Buprenorphine Can Reverse Methadone Overdose

 

 

 

In the February 2020 issue of Critical Care, Zamani et al. described a trial of the use of buprenorphine to reverse methadone overdose. This was only a pilot study, with a relatively small number of subjects. The study found intravenous buprenorphine appears to be safe and effective for use in people who have had an opioid overdose.

This study randomized 85 patients with respiratory depression from methadone; 56 received buprenorphine and 29 received naloxone. One person out of each group failed to respond to the medication given.

Fewer patients had to be intubated in the buprenorphine group, and fewer had precipitated withdrawal compared to the patients randomized to naloxone. None of the patients in the buprenorphine group died or had serious complications.

This study was done in a busy emergency department of an Iranian hospital that treats up to 28,000 poisonings annually. The protocol was only for patients who had overdosed on methadone, and they had to meet certain criteria, such a low blood oxygen level and low respiratory rate.

The patients in the naloxone group received from .04mg to 2mg intravenously depending on the rate of respirations, and re-dosed at 2-3-minute intervals. Once the patient responded, they were placed on a naloxone intravenous drip.

Patients in the buprenorphine group were further randomized to two doses; one group was given 10micrograms per kilogram intravenously over 6-9 minutes, and the other group was randomized to 15micrograms per kilogram intravenously over the same rate.

For all three groups, if treatment failed to reverse the overdose, the patient was intubated, and the treatment counted as a failure.

This is a fascinating study and lends support for the use of buprenorphine for opioid overdoses.

In this study, the buprenorphine was administered intravenously, but I’ve heard patients tell me it works sublingually. Over the past five years or so I’ve had two patients tell me – and this is third hand information, but still – they know of a person who had overdosed on opioids and someone on site had sublingual buprenorphine. They placed the buprenorphine in the unconscious person’s mouth, under the tongue, and they regained consciousness some minutes later. At the time, I marveled at the creativity of whoever thought to use that buprenorphine. Of course, they also called 911.

If I had both medications available to me, I’d still use the naloxone because of its proven efficacy, but this study hints that buprenorphine could possibly be of use too.

If naloxone can’t be obtained within a few minutes, placing buprenorphine under the tongue of the overdose victim could provide some benefit, in addition to rescue breathing and calling 911.

Just as a reminder to my readers, people who inject heroin or other opioids should use harm reduction ideas to reduce risk. These include:

-Don’t use alone. Use with someone present so that they can call for help or deliver naloxone if needed.

-Alternate dosing times. Someone in the room should remain “straight” while others inject, to be available to render help.

-Use tester doses. This means use a tiny amount of the material before preparing a usual shot. If the drug has more fentanyl than usual, the tester shot may warn the user that it is very potent.

-Don’t mix drugs. Sedatives like alcohol and benzodiazepines can suppress respirations and lead to overdose in people who are also using opioids of any kind, including heroin.

-Use new needles and clean equipment when injecting. Many more sources for free new needles are now available.

-Get a naloxone kit and use if needed. If you can’t get one from a pharmacy, contact your state’s harm reduction coalition.

-Consider enrolling in medication-assisted treatment for opioid use disorder.

 

  1. https://ccforum.biomedcentral.com/articles/10.1186/s13054-020-2740-y#Sec1

Something Great Happened Today

 

 

 

 

Today we admitted a young man to our opioid treatment program who was referred from a Big City Hospital, where he was started on buprenorphine/naloxone. Everything happened exactly like it should, and the patient got excellent care. This should happen everywhere.

This patient went to the emergency department at Big City Hospital at the urging of his family, who recently discovered he had opioid use disorder. They were worried about him and convinced him to seek help at the hospital close to them, BCH.

Big City Hospital admitted him for detoxification and started him on a low dose of a buprenorphine product. Over the four days that they kept him, they slowly increased his dosage to a total of 8mg per day. At that dose, his withdrawal symptoms resolved, and he had no cravings to use illicit opioids. BCH also drew blood from him, and he tested negative for infectious diseases and other medical problems.

