Coping in the Days of COVID19

My homemade masks

When I rolled into our opioid treatment program parking lot at 7 this morning, there was only one vehicle in the patient parking lot. When I got inside, the waiting room was empty.

It’s quiet at the opioid treatment program these days. We’ve already implemented accelerated take homes for most patients, which drastically reduced traffic through our lobby. Patients new to treatment on methadone are still coming daily, as are unstable patients, but many patients got anywhere from six to twenty-seven take homes, under the blanket exceptions we submitted to our state officials.

Our nurses wear protective gear and dose potentially infected patients in their cars, if they aren’t stable enough for take home doses. Our patients with severe immunosuppression or other conditions that place them at higher risk of death if they contract COVID19 are also dosed in their cars.

We have another group of patients, mostly older people with COPD, whom we dose in an expedited fashion, moving them to the front of the line to shorten their time of exposure to other people. That created resentment when we had wait times, but now that there’s practically no wait time (except for the last fifteen minutes of the day, because that’s always the busiest time), everyone gets dosed in an expedited way.

We are open for business as usual. I haven’t seen as many people seeking admission as usual, but there have been a handful this week. In accordance with SAMHSA (Substance Abuse and Mental Health Services Administration) and state guidelines for treatment in the age of COVID19, I’ve been trying to get new patients to agree to start on buprenorphine so that they can get take homes sooner. However, not all patients do well on buprenorphine, and some can’t tolerate it. A few patients, miserable on buprenorphine, wanted to switch to methadone this last week, and we did this. As good as buprenorphine products are when they work, they don’t work for everyone.

I’ve seen a handful of patients each day for various reasons but mainly for dose adjustments. I’ve helped the staff by wiping down doorknobs, computers, dosing counters and the like, taking turns with other staff.  I’ve had extra time to look at patients on our state’s prescription monitoring program. So far, no unpleasant surprises.

We made a bunch of decisions about take home doses very quickly, to try to prevent COVID19 spread in our community. I pray I’ve had the right decisions, and patients will be able to take their extra doses as prescribed.

Counselors are doing phone sessions to provide support for patients but are available to do in- person sessions as well, at six feet apart. We cancelled group sessions until the age of the COVID passes. I hate that, but we want everyone to be safe.

So, for now, at the opioid treatment program, I’m going to work each day. The time may come when I will need to telecommute, and that will be fine, too. I’m ready.

I see patients in my private office on Fridays, and most are people for whom I prescribe buprenorphine products. Tomorrow, instead of driving to my office, an hour away from my home, we are using telemedicine. Regular readers will remember I’m a bit of a dunce with technology, but my fiancé is a whiz. He has a computer program set up and showed me how to use it. I think I will like it. The sound and picture look great, and I’m hopeful it will work very well.

We’ve called all my patients to explain what they need to do to see me from the comfort of their home, via the computer. Most are younger than me and computer savvy.

We have one older gentleman, well over seventy, who doesn’t have the capability of getting on a computer. I completely understand. I plan to talk to him on the phone, see how he’s doing, and then send in his electronic prescription. Given his situation and that he’s been stable in his recovery for twelve years, I feel it’s reasonable to do phone sessions until COVID19 goes away.

The advantage to me is that I could go to work in my pajamas. I won’t, of course. But I could.

My home life hasn’t changed much. When I’m not working, there’s no place I’d rather be than home, so I’m an expert at “sheltering in place.” Since my fiancé, my dogs, and the cat are there with me, I’m happy. I have my hobbies: writing, weaving rugs, reading, and carving our backyard quartz into interesting shapes. We have several weeks of food at home, so we are more fortunate than most.

However, routine decisions can have big consequences. Over the weekend, I needed some little thing for cooking, and my fiancé was going to Lowes, so I asked him to stop by Walmart, which is nearby. While he was gone, I thought, “What have I done? There will be crowds at Walmart, and he could get infected and get sick.” I felt so guilty and worried. He laughed it off when he got home, but little decisions like that matter now.

To combat the feelings of unease, last weekend I did one of the most hopeful things I could think of: I planted a garden. I realize I might be pushing the season, and that we may get another frost, but I felt like I wanted to do something optimistic. I planted tomato seeds in little compartments, to grow into seedlings that I’ll plant later. Then I planted green and yellow squash, cucumbers, carrots, lettuce, and spinach into the ground. I do this every year, but usually not until mid-April.

