Treatment Implications for Intravenous Buprenorphine Use

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

During the admission of new patients for opioid use disorder treatment, I ask about prior use of all drugs. I include the medications we use for treatment. I’ve done this since I started working at opioid treatment programs (OTPs) seventeen years ago.

Over the last few years, more patients say they’ve used illicit buprenorphine in the past. At first, I saw patients who were using it sublingually (under the tongue), as recommended, though still illicitly. Most of them wanted to see if this medication would work for them before they committed to the time and expense of entering a treatment program.

Over the past year I’m seeing more and more new patients who say they use buprenorphine intravenously. This past month, I’d estimate that a fourth of the patients who use buprenorphine illicitly are injecting it. Only a few said they snort buprenorphine.

This presents a big wrinkle to the treatment process.

I see why people use intravenous buprenorphine. It has low sublingual bioavailability, at around thirty percent. That means injecting two or three milligrams gives the same blood level as eight milligrams sublingually. In the short term, people injecting buprenorphine feel like it saves them money. In the long term, I’m certain it will cost more than they can imagine.

Buprenorphine tablets and films were not designed to be injected. Pills and films have fillers in them, and they aren’t sterile. Heating a mixture prior to injection will kill off some of the bacteria, so that’s a harm reduction practice. Using a filter can remove some of the particulate matter, also reducing the potential for harm. However, heat and filters can’t remove all the risk of injecting.

People who snort buprenorphine also get higher blood levels than those who use this medication sublingually. Compared to intravenous use, it’s probably less risky to use in this manner, but still can cause problems with irritation to the mucosa of the nose and sinuses. We don’t know about long-term damage because – of course – no studies have been done on this topic, since the medication isn’t intended to be used intranasally.

People who have used opioids intravenously or intranasally often associate the act of injecting or snorting with euphoria. They can become addicted to the process of both means of ingestion. This can happen with buprenorphine too, though studies show most people who inject or snort are trying to keep themselves out of withdrawal with the medication, and not to feel euphoria.

Due to the ceiling on buprenorphine’s opioid effect, it is… arguably… one of the safest opioids a person could inject. But intravenous use is never safe.

Here’s only a partial list of complications from intravenous drug use:

  1. Overdose resulting in death, brain damage from low oxygen, stroke or heart attack from prolonged low oxygen
  2. Pulmonary edema (lungs fill with fluid)
  3. Skin abscesses and cellulitis
  4. Endocarditis (infection of heart valve that is life-threatening)
  5. Deep vein thrombosis (blood clot)
  6. Septic thrombophlebitis (infected blood clot)
  7. Contracting infections: HIV, Hep C or B
  8. Bacterial infections and abscesses in weird places like the spine, brain, joints, spleen, muscles, or eye
  9. Necrotizing fasciitis – rapid, “flesh- eating” infection, also botulism
  10. Pneumonia
  11. Septic emboli – when infected clots break off and go to the lungs, brain from infected heart valves
  12. Fungal blood/eye infections – (seen frequently when pills mixed with saliva are injected)

I have seen patients with every one of these complications. Most of them were in the distant past, when I was an Internal Medicine resident during the late 1980’s, but not all of them. Over the past year I’ve seen three patients with spinal abscesses from injecting drugs, though not necessarily buprenorphine.

When I posted about intravenous use of buprenorphine (November 2015), Dr. Wartenberg M.D. (pioneer in the addiction treatment field) wrote about the mitochondrial disease, which has caused liver failure, in European IV buprenorphine drug users. This disorder is specific to buprenorphine

So what are the treatment implications for a new patient who has injected buprenorphine?

First of all, these patients aren’t appropriate for office-based practices, even if the physician plans to prescribe the combination product with buprenorphine/naloxone. Clearly there are some patients who inject combination products, not only the monoproducts. Granted, it’s less common, but it still occurs.

But this is only my opinion. I can’t find any research that randomizes patients with histories of intravenous buprenorphine and/or buprenorphine/naloxone use to either care at opioid treatment programs with daily dosing, or care at office-based treatment settings.

There’s usually not enough oversight available at office-based practices to treat more complicated patients. I think they should be referred to opioid treatment programs, where they can be treated with methadone, or buprenorphine – with precautions.

Opioid treatment programs can do observed, daily, on-site dosing of buprenorphine.

At our OTP, we ask all buprenorphine patients to sit in a designated area while their dose dissolves. It usually takes around ten minutes, and they are watched by program personnel. Before they leave, each buprenorphine patient shows one of the staff their mouth, to show the medication is completely dissolved. It does feel a little “police-y” but we had a high incidence of diversion until we started this close observation. Some of the diversion was in patients who wanted to inject their dose later. This is particularly risky, given the bacteria that live in our mouths.

If a patient tries to spit out their medication, they meet with me. I’m rarely willing to continue to prescribe buprenorphine if it appears they are trying to divert their medication. I meet with the patient and we discuss the option of methadone. If they refuse methadone, we discuss depot naltrexone, or refer them to another form of treatment.

If patients with histories of injecting buprenorphine want treatment with buprenorphine, I tell them I’m willing to give it a try, but that they can’t expect take home doses for a very long time, after months of observed dosing and stability. So far, this approach seems to be working.

When/if to grant these patients take homes remains a huge question. I don’t want to unduly burden patients by insisting they must come every day forever, but I also don’t want to give patients take home doses that could lead to a relapse back to intravenous use.

This isn’t a perfect system. But for the most part, we give people with a history of intravenous buprenorphine use a way to use buprenorphine as a treatment medication and as an alternative to methadone.