Once he was stable, the social worker at Big City Hospital needed to find a program or provider  his community that could take over his care. As it happened, he wanted to move away from where he’d been living. He feared his friends, with whom he’d using drugs, could lead him to relapse back to drug use. He decided to move in with some supportive relatives, who happen to live near our opioid treatment program. The social worker called our program and arranged an appointment for admission for the day after he was to leave BCH.

BCH gave him a dose the afternoon he was discharged from their hospital, and he kept his appointment with our program early the next morning. He was just starting to feel a little withdrawal from his last dose of buprenorphine. Big City Hospital had already faxed his records to us, so those were available for me to review.

He was a nice young man from a good family who had fallen, as so many have, into opioid use disorder before he knew what was happening. He had a strong desire to change his life and leave his addiction behind. We continued his dose of buprenorphine products, and started intensive counseling right away.

I’m so happy that appropriate treatment was offered to this young man at the time he reached out for help. He was admitted, started on treatment and then transferred to us without any gap in treatment. A successful inpatient treatment episode flowed seamlessly into our outpatient program, without relapse and without the patient being forced back into withdrawal.

All worked as it should. It’s not that hard.

So how can a large hospital nearly a hundred miles away refer a patient to us but we don’t get referrals from our local hospital a few miles away?

My answer is that though our local hospital is close in miles, it’s far away in its ideology about the role of buprenorphine and methadone in the treatment of patients with opioid use disorder.

However, there’s reason to hope that this is changing.

A few weeks ago, I was asked to come to the hospital to give a presentation of opioid use disorder and its treatment with medication for nursing personnel. I was thrilled. Our program director and clinical director were thrilled. We scheduled a “Lunch ‘N Learn” for noon, with the hospital graciously furnishing the food.

I was surprised and pleased when a room full of people showed up for my talk. The head of pharmacy was there, who has always supported MAT, with a few pharmacy students. None of the staff nurses were there, but nursing supervisors were, and some people from our local mental health agency, who just got a grant to care for pregnant ladies on MAT. We had the director of the local health department, who has always been supportive, and many other people. Two doctors and at least two physician assistants were there too.

I gave my usual 50-minute presentation, and the audience asked great questions when I was done. Then, to drive the message home, we had a former patient tell her story of life on methadone, off methadone, and now back on methadone. She has that gift of speaking from the heart, and I think she helped inform audience members more than anything I could have said.

I wanted to get copies of TIP 63 to pass out to all people in the audience, but it was bad timing – TIP 63 wasn’t available because it’s being re-done. I like to give people TIP 63 because when they challenge me on this point or that, it contains all the pertinent studies supporting what I say about MAT.

One audience member appeared to disapprove of starting pregnant patients with opioid use disorder on methadone or buprenorphine. She claimed that all babies born to moms taking these medications had withdrawal when born, and that the withdrawal lasts for many months. I tried to describe the results of the MOTHER trial, done right here in North Carolina, since it was one of the most recent landmark studies.  It showed that around 50% of babies born to moms on buprenorphine or methadone have withdrawal bad enough to need medication, and that babies born to moms on buprenorphine had much less severe withdrawal and stayed in the hospital about half as long as babies born to moms on methadone.

I did not get through to her. I sensed she relied much more on her own perceptions and experiences than on data from research studies done on hundreds of patients.

Despite that disagreement, I thought the event was a great success.

Now we are asking to come back and do another presentation for the staff nurses.

We’ll keep trying. Someday I hope to see a local patient who arrives in our local hospital’s emergency department, gets diagnosed with opioid use disorder, is treated in a respectful and compassionate way, gets started on buprenorphine and then gets referred to our opioid treatment program (or other MAT program) right away.

I’d like to see a Big City response to our rural crisis.

Revoking Methadone Take Home Doses

 

 

 

(The information presented has been changed to protect patient identity.)

Last week, staff at our opioid treatment program had a lively discussion about take home doses for a patient on methadone. She’s been in treatment for several years and was on take home level five, meaning she dosed on premises once per week and was given six take home doses. We needed to talk about revoking her take home levels because she was recently arrested for sale of a Schedule II narcotic.