Last weekend, I made cloth surgical masks for our nursing staff. I took tightly woven cotton cloth, cut it up and constructed the masks, then ran them through the high-temperature cycle with Clorox. Of course, being 100% cotton, they came out wrinkly as hell. I ironed them flat with a steam iron, perhaps further killing the little viral/bacterial bugs. I reasoned that most masks aren’t sterile, outside the operating room, so these may be of some help.  I’m not very fast at it, though. It took me three hours to make seven masks. Staff were very appreciative.

Twelve-step recovery continues to flourish. Though some groups have ceased to hold meetings for now, online meetings have opened. On a recent Narcotics Anonymous meeting held on Zoom, over forty recovering people shared their experience, strength and hope in the traditional manner. Participants shared one at a time, sharing their fears and challenges, and how they were coping with difficulties without using drugs to mask their fears. There was a real sense of comradery, every bit as real as in face-to-face meetings.

People who want to attend these meetings should contact Narcotics Anonymous or Alcoholics Anonymous in their area, to get times and meeting codes. These meetings can be excellent support during these difficult times.

Even though the evening news is a horror show, I plan to carry on with life as best I can, like everyone else. I’ll do the best I can to protect me and the people I love from COVID19. In my free time, I’ll continue making the arts & crafts that relax me. I’m going to try my best to have as normal a life as possible, and enjoy every moment.

Update: Coronavirus at Opioid Treatment Programs

 

 

It’s only Wednesday but it feels like the week should be over already.

Our opioid treatment program is making sure that our patients know that as a healthcare facility, we will be open, and that we have enough medication to treat everyone as usual. Federal officials have stated that no shortages of methadone or buprenorphine products are expected. I hoped we have relieved patients’ worries with these reassurances. They will not be abandoned.

But treatment may look a little different.

On Monday, our OTP instituted social distancing by placing chairs in our lobby at least six feet apart. Someone in administration (not me) decided to let only ten people into our building at a time, while the rest stood in a line outside, standing at least six feet apart from each other. It wasn’t terribly cold that day, but some patients were uncomfortable and not prepared to wait in cold weather. Thankfully our forecast is for warmer temperatures this week. There was a little grumbling from a few patients about waiting outside in the cold. But more patients thanked us for taking precautions to reduce their risk.

Over the weekend, I decided, with input from our nurse manager, that I would no longer ask patients dosing with buprenorphine to wait in our lobby until dissolved. Since I recently found out that most other North Carolina OTPs already allow patients to place their buprenorphine dose beneath their tongue and leave before the dissolving process is complete, I thought it was reasonable to suspend observed dissolving of buprenorphine for now, until the risk of Coronavirus in gone.

Ten days ago, I sent in a bunch of exceptions for medically fragile patients whom I felt were stable enough for advancement of levels, so at least that issue was already resolved. Some medically fragile patients aren’t safe for extra take home doses, so we decided that when they come to the opioid treatment program, they get expedited dosing. This means they go to a separate area to wait, away from other patients, to reduce risk of virus transmission.

I worked a normal day on Monday, and did only one admission, which was a little slow. But I was able to do a few yearly physicals on established patients, and saw more patients for follow ups, dose adjustments, and the like. Between each patient I washed my hands with soap and water (we were nearly out of hand sanitizer) and wiped down the patient’s seat, my desktop, and door handles with Sani-wipes. In my few spare moments I paced the lobby and wiped down every doorknob I could find. I chatted with patients and all of them seemed to be calm, handling the situation well.

We had case staffing as usual, after closing at our usual time. We sat at least six feet from each other and talked again about plans to do some blanket exceptions for take homes for patients meeting certain stability criteria.

Over the weekend, SAMHSA issued statements to guide decisions about advancing take home doses, particularly for patients who are diagnosed with COVID, to help us make sure they get their usual medication despite being put into isolation either at the hospital or at home. They made it clear that previous barriers would be suspended to allow for continued care.

Then yesterday, our state SOTA also helped, both by issuing statements and holding a conference call. It was a very well-attended conference call; I think nearly all our state’s OTPs had representatives on that call. Requests for exceptions for extra take homes were discussed, as was the option of doing counseling sessions on the phone or some sort of teleconferencing. Our OTP’s previous decision to suspend group counseling to reduce risk of viral transmission was supported by our state officials, which made me feel better.

Later yesterday, I was on a conference call with the medical director of our company, and he crafted some blanket exceptions which were submitted to our state’s SOTA today and were approved. Starting tomorrow, we have permission to implement plans to give reasonably stable patients extra take home doses. These will have to be phased in over the next week, and the number of extra doses varies, depending on how long the patient has been in treatment and overall stability.