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Criminally Pregnant, Again: Tennessee’s Fetal Assault Law Won’t Die

 

 

Tennessee lawmakers are trying to revive a version of the Fetal Assault Law, originally passed in 2014 but allowed to sunset in 2016, after the state saw worsening outcomes for pregnant moms and babies. [1, 2]

I wrote two blog entries when this law was first passed – you can read “Criminally Pregnant in Tennessee” Parts 1 and 2 from April 12, 2014 and April 26, 2014. The second blog entry was supposed to be satirical. (I won’t try that again, after two out of six commenters thought I was being serious about putting the “addicted babies” in jail.)

This is the proposed law, in part: Notwithstanding subdivision (c)(1), nothing in this section shall preclude prosecution of a woman for assault under §39-13-101 based on the woman’s illegal use of a narcotic drug, as defined in Section 39-17-402, while pregnant, if the woman’s child is born addicted to or harmed by the narcotic drug and the addiction or harm is a result of the woman’s illegal use of a narcotic drug while pregnant,”

To summarize, the Fetal Assault Law says that a pregnant woman can be criminally charged if her baby is born addicted to or harmed by an illegal drug used by the woman.

The wording of the bill is scientifically wrong, of course. Babies can’t be born addicted, since addiction is diagnosed only in the presence of obsession and compulsion to use the drug despite adverse consequences. Babies don’t have obsessions or compulsions, and even if they did, we wouldn’t know it. But I know what lawmakers meant. The lawmakers likely meant to say, “physically dependent,” but lack knowledge about substance use disorder science to know the proper terms.

These types of laws are nothing new. We know the problems that occur with these laws, and Tennessee should learn from examples from the past – their own recent past.

Amnesty International released a 69-page report in 2017, titled “Criminalizing Pregnancy: Policing Pregnant Women Who Use Drugs in the U.S.” This report summarizes research about laws that criminalize behaviors during pregnancy and give some overall data, but the report focused on two states: Tennessee and Alabama.

https://www.amnesty.org/en/documents/amr51/6203/2017/en/

It’s an interesting report, and worth a read. I wish Tennessee lawmakers would read it, because they would have more information about what happened during the two years the Fetal Assault Law was enacted in the years 2014 – 2016.

According to the Amnesty International report, here are the biggest problems seen under the law:

Deterrence of prenatal care: Predictably, pregnant women are less likely to seek prenatal care if they are using drugs and fear being arrested. Even the women who did seek prenatal care were sometimes drug tested without their consent and even without their knowledge.

Uneven application of the law: Some areas of Tennessee had far more cases charged than others, because of the decisions of the local prosecutors. A total of around one hundred women were charged under the Fetal Assault Law, mostly in the eastern part of the state, where there are few treatment facilities available for pregnant women, and in Memphis, in the far western part of the state.

Also, nearly all the women charged in Tennessee were either poor, minorities, or both. The county with the highest number of women charged under the Fetal Assault Law (Shelby County, where Memphis is located), was also ironically a county with lower rates of drug-exposed newborns than other parts of the state. However, that county’s residents are predominantly African-American. It looks as if the prosecutor in that county was more zealous about charging women under the Fetal Assault Law.

Adding to the problem, drug testing policy during pregnancy isn’t uniform. Poor and minority women are more likely to be drug tested, with one study showing that black women were 1.5 times more likely to be tested than non-black women, despite drug use rates that are approximately equal between races. Black women testing positive were ten times more likely to be reported to authorities than non-black women. (Kinins et al., 2007, Chasnoff et al., 1990)

Lack of availability of treatment: Ironically, more women were charged under the Fetal Assault Law in areas with fewer available treatment options. Even when pregnant women with substance use disorders desired treatment, there were few options. Only 19 of Tennessee’s 177 treatment centers open during 2014-2016 treated pregnant women. At the time this law was active, there were no opioid treatment programs in Eastern Tennessee. Even in parts of the state that had opioid treatment programs, the state-funded TennCare program doesn’t pay for methadone treatment during pregnancy, which is the standard of care as noted by experts in the Addiction Medicine field.

The Amnesty International report tells of one woman in Tennessee who tried for three months to access treatment but was turned down repeatedly. She was charged under the Fetal Assault Law.

According to calculations, even if all available treatment beds were set aside for pregnant women with substance use disorders, those resources wouldn’t cover even half of the existing need.

I hope Tennessee doesn’t go backward and re-enact this Fetal Assault law. Since substance use disorders are illnesses, it makes more sense for these women to get treatment, not jail time.

After all, that’s how we treat alcohol abuse and cigarette smoking during pregnancy. We have far more data about harm done to the fetus from maternal smoking and drinking alcohol. But because these substances are legal, they are dealt with as a public health issue. Obesity also affects the outcome of pregnancies. In one article, the dangers of maternal obesity were outlined, and the authors concluded, “Even modest increases in maternal BMI were associated with increased risk of fetal death, stillbirth, and neonatal, perinatal, and infant death.” [3]

I doubt lawmakers would be comfortable setting laws around how much weight a pregnant woman can gain. But if their main concern is fetal well-being, and if they think criminalizing behavior is a way to fix problems, who knows? Maybe next year Tennessee will be patrolling obstetricians’ office for obese pregnant ladies.