The news of her arrest surprised us. She passed several bottle recalls, which is when we call a patient and give them twenty-four hours to return to the opioid treatment program with their take homes, so we can inspect them to make sure they haven’t been taken early or tampered with in any way. We do this because the state and federal regulations demand it and because it’s good practice. It’s like pill and film counts done by pain clinic providers and office-based buprenorphine providers. She hadn’t failed any of our bottle recalls.

As a treatment team, we discussed her situation at case staffing. (Twice a week, the nurses, counselors, and doctor meet to talk about the needs of newly admitted patients and the progress of other patients, among other things. We also discuss patient who are ready to advance in their treatment and get more take home doses, and those who aren’t managing their home doses as well as we’d like.)

Unfortunately, the patient in question had her picture published in the local paper along with an article describing her alleged criminal misdeeds. Both state and federal regulations say patients enrolled in opioid treatment programs aren’t allowed to receive take home doses if there is “recent criminal activity.” I suppose the officials think that if the patient is involved in criminal activity, there’s a risk the patient could sell take home medication on the street.

I understand this reasoning. And if the patient is accused of selling drugs, I don’t want to provide the patient with a drug they can sell.

But this regulation raises all sorts of questions. What constitutes criminal activity? Does driving to the treatment program without a license count as criminal activity? And what’s “recent”? Last week or last month would count to me, but what about a charge from two years ago that’s just come to trial?

And are we talking about criminal convictions only? Or is being arrested enough proof the person has been committing crimes? Sometimes criminal charges are dropped after more investigation.

What is the standard of proof that we need to use? Is an arrest alone enough to say the patient is engaging in criminal activity? Most patients, when confronted, insist that they have been set up by another person and that they don’t usually sell drugs, but were pressured to do so by a police informant who is trying to reduce their own legal woes.

I know this happens. Local police do use the people they’ve caught selling drugs to try to set up other people to do drug buys in order to charge them too. But if they allow themselves to participate in sales, that means they broke the law.

In my patient’s case, I was worried she had sold her methadone take homes. Eventually, she brought in a copy of paperwork she had been given by the police, and it appeared she’d been arrested for the sale of a handful of oxycodone pills.

But as her counselor said during case staffing, being charged isn’t the same as being convicted, and isn’t a person considered innocent until proven guilty? Another staff member said that applied to the criminal justice system, when a person may be denied their freedom, but in an opioid treatment program that standard of proof wouldn’t apply.

It’s a thorny issue. Patients must wait months to get take home doses, and after they’ve earned them, are extremely disappointed to have them revoked. I understand this; people need to plan their time, and dosing at the opioid treatment program claims time they could spend doing something else.

Some people will ask what’s the big deal? What’s a little more methadone on the street compared to the deadly fentanyl that’s covering the nation? It is a big deal to me, because methadone has (as Dr. Wartenburg says), “No sense of humor.” It’s easy to overdose and die with methadone because of its very long half-life. People take a little methadone, don’t feel much, take more, and by the time they feel a euphoria, they’ve taken a fatal dose.

It’s a dangerous drug to have on the street.

What if the patient were on buprenorphine instead of methadone? Since it is a considerably safer drug, would I still revoke take homes? In this situation, yes.

Opioid treatment programs want to keep our patients alive and to help them lead their best lives. And we also have an obligation to our communities to be good citizens. We don’t want to promote the black market use of any drug, and diverted buprenorphine, though safer than methadone, can still kill an opioid-naïve person or a child

When this patient was told that we were revoking levels, she blew up with rage. She felt she was being treated very unfairly, since no one had proven she’d done anything wrong. We tried to tell her this is a state regulation, but that didn’t help much. She said some choice words about our program, and they weren’t positive in nature.

After a few days, she’d cooled down some. She wasn’t happy, but she has dosed with us daily because she had no other choices.

Now she’s been at take home level one for over a month, dosing with us on site every day except Sunday. She wants her take home level back and I’m not willing to approve any more take home doses yet.

Some of the staff thought that was too harsh, and that she ought to be given a second chance. Other staff members agreed with me that it was too early for more take homes. What had changed, after all? She still didn’t see anything wrong with her behavior and blamed other people for her criminal charges.