We are giving a lot of extra doses to patients. Even though I think it’s the right thing to do in order to reduce our patients’ risk of contracting COVID19, it makes me nervous. I don’t want to lose a patient from a methadone overdose from inappropriate consumption these take home doses, either.

So far, there are no positive COVID tests in our county. This isn’t because we have all healthy citizens, but rather because patients aren’t being tested unless they have traveled to a high-risk area or have known exposure to someone with a confirmed COVID diagnosis. People with only cough or intermittent fever aren’t being tested. They are being told they don’t meet criteria for testing. You can read more about this nationwide dilemma here: https://www.theatlantic.com/science/archive/2020/03/who-gets-tested-coronavirus/607999/

Medical professionals in this area don’t have enough test kits yet. We won’t know how many infections we have until symptomatic people can get tested. And what do we tell people with symptoms but no test? Should they isolate themselves? For how long? Word has it that our county is expecting to get test kits soon, so this situation will (hopefully) resolve soon.

We ran out of hand sanitizer yesterday. But this was no problem. This being Wilkes County, famous for home brew and moonshine, my Program Director decided to make her own. As it turns out, there are simple recipes on the internet to make hand sanitizer. All you need is some aloe vera gel and rubbing alcohol, or ethanol, and mix them together in a certain ratio to form hand sanitizer. She poured her concoction into empty sanitizer containers and they worked well. The alcohol content is adequate (more than adequate by the smell) to do the job. One problem solved, at least.

She’s inspired me. I like to do crafts, so I think I will make some fabric face masks over the weekend.

We will get through this. For however long this contagion lasts, we will take all the precautions we can, and strive to be examples of courage and calm in the face of difficult uncertainties.

Above all else, we must reassure patients that they won’t be abandoned.

Coronavirus and Opioid Treatment Programs

covid19

 

 

 

I intended to blog this week about the new mobile opioid treatment program proposed rules, but I’m saving that for later. This week I’m writing about dealing with the Coronavirus at the OTP, and dealing with the fear of the Coronavirus.

Let me preface this blog post by saying I’m not an infectious disease expert, and that I don’t have specific knowledge about the coronavirus outbreak. But I’ve been thinking about ways to protect patients and staff at our opioid treatment program, talking to other Addiction Medicine specialists in our state, and reading advisories for OTPs issued by state and federal agencies.

Those agencies have given us some guidelines and ideas of how to continue to treat our patients as safely and seamlessly as possible, even if some patients and staff contract Coronavirus. That’s the main goal of this blog post: to reassure patients that their OTPs are reading recommendations from SAMHSA (Substance Abuse and Mental Health Services Administration) and SOTAs (State Opioid Treatment Authority). We want to do the best job possible, and we won’t abandon our patients.

Let’s not panic. All of us are scared, unsure what the next days and weeks will bring. But panic often brings more problems than the actual situation. Just look at the unfortunate effect from private citizens who hoarded medical face masks. Now medical personnel are having trouble obtaining face masks that are essential for their jobs. Let’s also take a deep breath and think about how much toilet paper we really need for the foreseeable future, before panic-buying the shelves bare. The plunging stock market is worrisome, but maybe it’s also an opportunity. If I had extra money lying around, I’d invest it now. Again, I have no financial expertise except “buy low, sell high.” And this is as low as the stock market has been for some time.

Our OTP will remain open. We do not plan to close our facility. Personnel who become ill will be asked to stay at home, and we may be short-staffed on some days, but we will be open. Patients do not need to panic about getting their medication. Authorities say they do not expect any shortages of either methadone or buprenorphine products over the coming months, which should be a relief to all patients.

Here are some of the highlights from CSAT (Center for Substance Abuse Treatment), a division of SAMHSA:

-Extra take home doses can be given, after seeking exceptions through the extranet exception website, for patients with confirmed COVID19 infections who are quarantined. This can also be available for people in quarantine because they’ve been exposed to people with COVID infection. These diagnoses and exposures need to be verified by the patient’s healthcare provider, of course.  OTP providers can ask for up to 14 days of take homes, where appropriate.

-Teleconferencing or even just telephones can be used for counseling if face-to-face meetings aren’t feasible, if the technology used meets patient confidentiality standards.

-If a patient is ordered to quarantine at home, authorities are allowing OTPs to deliver medications, or allow a designee to pick up medication and take it to the patient, if chain of custody documentation is done properly. Of course, proof of quarantine will be required.