  1. http://www.wmcactionnews5.com/2019/02/12/tennessee-bill-revive-fetal-assault-law-would-prosecute-women-who-use-drugs-during-pregnancy/
  2. https://www.npr.org/2016/03/23/471622159/tennessee-lawmakers-discontinue-controversial-fetal-assault-law
  3. Aune, et al, “Maternal Body Mass Index and the Risk of Fetal Death, Stillbirth, and Infant Death: a Systematic Review and Meta-analysis,” JAMA, 2014; 311(15):1536-1546.

Product Review: Generic Buprenorphine/Naloxone tablets

 

 

I’m thrilled to be able to present an in-depth review, compiled by one of my patients, of the generic forms of the buprenorphine/naloxone combination tablets. My patient thoughtfully composed this to help other people prescribed these products, and to share his own experience and opinion:

In active recovery it is extremely important to maintain a predictable and consistent titration of dosage in the slowest possible manner to reduce withdrawal. One patient has mostly eliminated the debilitating and relentless effects of withdrawal over a course of many years.

Years ago, this patient’s plan for recovery involved incredibly slow and methodical reduction of the suboxone tablets milligrams at a rate which would be monitored and progressively smaller. However, over the course of 2 years of slowly reducing the dosage, another factor came into play: that is the reported and vastly different half-life and strength in generic Suboxone.

At the beginning, this patient had been taking 2 of the 8mg tablets, or 16mg per day, for several months, after ending a habit which at its worst exceeded 120-140mg per day of OxyContin. Each year since ending any opiate pills, the suboxone was gradually reduced over the course of 12 years from 16mg per day to one-half of a 2mg/.5mg buprenorphine/naloxone tablet per day.

In August of 2018, Walgreens pharmacy reported to the patient that the Amneal NDC #65162-0416-03 became “unavailable for refill.” The reasons for this are unclear but it set into motion a series of trials of the several available 2mg/.5mg buprenorphine/naloxone tablets which resulted in the following analysis based on this patient’s experience:

NDC #65162-0416-03 is Amneal 2mg/.5mg buprenorphine/naloxone tablets. They are orange, small and compact with an “A” embossed on one side and a “14” on the other. Their price is about $8 per pill before insurance. Their taste is distinctive, not sweet nor bitter but a tolerable attempt most comparable to Saint Joseph’s baby aspirin, like a sweet and low version that is far less sweet. The half life is reported to be consistently close to 18 to 22 hours. The only real downside is that these little pills take an incredibly strong finger grip to manually break into a clean and even one-half pill. Even the most expensive pill cutter machines take great manual strength and accuracy to evenly break into halves without crumbs. This pill overall is an 8 on a ten scale largely due to its consistent half-life.

NDC #50383-0294-93 is from Akorn Inc. which produces a very low cost 2/.5mg buprenorphine/naloxone tablet, which are about $2 per pill. They are very small, white and come in a blister pack. They are so small and compact that it is all but impossible to cut in half. Their taste is bitterly distinctive and hardly tolerable as a sublingual. They taste as if the sublingual aspect was not considered at all. The half-life is reported to be consistently bad at no more than 6-8 hours at best. Strangely, these little pills are sometimes completely ineffective, and one wonders if there is any medicine at all in these pills. It would be disconcerting to think that these pills would be administered in a controlled, prison or public health environment as their bitter taste and ineffectiveness may lead one in recovery to compare this pill’s experience to one of all Suboxone pills and thereby keep one from seeking this type of maintenance. This pill is a 2 on a ten scale only because it might help one for a few hours.

NDC #00406-8005-03 is from SpecGX Inc. which produces a lower cost 2mg/.5mg buprenorphine/naloxone sublingual tablet which are about $3.50 per pill. They are smallish and orange and come shaped as a stop-sign. Their taste is also distinctive, not sweet nor bitter but very similar to the AMNEAL described above. Their taste is also a less sweet version of Saint Joseph’s baby aspirin. The half-life is reported to be less than AMNEAL version at only 10 to 12 hours, however. The same breakability issues pervade this orange pill as they are compact and hard to divide. This pill is a 5 on a ten scale only because it helps consistently but only for up to 10 hours.

NDC #00054-0188-13 is from Hikma 2mg/.5mg buprenorphine/naloxone tablets. They are a shade lighter orange, a bit larger than the other orange pills but with a “54/122” embossed on one side and blank on the other. Their price is about $5 per pill before insurance. Their taste is a bit less bitter than the others; however, still distinctive, and a tolerable orange taste. The half life is reported to be very consistent at 20 to 24 hours. They easily and manually break into a clean and even one-half pills without much crumbling at all. This pill overall is a 9 on a ten scale because it does what it is supposed to: be consistently manufactured to be predictably effective to keep withdrawal symptoms to a manageable minimum.

I hope my readers find this information useful. This is not a scientific evaluation but rather a patient’s rather extensive experience with generic buprenorphine/naloxone products. I am grateful to him for the time and trouble it took him to compile this.

 

My “Hopeless” Patient

 

 

 

 

 

(Details have been changed to protect patient identity)

I have a patient in my office-based practice whom I see only every two months. If you had told me ten years ago, when I first met him, that he would become a stable and productive member of society, I would have scoffed. If you told me he would someday have over three years of freedom from active addiction, I would have rolled my eyes in disbelief.

I think of this person when I’m tempted to write off any patient as hopeless.

He was one of the worst. I first met him when I worked at an opioid treatment program (OTP) over ten years ago. He was often impaired and belligerent. At least once he had to be transferred to another OTP, due to aggressive behavior towards the staff and other patients. He was belligerent with me too, and I dreaded my appointments with him. He had a terrible cocaine addiction, and almost all his drug screens were positive for cocaine and benzodiazepines. On several occasions I referred him to a local inpatient program, but he left against medical advice or was asked to leave.