I do listen to staff’s thoughts and opinions, but in the end the decision is mine. I need a good understanding of regulations, mixed in with common sense and compassion – for both the patient and our community. These are difficult decisions.

 

Revenge for the Opium Wars?

 

 

 

 

China may have been defeated in the Opium Wars of the past, but maybe they’re getting revenge on the West now.

Back in the 1840’s, China declared its own war on drugs, confiscating opium brought to its shores by British traders. Chinese authorities were worried about the growing problem of opioid use and dependence in their citizens, fueled by foreign traders from the West, peddling their opioid products. The British East India Company sought to sell opium from India to the citizens of China, in violation of Chinese laws.

In 1839, the Chinese authorities confiscated a shipload of opium from England. When China refused to pay the full street value of the drugs, British forces attacked China in an inglorious manner. They bombarded coastal towns into oblivion, deeply shaming Chinese people and creating a lot of bad feelings towards the West. The war settled with a treaty dictating that China give Hong Kong to the British and that they establish five ports to be available to Western traders. It also dictated the Chinese pay millions of dollars to the British for reparations.

The second Opium War, around 1856, broke out when the Chinese leader at Canton, which was one of the designated ports open to foreigners, arrested British sailors and put them in chains for importing opium to China. This reignited conflict between the British and French against China. The treaty at the end of this war legalized the importation of opium, along with other concessions that China had to make to Western powers.

Today, we are into the third wave of the opioid epidemic in the U.S. The first wave of overdose deaths was mostly due to prescription pain pills. As providers were better educated about the dangers of profligate prescribing of opioid pain medications, pills grew relatively harder to buy and heroin became more available. It was also cheaper, with higher purity than before. Heroin thus fueled the second wave of our opioid situation.

Since it’s cheaper to make fentanyl in a lab than it is to harvest and process opium into heroin, drug cartels became more interested in making and selling fentanyl.  Fentanyl is also much more potent than heroin, so it takes less product to provide a drug effect per person, making it easier to transport for sale. Therefore, fentanyl is replacing heroin and causing our third wave of overdose deaths from opioids in the U.S. And most of the fentanyl precursors are being sent from China to Western labs, in Mexico and other places, to be made into fentanyl, packaged for sale, and transported to the U.S. and Canada.

I just read an interesting book, “Fentanyl, Inc.,” written by Ben Westhoff, which describing how most of fentanyl’s precursor chemicals now come from China. These precursors are sent to the West to be made into fentanyl and its analogues, often via Mexico, fueling this third wave of our opioid epidemic. The author mentioned the ironic link to the past Opium Wars, which was intriguing. [1]

The book presents an interesting idea. Maybe the West’s karmic chickens are coming home to roost. I don’t think the book ever suggests China is intentionally targeting the U.S. It’s business; Chinese chemical manufacturers see an opportunity to make money and are taking advantage of it.

Unlike in the U.S., it’s not illegal to make and sell some fentanyl precursors in China. These precursor chemicals don’t cause intoxication but are the necessary ingredients to make fentanyl and potent analogues. Many businessmen in China sell a great deal of precursor to the West to be made into fentanyl. Much of these precursors are sold to buyers in Mexico, where they are turned into fentanyl or even more potent analogues of fentanyl.

As early as 2006, fentanyl from Mexico, made from Chinese precursor products, was responsible for around a thousand deaths in Chicago and Philadelphia. Soon after that episode, the two main precursor chemicals, abbreviated NPP and 4-ANPP, were placed on the DEA list as Schedule 1 and Schedule 2 respectively. This means these products can’t legally be made in the U.S., or in the case of 4-ANPP, only with extensive regulation and oversight.

In China, as in other countries, the precursor chemicals weren’t controlled at all until 2017, when the International Narcotics Control Board asked China to sign a treaty agreeing to closer control of their manufacture and sales. However, after the treaty agreement was finally implemented in China in late 2017, the largest manufacturer switched to making other, unscheduled, fentanyl precursors not covered by the treaty. These other chemicals can be made into fentanyl, though it takes more chemical reaction steps to do so.