-CSAT recommends good infection control practices: handwashing, wipe surfaces frequently, ask patients with cough or fever to use masks if available, and use social distancing Though there’s no safe distance to prevent COVID transmission, six feet is recommended. That may be difficult in small counseling offices, but we can get creative.

Though I’m the only physician or medical provider at our OTP, I can work from home if I’m diagnosed with Coronavirus, or exposed to it. These days, secure video conferencing technology is advanced enough that I should be able to carry on with patient care. And thankfully, even though I’m clumsy with technology, I live with my fiancé who is fluent with computers and their programs.

The most medically fragile OTP patients may be able to get more take homes than usual, as decided by the medical director of each OTP. The benefits and risks must be weighed carefully, and the medical director can go through SAMHSA’s exception website to ask permission to give these patients more take homes than usually allowed.

At case staffing a few days ago, we talked about the importance of good hand washing, use of hand sanitizers, and wiping down surfaces frequently that are touched by many people. This would include doors, handles, counters, and the like. To set a good example (and because it was really slow, and I had no patients waiting to see me) I wiped down lobby chairs with sanitizing wipes. I gave them a good scrub and asked our employees to remember to wipe down offices and doorknobs frequently. Am I going to prevent Coronavirus from darkening our doorway? Maybe not, but I felt better as I pictured the Sani-wipes murdering Coronavirus on our patient chairs.

Our OTP has discussed how to change dosing procedures for patients with COVID infections, patients exposed to COVID infections, and for suspected cases of COVID. We want to keep those patients away from the rest of the patients and limit their contact with staff, while still providing needed care. These procedures may cause delays and I hope patients will be patient.

We’ll keep an ear to the news in our area, to stay informed about confirmed cases. I think we will see a spike in the number of COVID19 cases once test kits are available. That will be alarming, but it’s expected, since we haven’t been able to diagnose suspected cases over the last few weeks, due to lack of testing equipment at our local hospital and Health Department.

My biggest message is this: we will not abandon our patients. We will keep working to provide the best care possible under difficult circumstances.

As this pandemic unfolds, we will constantly evaluate the risks and benefits of how we are providing care at our OTP. We’ll look to see what’s working and what’s not working. We may change our minds about procedures as time goes on and we get more information. I think the coming week will give us more data about the extent and locations of COVID infections.

We’ll stay flexible, and we will hope our patients will be patient as we all get through this thing together.

More Phun with Pharmacies

It seems to come in waves. Weeks will go by without any pharmacy troubles, and then all at once several crazy or annoying things happen at once.

 

First, I got a message from a patient asking why he received fewer films than I usually prescribe. This patient is a star. He’s been in recovery over ten years and prefers to stay on buprenorphine/naloxone films to treat pain from a chronic medical issue, rather than taper off the medication. I’ve had the pleasure of treating him for over ten years, and he’s never had unexpected drug screen results. He always keeps his appointments and is flourishing in his life.

I thought the issue was likely due to his insurance, but knew I’d have to talk to his pharmacy to figure it out. So, I called, and a pleasant pharmacist tried her best to be helpful. I’d written for one and a quarter films per day and wanted #40 dispensed.

Technically, the pharmacist explained, I should have prescribed 37.5 films, but of course that’s not possible, so insurance would only pay for 38 films per month.

“OK,” I said, “But why did you only give him 35 films, instead of 38, then?”

There was a moment of silence until she said, “Huh. Well, that’s a good question. I don’t know.”

“Who would know?” I asked, foolishly.

“I don’t know.” Maybe the head pharmacist?”

“Can you ask, if you don’t mind? I’m kind of curious.”

She said she would, and that she would call me back with an answer. It’s been a week and I’m not expecting a call back. It’s really a minor thing, and maybe not worth anyone’s time, except…WHY?????

Today, I was enraged at the experience of another patient. He’s been in recovery for around twelve years and has been doing very well for the past six years with no illicit drug use. He has a family and just started his own business employing several other people. He’s doing well and made much progress in recovery.

He got a tooth pulled recently, a procedure that was more complicated than usual. His dentist gave him a prescription for ten hydrocodone pills for pain, and he tried to fill it at his usual Walgreen’s, where he fills his buprenorphine/naloxone tablets, prescribed by me.

He said the pharmacist said no. She told him that people being prescribed buprenorphine/naloxone can’t fill prescriptions for opioids. She didn’t offer to call the dentist, or to call me, to see if it was medically appropriate to fill the prescription, which it was. She just said no.