A few years after I left that OTP, he called my office-based practice to ask if he could switch to buprenorphine. The woman making appointments scheduled him with me.

The next week, looking at my schedule, I remember saying, “Oh HELL no. I’m not seeing this guy. He’s not going to stabilize in an office-base practice.” But he had already paid to hold his appointment slot, so I felt obligated to see him. My plan was to tell him he wasn’t appropriate for an office-based program, and to recommend inpatient treatment, as I had so many times in the past.

At the first visit, he was less belligerent than I recalled, and had been free from cocaine for several months. He appeared to have a little more insight into his behavior and his addiction. I sensed he had a strong desire for change. Skeptically, I agreed to start him on buprenorphine, secretly assuming he would drop out of treatment after a few weeks.

From the start, his use of illicit opioids dropped impressively. From that point of view, he made immediate progress.

However, during his first year in treatment in my office-based practice, he had periodic relapses to cocaine. He’d come into my office, fling himself into a chair, and say, “Don’t bother giving me a drug screen. I messed up. I got high on cocaine and then took benzos to come down.” I was impressed with his honesty and I was impressed by how much his relapses bothered him. I was also impressed when he made – and kept – appointments with a psychologist for addiction counseling. He was dismayed and frustrated, because he said he didn’t really enjoy using drugs anymore, but still couldn’t stop using them. This angered and baffled him.

He’d get so frustrated with his own behavior that he would start crying. The first time it happened, I was uncomfortable and worried. He was the ultimate tough guy, more likely to yell than cry. I worried the tears meant a severe mental illness. As time went on, we both got more comfortable with his tears. I saw he was experiencing the pain of his powerlessness over addiction.

He’d been in and out of 12-step recovery for years, and didn’t feel like the meetings helped him much, but he’d go once in a while. He kept going to counseling, though he was only able to afford sessions once or twice per month. He kept his frequent appointments with me. Above all else, he kept his appointments.

I had moments of grave concern, worried he really wasn’t stable enough for me to be treating him in an office-based setting, and on several occasions mentioned my concerns to him.

In my own mind, I also worried about how someone reviewing his chart would view me as a doctor. If someone from the DEA or Department of Health and Human Services wanted to review his chart, they would think I was careless with this patient, and that I should have referred him back to the methadone clinic. During his relapse years, I worried that I was giving this patient inadequate treatment, yet knowing him as I did, I didn’t think he would ever go back to an OTP or inpatient treatment. I also really believed he was going to make progress in recovery, though I didn’t have much to justify my belief.

I also leaned on him to consider an inpatient program. He was set against both an opioid treatment program and an inpatient program, saying he was sick of being treated like a child, and that he didn’t do very well when people told him what to do.

I saw what he meant.

In opioid treatment programs, sometimes a milieu of “us versus them” can be pervasive. Despite using kind and collaborative counseling approaches, patients often feel they are unfairly told what they can and can’t do.

They are right, of course. Opioid treatment programs have to follow an amazing number of state, federal, and local regulations in order to stay open. These rules rankle patients, who feel like they’re being treated like children by irrational parents.

I do get that.

In an office-based setting, there’s more freedom to individualize treatment. By that I don’t mean patients can or should get by with less care. But I have more flexibility, and more opportunities to build rapport with patients in my office than in the OTP.

Addiction treatment literature describes a type of counseling known as motivational interviewing (MI), or motivational enhancement. I’ve read books about this practice, and though I’m a beginner compared to experienced therapists, I do try to use MI methods where I can.

MI encourages treatment providers to listen closely to the patient, clarify what the patient is saying, and ask the patient to participate in solving problems. MI is a collaborative type of counseling, believing patients know more about how to help themselves than more traditional counseling techniques give them credit for knowing. MI also teaches that confrontations with patients aren’t usually helpful.

At the OTP, this patient had a hard time controlling his temper when an authority figure (me) confronted him about drug use and bad behavior. In my office setting, I didn’t confront him but asked him to describe how his relapse happened, and asked him what he thought triggered the overwhelming desire to use the drugs. I asked him what he thought could be helpful for next time, and he had some good answers.

This approach worked well. The time between relapses grew longer, and he appeared to have more and more insight into what caused him to relapse and how he could avoid those situations.

For example, in the past, he got into physical fights at his work place, would get fired, and go use cocaine. At one session, he told me how he’d love to punch his boss in the face. He said it would feel good, but only for a few minutes, and then he would lose another job. He didn’t like his job, but wanted to leave it on his own terms.

Eventually, that’s what he did – he gave a 2 week notice, and left with another job already lined up. Sadly, he couldn’t afford health insurance at his new work. I told him to petitioned Reckitt-Benckiser’s program of free medication for one year for patients in dire financial conditions, and he met their requirements. I also agreed reduced my office fee temporarily, until he got back on his feet.

Then his mother was diagnosed with end-stage cancer. He worked at night so he could help take care of her during the day. He was less angry but more depressed, and he finally agreed to start taking an antidepressant medication. During her prolonged illness, he still struggled with occasional illicit drug use, but he was able to work full time and also help care for his mother. He was very distraught when she died, but happy he’d been able to spend time taking care of her at the end of her life. Ironically, the rest of his family, who had once written him off as the black sheep, came to depend on him during this difficult time for them all.