To make matters worse, the Chinese government gives tax breaks to companies that make these fentanyl precursors. According to the author of the book, it’s unclear whether China is aware that these policies encourage export sales of fentanyl precursors, as well as precursors to other drugs like synthetic cannabinoids, stimulants, and hallucinogens.

The author of “Fentanyl, Inc.,” is an award-winning investigative reporter. He seems to be brave, foolish, and persuasive in equal amounts, because he writes about how he went to China and got a tour of a fentanyl precursor manufacturing lab. That’s plenty bold.

He describes these Chinese business owners as ordinary men and women who act and dress conservatively, vastly different from the stereotypical image of the drug bosses of Mexican and Colombian drug cartels. He asked his Chinese contacts if they know they are providing chemicals which cause suffering and death to people in the West who become addicted. Overall the answer was yes, they feel a little bad, but they must work and make a living too.

Despite the title, “Fentanyl, Inc.” contains many chapters about non-opioid NPSs, the abbreviation for “novel psychiatric substances.” NPSs can be synthetic opioids, new psychedelics, synthetic cathinones and cannabinoids. The book provides a quick education about the extent of the newer wave of synthetic drugs, which often provide a more intense highs with more intense side effects too.

I read through the book, hopeful that the author would talk about evidence-based treatment for opioid use disorder: medications such as buprenorphine, methadone, and naltrexone.

Finally, near the back, I found two pages in the Epilogue about treatment. The author says a little about buprenorphine’s potential benefits, and to a lesser degree, methadone’s. The paragraph about methadone came with a warning that methadone dependence was a “problem in itself,” and that it’s frequently sold as a street drug and has caused thousands of drug overdoses per year.

Sigh.

This book was so extensively researched that I hoped for better from this author. In truth, methadone has been studied more intensely than any other drug on earth and is effective at saving the lives of people with opioid use disorder. It can be dangerous when used inappropriately. However, methadone overdose deaths peaked around 2007 and were due to prescriptions from pain clinics where there was little oversight, not from opioid treatment programs. OTPs are highly regulated and while diversion still occurs, it’s relatively rare.  Overdose deaths rates from methadone have continued to drop since 2007, when pain clinics were asked not to use methadone.

To be fair to the author, this book isn’t about treatment of opioid use disorders, so perhaps I shouldn’t have expected the author to research treatments. It was about how these novel psychoactive substances are replacing the more “classic” drugs and how they are being manufactured and marketed, largely over the internet.

It’s overall an interesting read, with intriguing ideas linking the past to the present.

  1. “Fentanyl, Inc.: How Rogue Chemists are Creating the Deadliest Wave of the Opioid Epidemic,” by Ben Westhoff, 2019, Atlantic Monthly Press, New York

Lawsuit with a Purpose

 

 

 

(Please note that details have been changed to protect the identity of this patient).

One of my patients made me so proud today. I was beaming with joy as she told me what took place at her last job.

At her last visit, she said she thought she was about to get fired from a relatively new job because an ex-boyfriend told her co-workers that she had a drug use history and was on Suboxone for treatment. In turn, her boss accused her of taking drugs at work and stealing from the company. He asked her directly if she was taking Suboxone. Caught off-guard, and unsure how it was any of his business, she lied and told him no, she wasn’t taking Suboxone. Coincidentally, she had an appointment with me later that day, and we talked about her dilemma during her visit.

Please note that her job wasn’t safety-sensitive, the employer had no policy relating to drug screening of employees, and no one had seen my patients taking Suboxone or any other medication. There was no allegation that she had been impaired at work or unable to do her job.

At her visit, she told me she hated to lie and felt like she should tell the employer that she was on Suboxone. I told her that of course that’s her choice, but that I didn’t think it was proper for an employer to ask about any medications.

I did offer to write a letter she could give to her employer stating that she’s on Suboxone for the treatment of a medical condition, that she’s been in recovery for many years, and that the medication does not impair her ability to work. She wanted this letter, thinking it could help her keep her job. I also added a paragraph at the end that said patients on medication for treatment of opioid use disorder are protected under the Americans with Disabilities Act.

Because I write so many letters, I was able to type it quickly, printed it on my letterhead and have it ready for her by the end of her visit.