I saw red.

“What did you do? Did you call the dentist? Did you talk to her boss?”

“Nah, I didn’t want to make her angry and I wasn’t in that much pain. I just took a whole lot of ibuprofen along with Tylenol and got by.”

“If that happens again, please call me. I’d be glad to set this pharmacist straight. In fact, what’s her name? I’ll call her now.” I was fired up and ready for a fight.

He couldn’t remember her name and seemed a little reluctant.

I get it. He must deal with that pharmacist to fill his medication and didn’t want to make waves. I didn’t call, but told him if he ever had a similar experience, let me know, and I’d call and explain that being on buprenorphine products doesn’t mean a patient can never be treated for pain.

Then tonight was one of the funniest and most bizarre things I’ve heard from a pharmacy.

It started when my fiancé (and therapist to my patients) told me he had a message from a patient, saying that my E-prescription couldn’t be processed because it needed to be in a different format.

Well that’s odd, I thought. The format is determined by the electronic prescribing platform, and is fairly standard. Alas, I’ve had to learn two different e-prescribing software programs.

Again, I was going to have to speak to the pharmacist directly.

Initially I spoke with a nice gentleman who tried hard to help me. I asked him what the problem was, and he told me my DEA number had to be in a “Nadine” format.

“Wait, what? What are you talking about?”

“You need to put in your N-A-D-E-A-N number.”

“Do you mean my DEA X number?”

“No, it’s the NADEAN number.”

“You’re going to have to explain that to me. I don’t understand.”

“Ms. Burson, I’ll get the pharmacist to help you.”

“OK,” I said.

I had my phone on speaker, and I thought he had put me on hold. I sighed and asked my fiancé, “Did he just call me Ms. Burson?”

I wasn’t on hold.

“I’m sorry, I should have said Dr Burson. It’s just habit,” he said.

I felt a little ashamed about complaining. It’s not a big thing. I went to med school in the 1980’s, so I’ve had many colleagues, nurses, patients, AND pharmacists call me “Ms.” instead of “Doctor” over the years. But then again, it is 2020, so maybe it’s time to realize that females are doctors, too.

Anyway, another nice pharmacist came on the phone and explained that the DEA must be formatted in a specific way. All CVS pharmacies had been given instructions not to fill buprenorphine products unless they were formatted thus:

NADEAN:X and the rest of the DEA number.

I had not used this format – instead, I typed “Use DEA X1234567.” (not my actual DEA number, of course),

I said I did put the DEA X number on the prescription. I asked her if she saw it. She said yes, she did, but the NADEAN stands for Narcotic Addiction DEA Number and if it wasn’t submitted in that format, it couldn’t be filled.

I thanked her for her time, and told her I knew she was only the messenger, and said I would cancel the prescription I had just electronically submitted and re-issue another with their preferred format of “NADEAN:X1234567”

I’ve seen plenty of inefficient and even counterproductive things in my career in Addiction Medicine, but this is probably the funniest and most ridiculous bit of red tape I’ve seen in a long time. It was so silly I didn’t even get angry. I was giggling to myself, thinking was a great blog post it would make.

Obviously, someone was over-interpreting a corporate message that was trying to say that the X DEA number needs to be on every electronic prescription. But it is being literally interpreted, at least at this CVS, that NADEAN:Xnumber has to be in that format. Prescribers beware: if you are sending a prescription to a CVS, use this format or your patient will be unable to fill their prescription, even if you have your DEA X number on it.

News Briefs

 

 

 

 

I just got my copy of the most recent issue of the Journal of Addiction Medicine, my favorite medical journal. It was filled with interesting articles. Here are highlights from a few articles.

One study found that vitamin D supplementation improved cognitive functions and mental health status of patients in methadone maintenance treatment in Iran.

The incidence of opioid use disorder is rising in Iran, with opium as the most common drug, followed by opium ashes, illicit methadone, heroin and morphine. This article, by Ghaderi, et al., said about 1.2 million Iranians have opioid use disorder, giving a prevalence about three times what is found worldwide. About half a million people in Iran are now in treatment with methadone and buprenorphine.

The author of the study wanted to see if vitamin D supplementation improved cognitive function in patients in methadone maintenance treatment. Several past studies showed higher incidence of cognitive deficits in patients undergoing treatment for opioid use disorder, and other studies have shown lower Vitamin D levels in patients on methadone maintenance programs compared to controls not on methadone treatment.  Also, previous studies have shown that low vitamin D levels are associated with impaired mental function and mental health disorders.