Since then, he’s been diagnosed with several chronic medical problems, but he has a good job that he likes, and he has good insurance coverage. This allows him to see his primary care doctor regularly. He helps his father around the house and helps financially when he can.

He gradually transformed into a productive member of society.

I have come to enjoy his visits. He’s actually very funny, with a droll sense of humor. His last positive urine drug screen was more than three years ago, and this was his last illicit drug use.

His life isn’t perfect. He has problems with relatives, and has some unmet goals in his life that he’s working on, but looking at him now, you wouldn’t guess he once had serious and life-threatening issues with addiction.

A couple of times a year, we discuss whether he wants to taper off buprenorphine. So far, he said he doesn’t want to risk it, and prefers staying on buprenorphine. I agree with him; he’s doing so well now, I don’t want to risk making changes that could harm him.

What helped this patient? Was it relief from an overly authoritarian opioid treatment program system? Did he age out of his addiction and youthful antics, as so many people do? Did he benefit from the motivational enhancement counseling I tried to provide? Or was he sick of the addiction, and just needed a little help while he got better on his own? I don’t know, but it’s been a delight to be even a small part of his recovery.

When I’m tempted to write off a patient as hopeless, I think of him.

Advice for New Prescribers

 

 

 

The medical care providers of this nation are being encouraged get training necessary to prescribe buprenorphine products (brand names Suboxone, Zubsolv, Bunavail, Sublocade, and the generics) for the treatment of opioid use disorder in their patients. We need more good prescribers, because even after twenty years into this opioid situation, only about twenty percent of patients who need treatment can get it.

I’ve written on this topic a few times in the past, but this blog entry will contain some advice directed to new prescribers of buprenorphine products. Hopefully it will help them have good experiences prescribing medication-assisted treatment.

Here are some ideas that work for me at my office:

Treat the patient with opioid use disorder with the same attitude and compassion that you would for any other patient with a potentially fatal chronic illness. If you can’t do that, then don’t treat patients with substance use disorders. Patients detect negative attitudes such as distain and dislike even when those attitudes are communicated non-verbally. For whatever reason, if you can’t put judgment aside, then work on your own issues before you attempt to treat suffering people trying to get well.

Patients will resent a physician with a bad attitude. That will contaminate the relationship with predictable results.

For example, I talked to one physician who had his waiver to prescribe buprenorphine from an office setting. I asked him why he wasn’t using his waiver to treat patients, since there were so many in our community that needed help.

He told me the visits with the first two patients went poorly. He said both these patients threatened his life and the lives of his family members. After that, he decided not to risk treating anyone with opioid use disorder.

I was shocked. I’ve never, in the thirteen years I’ve been prescribing from an office practice, had any patient threaten my life, though I’ve made some angry at me. I had to wonder what kind of bedside manner this doctor had, for his first two patients to want to kill him. That sounds like I’m blaming the doctor, and maybe I am, but his experience was so contrary to my own that I had to wonder what was going on. I suspect his patients didn’t feel respected by him.

I’ve had one patient threaten me with bodily harm, but that was at an opioid treatment program in Gastonia, NC, more than a decade ago. The patient was an avowed KKK member, tall and large, with tattoos of hate groups on his muscular arms. I might have been worried, except at the time he threatened me, he was so impaired on benzos that I could have pushed him over with a finger. I’d just told him he couldn’t dose with methadone that day, due to impairment. The next week, he greeted when we passed in the hall. I assume he had been in a blackout from his benzodiazepine ingestion the week before and didn’t remember our previous interaction.

Be clear with your patients about your expectations. At the first visit, I sit with the patient and go over a patient agreement form. I adapted it from a SAMHSA website where you can find helpful forms, tools, and ideas.

https://pcssnow.org/resources/clinical-tools/

https://www.samhsa.gov/medication-assisted-treatment/training-resources/publications

In that agreement, I outline my expectations. I have paragraphs indicating that disruptive or violent behavior won’t be tolerated and are grounds for immediate dismissal from my practice. In thirteen years, I’ve never had one patient become rowdy or disruptive. Having said that, I do realize other prescribers have had different experiences.

I ask patients to keep and be on time for appointments, and if they don’t show up and don’t call, they will be charged for the missed visit. I tell patients I won’t call in prescriptions if they miss a visit. Having said that, I’m also flexible enough to know that things do come up – cars break down, traffic jams occur, etc. In the winter, travel can be treacherous, so that’s another factor to be dealt with. All I ask is that the patients communicate problems early so we can find a reasonable solution.

Patients who miss appointments, don’t call, and won’t answer our calls to find out what’s going on will have problems at my practice. It may or may not be their fault, but if it doesn’t work out they will need to find a new provider.

My agreement also says I won’t “fire” a patient before I talk to them face-to-face. Patients tell me they’ve been dismissed by a practice by letter, for some issue or another. I think that’s cowardly, and disrespectful to the patient. If there’s a reason I feel I can no longer to continue treatment as we are, I owe it to the patient to tell them exactly what the problem is. Sometimes we can find solutions short of termination and sometimes we can’t. At least the patient will know I respect them enough to talk to them, and they will know the basis of my decision. They will also get a referral to a new provider, or at least a recommendation.

Be careful with patient selection and try to match the patient with the best level of care.

Not every patient will do well in an office-based setting. For example, if a patient has been using buprenorphine products illicitly by insufflation or injection, that patient probably is best treated in an opioid treatment program, where observed dosing is done.