I mentioned in passing that I’ve seen similar cases where an employer fired a patient on Suboxone but then to avoid charges of violating the ADA, claimed the termination was for other reasons, and it becomes difficult to prove.

My patient heard this, because when she met with her employer the next day, she secretly recorded him on her cell phone. At her visit with me today, she played the recording. He bluntly told her he didn’t want anyone on drugs working with him and that it was a small town and people talk and he wanted to keep his good name. My patient didn’t interrupt him, letting him dig his own hole a little deeper with each sentence. She was told she was fired at the end of this meeting, despite giving him my letter stating she was able to do her job without problems from the Suboxone.

Here’s the delicious part: armed with the recording, she went to a lawyer in a local big city, who feels she has an excellent case of discrimination because she’s on Suboxone. He took her case and sent an initial demand letter to the ex-employer asking for a healthy six-figure settlement.

I love this. For too long, people in recovery have endured discrimination of all kinds. Here, it appears, is a winnable case that might make people think twice about firing people for being in recovery.

I’m so proud of my patient for taking the initiative and pursuing action on her own behalf. I don’t know how things will turn out, but I hope she gets a nice settlement for being the target of discriminatory behavior.

I have permission from my patient to discuss this on my blog, so I will keep you posted.

Spending Holidays with the Family

 

 

 

The holidays are upon us. For many people in recovery and their families, this means family celebrations and interactions. Many of us feel stress about this. No matter how much we love our relatives, there can be misunderstandings and hurt feelings. To help families identify what could lead to problems, I composed this guide last year, and I decided to re-run it this year:

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.

 

  1. 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.

 

  1. 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.

 

  1. 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.

 

  1. 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 life and death 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.

 

  1. 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.

 

  1. 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!

 

Reproductive Health of Women in North Carolina’s Opioid Treatment Programs

 

 

 

 

 

The November/December issue of the Journal of Addiction Medicine, (Volume 13, Number 6), published a great article based on a 2017 survey of opioid treatment programs in North Carolina. This study was done by the University of Chapel Hill, and the article was titled, “Provision of and Barriers to Integrating Reproductive and Sexual Health Services for Reproductive-age Women in Opioid Treatment Programs.”

Of course, since this data is from my state of North Carolina, I read it with extra interest.

The article reminds us of what we know about women with opioid use disorders: they are more vulnerable to reproductive health issues. These women tend to have more pregnancies, with about 54% having four or more lifetime pregnancies, compared to 14% of women without opioid use disorder having four or more lifetime pregnancies. About 85% of the pregnancies of women with opioid use disorder are unintended, compared to around 45% for women without opioid use disorder. Women with opioid use disorders are less likely to use contraception and about five times more likely to have had an abortion.

Opioid use disorder increases the risk of gender-based violence and increases the risk of infections, for Hepatitis C and B, HIV, and sexually transmitted diseases. Adverse childhood events, termed ACEs, include stressful or traumatic life events, and are associated with reproductive health problems. Women with ACE history are much more likely to develop substance use disorders in general, including opioid use disorder, so a large portion of women enrolled in treatment at OTPs have this additional mental health burden affecting reproductive health.

Since medication is recommended for all patients with opioid use disorder, the authors of the article say pregnant and nonpregnant women with opioid use disorders could get care for reproductive health services within the opioid treatment program. They suggest this would be a way to reduce unwanted pregnancies, opioid-exposed pregnancies, sexually transmitted infections, and improve the overall health of women in these treatment programs.

The article described a survey sent to the medical directors and program directors of all forty-eight opioid treatment programs in the state, in order to assess the extent of reproductive health services offered to reproductive-age women enrolled in NC OTPs, as well as to explore perceived barriers to integrating such services into the care provided at OTPs.

Of the forty-eight OTPs surveyed, thirty-eight completed the survey. Of the programs that responded, 37% were private nonprofit organizations and 63% were private for-profit organizations. Thirty-four percent were in rural counties, 29% located in urban areas and 37% in suburban areas.

Only 21% of the responding OTPs offered female-specific programs.

