experience miss evidence the patient is selling medication. I hate to see diversion, even as I recognize the benefits of buprenorphine when used off the black market. I also know that every day a person with opioid use disorder takes buprenorphine instead of fentanyl, the risk of overdose is decreased. And that’s worth a lot.

Will dropping the eight-hour training requirement prompt more physicians to prescribe buprenorphine? Perhaps, but as I said above, it’s hard to convince doctors that this is a disease that can and should be treated, and not criminalized.

Here’s the biggest value I see with these new guidelines: hospital-based physicians can prescribe buprenorphine without needed the “X” DEA number.

For years, I’ve wished our local emergency department physicians would start buprenorphine when they see patients with opioid use disorder. They have not, partly because they say they don’t have the required “X” number, and partly because they say they don’t have anywhere to refer patients newly started on buprenorphine products.

This new guideline will eliminate the first problem, and the second problem has already been solved. Our opioid treatment program does intakes five days per week, Monday through Friday. Even if the patient is seen on a Friday night, the emergency department physician could write two days of medications to last until we can evaluate and admit the patient on Monday.

And there are three or four office-based providers of buprenorphine in the community now, as well as another good opioid treatment program. Surely we can all get together to make a plan to admit a patient to treatment very quickly.

I plan to keep pushing for this, because the studies show the reduction in the risk of overdose and death. At some point, it will be malpractice NOT to provide life-saving treatment to people with opioid use disorder.

Hopefully we will continue to make progress. That’s why I started this blog in 2010. I wanted a platform to tell people about the mountain of evidence to support the treatment of opioid use disorder with medications and get patients and providers interested.

Change takes time.

And change also takes patience and perseverance.

  1. https://www.hhs.gov/about/news/2021/01/14/hhs-expands-access-to-treatment-for-opioid-use-disorder.html?mc_cid=d21a328f2d&mc_eid=9c7edff92d

Compassion

Maybe with all the suffering around us, it’s easier to feel compassion. I don’t think I’ve had a year when I felt more concerned about other people, to the point I pray more for them, have donated more to charitable organizations, and even started donating blood on a regular basis. I’m not bragging; I’m just happy I’ve felt more like doing these things. I’m at my best when I have that feeling of wanting to be helpful, and I tend to be happier with myself.

I am not, by nature, a very compassionate person. Left on my own, I can be judgmental, the opposite of compassionate. But I don’t want to be that kind of person. Thankfully, over the past twenty-plus years that I’ve been in recovery from substance use disorder, I’ve learned a few things. I’m better at recognizing my own negative attitudes and challenging them.

 It helps me to be around other compassionate people. I’m grateful I have such people in my life; my sister has natural compassion, as do many of my friends and my best friend of all, my fiancé. Spending time with these people helps change my outlook.

 Prayer helps change me. I ask for compassion each day on my way to work. I pray to be able to see people as my Higher Power sees people and to treat them accordingly. I also read books that help me cultivate compassion. Alternatively, focusing on negative content in my conversations and reading can dampen my mood and tip me into more pessimistic attitudes.

Compassion doesn’t always look warm and fuzzy. Sometimes true compassion leads to difficult conversations, odd as that sounds. It can even lead to conflict, if I don’t remember to be respectful. If I didn’t feel compassion for patients, I wouldn’t take pains to talk to them about their lives and their desires for change.

No one is compassionate all the time. I have my early warnings that I’m slipping back into old patterns of thinking. For example, when I start making sarcastic jokes at other people’s expense…not good. I can justify by saying I’m blowing off steam and I’m only joking, but as a close friend pointed out to me, sarcasm is “flesh-eating” humor. It can be damaging to the person who is the butt of the joke and corrosive to me.

When I start muttering negative things under my breath at work…not good.

So, what do I do when I start feeling negativity?

First, I don’t have to express it. Expression of negativity contaminates my workplace. It can make my home life feel heavy. I try to keep it to myself. It’s my issue and I don’t need to make it my co-workers, patients, or friends’ issues.

Next, I try to decide why I’m feeling what I’m feeling. Usually, it’s because I’ve decided other people aren’t acting like I want them to. I’ve slipped into a pattern of thinking that other people, organizations, politicians, whatever, need to conform to my ideas for them. Which brings up the real issue: such an attitude shows I haven’t accepted the basic truth that there are many things in the world that I can’t control and shouldn’t try to control.

When I can accept people as they are, while still being willing to extend myself towards them when they request help, I’m in a good place.

Compassion helps me do my job better. Patients wanting help are more likely to engage in treatment when they sense their helpers are rooting for their success, and willing to go an extra mile to help them. Patients sense these things; a helper who is just going through the motions doesn’t inspire patients effectively.

I started to write this blog thinking that compassion is a difficult subject; the blog post could end up being a self-serving treatise extolling my virtue of compassion. Or it could reveal how much I struggle with compassion because at heart, I’m not a very nice person. I hope this blog post has threaded the middle ground by presenting the message that we can feel and act with more compassion by practicing, like any other habit. We can also refuse to cultivate more negative personality traits, like negative thinking and speaking. I’m not saying we should ignore problems when we see them, but rather try to focus on solutions.

Anyway, I hope 2021 is a better year for all of us. May we all feel more compassion for ourselves and others, and struggle less with negativity.

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.