Most patients need to be on the combination products buprenorphine/naloxone. Adverse reactions do occur with the monoproduct, but they are rare, and drug diversion is not. If a new patient needs the monoproduct, I refer them to an opioid treatment program where they can be properly observed.

If that patient has been treated in another office-based setting with medical records that support their progress and compliance on the monoproduct, my recommendation would be different. Many factors influence my treatment decisions, so I need all the information I can get to make the best decisions.

This leads me to my next recommendation: get old records. Make the effort to get records from a previous practice. Sometimes patients, to curry favor with a new prescriber, will tell tales about how awful their last prescriber was. That may be true…or there may be more to the story, so get records to get a better idea of what happened at the last practice.

Don’t falsify your own records. It’s unethical and probably illegal to bill for services you document but don’t provide. To get higher insurance reimbursements, physicians sometimes chart long review of systems and/or physical exams than were performed. This is called “up-billing.” I suspect up-billing when I see records with four pages of single-spaced type for each visit, but then notice the same four pages for each monthly visit, with no changes.

I blogged before about a patient whose records recorded an exam saying “consistent with eight-month pregnancy” for every monthly visit for over a year. Yeah…kind of suspicious…using that cut-and-paste feature, I think.

If you do telemedicine, make sure you have some sort of medical personnel on site with the patient to look for physical finding you may miss with telecommunications. I just admitted a patient to our opioid treatment program who had been on Suboxone for six months from a provider he only saw online. This patient was injecting his medication, but his prescriber couldn’t see it. His most prominent tracks were on the side of his neck, which could be hidden with a high collar. Obviously, this could have ended in disaster had the patient not realized he needed a higher level of care.

Be careful about lab schemes. If a laboratory diagnostic service is charging patients $500 for one drug screen, it’s probably a scam. In past years, these organization popped up like mushrooms in manure, saying they could do extensive lab testing for all patients, but only charge those with insurance. Uninsured would get free testing.

As it turns out, some of those companies charged outrageous fees to the insurance companies, including Medicaid and Medicare, for expensive and unnecessary testing, in get-rich-quick schemes. Here’s a link to an article that explains how this works:

https://www.healthcarefinancenews.com/news/report-urine-based-drug-tests-helping-some-doctors-soak-profits

Good providers don’t want to sully their name by associating with shady laboratory service providers. Physicians can do good point-of-care testing on site for $10 or less. Sometimes patients need more extensive testing, and this can be decided on a case-by-case basis rather than testing every patient for dozens of drugs that aren’t commonly used in the community where you practice.

Be aware of what drugs are trending in your area and make sure they are included in your drug testing protocol. In the past, heroin was rare in rural areas, but that’s changed. As I’ve discussed on this blog, heroin frequently contains fentanyl, a much more powerful opioid that’s responsible for many overdose deaths.

Ask your new patients what drugs are being used in your community. They can be great sources of information, as can local addiction medicine educational conferences, and your local law enforcement officials.

Make friends with the medical director at your local opioid treatment program. Most physician medical directors at opioid treatment programs are happy to work collaboratively with office-based providers. We share patients all the time and need to do what’s best for the patient. We don’t need to look at each other as competitors, because there are more than enough patients for everyone, unfortunately. Let’s work together to get people into treatment, and to match the patient with the right level of care.

It can be a relief for an office-based provider to know they have a facility willing to deliver a higher level of care when necessary. Sometimes the patient may need inpatient treatment, but at other times it might be an opioid treatment program, where the patient may come daily for dosing and oversight.

Again, some patients, in an effort to curry favor with a new prescriber, may talk disparagingly about another treatment facility, so don’t take a patient’s word that an opioid treatment program does an awful job.

Decades ago in my previous life as a primary care physician, I learned that the new patient who tells me how wonderful I am compared to their last terrible doctor will soon be saying the same thing to another new doctor, about how terrible I am. I know there are terrible doctors, but there are also some patients that can’t be pleased no matter how good the physician.

Finally, get involved with organizations that can help you. You don’t need to re-invent the wheel; as I mentioned above, help is available from several sources.

Go to the SAMHSA website mentioned above and you will find helpful resources. Or you can go to the American Society of Addiction Medicine website for information: https://www.asam.org/  You may decide to go to one of their excellent conferences.

Go to the Providers’ Clinical Support System (PCSS) website and search their educational offerings at https://pcssnow.org/ They have archived webinars, mentoring programs, and other great things available.

If you work in North Carolina, there is the UNC ECHO program, which offers live teleconferences three days per week on issues surrounding medication-assisted treatment of patients in the office setting. You can hear cases presented and listen to input from experts and other prescribers, while getting free (yes I said free) CME hours. Once involved, you can present your own difficult cases to get help with difficult patient situations. You can go to their website at: https://echo.unc.edu/ or leave me a comment with your email and I can connect you to the organization.

It can be difficult to persuade new prescribers that treating patients with opioid use disorder is rewarding and fun. I became a physician because I wanted to help people, sappy as that sounds. I didn’t feel the sense of satisfaction during the decade I worked in primary care, for whatever reason, that I now feel working in the field of Addiction Medicine.

Complex Connections: Pain, Opioid Use, Suicide, and Opioid Use Disorder

 

 

 

Early this month, the New England Journal of Medicine published a review article about this topic. This article, titled, “Understanding Links among Opioid Use, Overdose, and Suicide,” summarized what we know so far about the twin epidemics of suicide and opioid use disorder. [1]

According to the authors, as unintentional opioid overdoses have risen over the past few decades, so have suicide rates, with both more than doubling from 2000 to 2017. We know that opioid use increases risk of unintentional overdose, but it’s been found that opioid use also increases the risk of suicide. People with opioid use disorders are more likely to commit suicide than people with other types of substance use disorders.