Most OTPs accepted Medicaid, at 68%, and those programs served more women of reproductive age than did the non-Medicaid programs, which makes sense. The average length of treatment was longer for women in Medicaid program compared to non-Medicaid programs.

Twenty-one percent of OTPs offered non-prescription contraception, while only one program offered prescription contraception.

Only 89% of OTPs did on-site pregnancy tests, meaning 11% are not performing this simple and necessary test for patients.

To summarize this study, the OTPs of NC aren’t doing all they could to address female patient’s reproductive and sexual health issues.

I agree with this finding, and yet, I was a bit offended with the accompanying commentary in this issue of Journal of Addiction Medicine. Dr. Tricia Wright says that OTPs believe it’s outside the scope of their service to provide reproductive and sexual health services, and that this view is “dangerous and wrong.” She says such care is basic care and OTPs can and should do better for their female patients.

Now you’ve stepped on my toes and I’m going to have to step back.

I agree that more services should be provided, including female sexual and reproductive health. After all, as the article’s authors concluded, such efforts have the potential for great good. Increasing reproductive health of our female patients promotes health of children and families, and ultimately, society.

However, as this survey or providers discusses, there are obstacles to providing such services.

First, OTPs care for people with other equally important challenges. Our patients struggle with homelessness, lack of food, serious mental and physical health issues, all of which need addressed. Our resources are limited, both of time and money.

For example, a new patient injecting heroin might be homeless, with no way to afford food, and have serious mental health issues. Such a sick patient needs inpatient care which usually is not available. For example, our state-run program refused to admit a homeless diabetic because her blood sugars weren’t under control. They refused to admit an HIV positive patient because she wasn’t on proper medication for her HIV. Of course, with substance use disorders raging out of control, those goals weren’t realistic.

Our OTP takes care of many such challenging patients as best we can, because usually it’s their only option for care. Ultimately, we do hope to get them care for their other issues, in the form of referrals, because we don’t have the time or personnel to provide those services.

Second, OTPs may not have personnel with the expertise to manage reproductive health needs

I am trained in Internal Medicine. This means I could manage some simple primary care and even some uncomplicated gynecologic and mental health care for OTP patients. But my time is spent providing medication-assisted treatment to those patients. I would have to work additional hours if we provided primary care, probably at least double the hours that I now work. I would need a way to care for those patients for after-hours emergencies. I don’t work for free, and neither do the nurses. The company I work for would have to pay for this expense. They could bill Medicaid, but at least half our patients don’t have any insurance at all. Most uninsured patients get their OTP treatment paid for with grant money, but that doesn’t cover primary care services.

Many OTPs have a psychiatrist as a medical director. They could address mental health needs, but probably wouldn’t be comfortable doing and primary care, and certainly not reproductive health.

In order to meet even some of the reproductive and sexual health needs of just the female patients (ignoring male patients completely for some reason), additional providers would have to be hired. Who pays for that?

It makes more sense to me to have providers come to our OTP to provide essential services under one roof. One day could be for obstetric/gynecologic care. A local OB could come to our facility and see patients all day. Another day could be for a psychiatrist to come and treat patients, and maybe two days for primary care providers to see our OTP patients. It’s an ideal solution, except for finding willing providers, and a way to pay them.

Don’t even get me started on our patients’ dental care needs. We could hire a full-time dentist and keep her busy with only our opioid treatment program patients. But again, who would pay?

I get weary of unfunded mandates and recommendations for opioid treatment programs. I feel like much is expected of providers at opioid treatment programs, mainly because no other providers want to treat these patients.

Our patients often get superficial and substandard treatment from the local emergency department and local providers’ offices due to the stigma against people with substance use disorders in general. Part of this could be because some of our patients offend providers with their desperation and neediness. Patients enrolled at “that methadone clinic” face extra judgment from some providers, making it more difficult for our patients to access appropriate medical treatment.

It’s not feasible for OTPs to provide all the services that patients need, and certainly not fair to expect OTPs to provide this care for free because other providers don’t want to deal with our patients.

OTPs have and will pick up what pieces we can, but maybe it’s not fair to ask OTP providers to fix a broken healthcare system.