The authors of this present study have done past studies that demonstrated vitamin D administration helped patients with major depression, improving depressive symptoms.

However, the authors acknowledge that a meta-analysis study by Gowda et al., 2015, plus two other meta-analyses, showed no significant reduction in depression scoring after vitamin D administration.

This study was done to add to the literature around vitamin D supplementation in people susceptible to having lower vitamin D levels, who were also diagnosed with opioid use disorder and in treatment with methadone maintenance.

This was a randomized, double-blinded, placebo-controlled study, so the design was good. However, not many patients participated in this trial. Out of the screening of 425 prospective trial subjects, only 90 were interested in participating in the study. Those ninety subjects were reduced to 70 after twenty didn’t meet inclusion criteria.

These 70 people were randomized to either placebo or vitamin D treatment. Oral supplements were the only form of vitamin D that was counted; for obvious reasons, it would be quite difficult to quantify the amount of vitamin D that each subject got from sun exposure. The test subjects were compliant with taking their dose of either vitamin D or placebo, and the group of subjects on vitamin D had significantly higher vitamin D levels after twenty-four weeks of supplementation compared to subjects in the placebo group.

The vitamin D group had improved mental function. Specifically, this group performed better on a test known as the Iowa Gambling Test, which is a test designed to simulate real-life decision- making abilities. They also had better verbal fluency, logic and memory scoring. Results of the study showed improved depression scoring but no effect on anxiety test scoring.

How intriguing this is! I advise my patients with poor nutritional habits to take a one a day multivitamin, which should have all the vitamin D most people require. Vitamin D is one of the stored vitamins (along with vitamins A, E and K) so it is possible to get too much of a good thing, but routine supplemental doses are helpful for many people.

The study was interesting, but hardly conclusive. The study was relatively small, and most patients opted out of participation, for some reason. A larger study would give results more statistical power.

For now, I’ll keep recommending daily multivitamins in patients with unhealthy dietary habits, which includes vitamin D.

 

Another article was a study of job satisfaction of medical providers at methadone maintenance programs in China. Knowing next to nothing about methadone maintenance in China, I didn’t realize China has had methadone maintenance treatment available for the past twenty years. To be sure, that’s not long, compared to many other nations, but I was pleased to read of their programs.

The article, by Chen et al., said there were nearly eight hundred treatment programs in China as of the end of 2015, treating over 167,000 patients.

At Chinese methadone maintenance programs, doctors see these patients and do physical exams, some counseling, and prescribe methadone. Those patients (called clients in this article) take their prescriptions to pharmacists, and nurses then administer the medication and observe their dosing.

Some of the Chinese opioid treatment programs offer other services, like testing for sexually transmitted diseases, social support counseling, or employment skills training.

This present study was done in order to explore factors relating to job satisfaction among these medical professionals. Previous studies found challenges to medical personnel working at opioid treatment programs including worry about their safety, low pay, large workload, and negative attitudes toward methadone maintenance treatment in general in China.

Ten methadone maintenance programs were included in this study, and they were all located in urban areas. The average number of patients treated at the programs was 114, so these were relatively small programs compared to what we usually see in the U.S. There were only seven to fifteen employees total at these programs, and the study was only open to medical staff members, meaning doctors, nurses, or pharmacists. Only seventy-six subjects were included in this study.

The subjects were asked questions about their demographics and work history, about their job satisfaction, about perceived institutional support, and about perceived stigma due to working with drug users.

The results showed that low job satisfaction was associated with working at a program that was associated with the Centers for Disease Control, high perceived stigma due to working with drug users, prior experience outside of infectious disease areas, and perceived low institutional support.

Several of the findings make sense, but why was program association with the CDC negatively correlated with job satisfaction? As it turns out, physicians and nurses who work at these programs are largely contract employees. These workers tend to have lower pay and benefits and are asked to work more on weekends and holidays. They also may perceive less job security.

As for the other findings, the article says that in China there’s a belief that heroin users congregate at methadone maintenance programs, making them dangerous places. Some workers felt their personal security was at risk and that they may be exposed to infectious diseases by working with this patient population.

I think some medical workers in U.S. programs feel the same way. I don’t know of any statistics showing that this is the case; exposure to infectious diseases can happen in any medical field. I don’t feel my personal security is at risk where I work, but I can understand if some workers feel this way.

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.