Why is this?

The article points out some specific pathways that cause vulnerability to overdose and suicide.

Pain causes changes in the brain that alters its reward system. We know patients with chronic pain are at increased risk for suicide, as well as riskier use of opioids. When opioids became more available at the turn of the century, due to efforts to treat pain more adequately, the average dose per capita increased seven-fold between 1997 and 2007. This availability increased the numbers of people who developed opioid use disorder, which is linked to both unintentional overdose and suicide. Higher doses of prescribed opioids are associated with higher risk for both unintentional overdose and suicide.

This article explained the two primary theories about the connection between increasing rates of both suicide and opioid overdose deaths.

The first theory says that both types of deaths are “deaths of despair,” meaning they occur in people whose general economic conditions are falling. Due to lack of opportunities, social isolation, legal problems and/or economic inequalities, people feel desperate, and look for ways to cope. Opioids dull emotional pain as well as physical pain, but according to this theory, also cause worse depression. This increases suicide risk and overdose risk. This theory is called the demand-focused hypothesis.

Or it could be the other way around, as the second theory explains: increased use of opioids causes decline in social function and increased risk of opioid use disorder, which may increase depression. This is called the supply-focused hypothesis. Studies that show increased suicide risk with higher doses of prescribed opioids would tend to support this hypothesis

To tell the difference, we need quality longitudinal studies to show which occurs first. We don’t have such studies, and we need them. The authors say it’s important to know which theory is more accurate, since public policy approaches to fix the problems would be different if one theory is more correct than the other.

Of course, sometimes we don’t know if a death in unintentional or suicide. Sometimes the people involved don’t even know. I’ve talked to many patients with opioid overdose history. When I’ve asked if it was a suicide attempt, they answer, “I don’t know. I just wanted to feel better. If I died, so be it.” How do we classify such an event?

For sure, opioid use disorder brings despair. Some of my patients tell me that they want to live, but they also want their painful struggle to stop. Since death would be one route of release, it becomes a more acceptable option. Hearing this magnifies the importance of getting patients into treatment.

Or maybe the person alters their description of the event, after they survived. If they admit to suicidal intent, they might fear an involuntary commitment to a psychiatric facility, which usually means enforced opioid withdrawal (at least in my area…in some states, psychiatric facilities do provide MAT), so they claim the incident was accidental.

There are shared risk factors for both types of deaths. Both suicide and overdose deaths are more than twice as likely to happen to men than women. White or Native American people have higher rates of both compared to black or Asian people, and highest rates are found in those in their middle years, 41-64.

All mental health conditions are related to higher risk of unintentional overdose, as well as increased risk of suicide. Risks of both events are even higher in people with both mental illness and opioid use disorder.

Knowing the profiles of people at highest risk, can we use that data to intervene and prevent both causes of death? Yes, if they can access help. These patients do the best when both opioid use disorder and mental disorders are addressed at the same time.

Many prescription monitoring programs use numerous factors to determine who is at highest risk for overdose death. Those patients could be given more attention, with detailed assessment and referral to appropriate treatment.

North Carolina added an overdose risk score to its prescription monitoring program recently. It needs fine-tuning, since scores are adjusted upward for factors not always under a patient’s control. For example, I had a patient who is prescribed two Suboxone 8mg films per day. Her pharmacy doesn’t always have them in stock, forcing her to go to other pharmacies. When she does this, her overdose risk score goes up, but it’s not due to anything my patient is doing. In fact, instead of getting discouraged and giving up, she does what she needs to do to stay in treatment. That should adjust her score downward, in my opinion. But the data collectors at the state level have no idea why she’s at multiple pharmacies and assume it’s risky behavior.

I was happy to see this article emphasized the importance of increasing access to medication-assisted treatment for patients with opioid use disorder as a life-saving measure. Of course, they also emphasized a combined approach to treatment, with inclusion of evidence-based forms of counseling.

This study addresses the dilemma of the patient with chronic pain. We know that higher opioid doses are associated with increased risk of overdose death, but we don’t have data that shows tapering that dose reduces the risk of overdose or of suicide. Many practitioners now advocate reduction of patients’ opioid doses to at, or below, the 90 mg MME (morphine milligram equivalents) recommended by the CDC (Center for Disease Control and Prevention) for reducing risk. Might such a reduction make pain worse and trigger suicidal intent? We don’t know.

Some patients on chronic opioids develop hyperalgesia, a condition where the body becomes more sensitive to pain due to adaptations from chronic opioid use. Often those patients feel better as opioids are tapered, but this is far from a universal experience for pain patients.

What I learned from this article was that while we know pain, opioid use, suicidality, and opioid overdose are linked, we are far from understanding precisely how one condition influences the others. So far, we have developed profiles of patients most likely to be at risk, and we should be talking to those patients, doing better assessments. Then we need to increase access to care using evidence-based treatments.

We see the best outcomes when mental illnesses are treated along with opioid use disorders.

  1. Bohnert et al., “Understanding Links among Opioid Use, Overdose, and Suicide,” New England Journal of Medicine, January 3, 2019, pp71-79.

Patients with Substance Use Histories Denied Primary Care

Shocked and Appalled

 

 

 

 

 

One of my long-time and very stable patients saw me a few weeks ago for her yearly history and physical. That’s a minimum requirement for the patients I treat with methadone or buprenorphine at the opioid treatment program. For patients in treatment for many months, I no longer need to see them frequently for positive drug screens, dose adjustments, and other things, so we make sure to set aside time each year for me to catch up on how they are doing.

This isn’t only good medical care, but it’s fun for me. I love talking to patients and hearing the ways in which their lives have improved. It’s fun for them to discuss how they are accomplishing their life goals.

This day, after asking about the adequacy of her dose, her mood, her sleeping habits and biggest sources of stress, I asked about her overall health. To start with, I asked the name of her primary care physician. She told me she couldn’t get one, because of her history of opioid use.

I asked for further details: she called a local practice about becoming established as a patient, and part of their screening was to ask if she’d ever been prescribed opioids. She said yes, but that problem was in the past, and she didn’t need opioids now. She was then told that the practice wasn’t accepting any patients with a history of opioid use.

Merely opioid use, mind you – not opioid use disorder.

This wasn’t because of her insurance status, as she is covered by the largest private insurance carrier in the state, Blue Cross/Blue Shield of NC.

She said her feelings were hurt, and she started crying as soon as she got off the phone. She said, “They made me feel like a piece of shit.” She even teared up in my office as we were talking two weeks later.

This does not sit right with me.

I gave her the website of the North Carolina Medical Board and gave her the web address and phone number of where and how to file a complaint against that practice. I told her that denying entry to primary care for a patient because of past opioid use was immoral, if not illegal. I’m not a lawyer, but I figured if she let the medical board know, they could figure this out.

She hadn’t even told them she was on methadone. I know it’s a violation of the American with Disabilities Act, the ADA, to discriminate against someone with opioid use disorder who is in recovery on medication-assisted therapy. But I didn’t think that was the case for her, since she didn’t have time to tell them she was on methadone. By her description, their decision was based only on her history of receiving opioid prescriptions in the past.

I doubt there was any misunderstanding on her part, since she’s not the first patient we’ve had who reported similar situations. Also, local practices tell our patients on methadone or buprenorphine that they don’t have the “expertise” to care for them if they are taking methadone or buprenorphine from me.

This is ridiculous, since primary care physicians care for patients with specialty medications all the time. Cardiac patients on complicated heart medications still get primary care. HIV patients on powerful anti-viral medications still get primary care. Patients with opioid use disorder are no different.

But to be denied primary care merely because opioids have been prescribed in the past…it’s a step beyond the usual discrimination I see.

Of course, if the medical board does investigate, I expect that practice will blame the patient for misunderstanding, and say they accept all patients. Maybe…but at least they will be on notice that discriminatory practices can and will get them into problems. Hopefully they will be less likely to do this again.

No wonder local death rates increased. Not only are we dealing with the continued opioid use disorder epidemic with its opioid overdose death risk, but also with a lack of medical care for those people who survive opioid use disorder. It’s a double assault on patient health.

I live in a beautiful part on this country, but the medical care in this community often baffles me.

After a free-for-all on prescribing opioids, benzos and stimulants for a decade or two, the patients in this area for whom those were prescribed now can’t even get a primary care practitioner. It’s as if local doctors think that after the pendulum swung so far in one direction, it must swing too far in the other.

Common sense should dictate care – let’s not prescribe controlled substances willy-nilly but let’s not be stingy with opioids in cases of acute pain. And let’s not deny patients care if they’ve been prescribed opioids in the past.

What about repercussions from insurance companies? Will insurance companies allow certain prescribers to opt out of treating their covered enrollees because of past prescriptions?

Here’s another discriminatory wrinkle: life insurance companies are turning down coverage for people who have filled prescriptions for Narcan. A friend of mine sent me a link to this story:

https://www.npr.org/sections/health-shots/2018/12/13/674586548/nurse-denied-life-insurance-because-she-carries-naloxone

This is a link to the story of a nurse who was turned down for life insurance because she has filled a prescription for Narcan. This nurse works at an addiction treatment program and wanted to be able to revive people and save lives. The insurance company, Primerica, is now being criticized because it turned down her request for life insurance since she filled a Narcan prescription.

Now that they are being criticized for their stance, they issued a statement saying something to the effect that they support efforts to turn the tide on the opioid epidemic. But it appears that support doesn’t extend to offering life insurance to people who have obtained a Narcan kit.

This nurse applied at a second company and was turned down again, though she was told if she got a letter from her primary care doctor explaining why the Narcan was prescribed, they might re-consider. The trouble is, in Massachusetts, personal physicians don’t write prescriptions. To reduce barriers to receiving Narcan kits, the state allows any person who wants a kit to be able to get it under a standing order.

The physician behind this standing order is a well-known and well-respected physician, prominent in the Addiction Medicine field, Dr. Alex Walley.

Doctor Walley says he’s written other letters for similar situations where people are denied life insurance due to filling Narcan prescriptions to have on hand to save lives. He’s worried – obviously – that people will be discouraged from getting Narcan kits. These kits and their availability have been responsible for saving many lives in this nation.

These examples of poor decision making do nothing but extend the misery of people with opioid use disorder, in or out of treatment, and their families.

I’ve been working in my community for seven years, trying to inform and educate other medical providers about medication-assisted treatment. Most of the time, I feel positive, thankful to form good relationships with some providers and to coordinate care for my patients on medication-assisted treatments.

Then there are days when I feel so discouraged. it feels like there’s been no progress at all with deeply embedded bias and stigma against people with opioid use providers, their families, and the professionals who try to provide care to them.