Tiny Candle of Hope

 

 

Every Friday at 6 pm at the Crossfire Biker’s church in North Wilkesboro, NC, people gather to attend a tiny meeting of Narcotics Anonymous, called the Brushy Mountain Group.

It’s not a large meeting; only six to eight people are there on any given Friday. It’s not an old and established meeting; it only started three months ago. But this meeting’s impact could be massive because it has the potential to change the lives of the participants.

This meeting was started with the intention of giving all people seeking recovery a place to get well. Applying the spiritual principles of acceptance and unconditional love, this NA meeting welcomes every person who wishes to recover from the disease of addiction.

This meeting makes no distinction between members who are prescribed methadone, buprenorphine, anti-depressants, stimulants, or other medications. Everyone is welcome to attend and everyone is welcome to share their experience, strength and hope. The recovering people who happen to be prescribed methadone and buprenorphine are treated as full members.

For critics who say Narcotics Anonymous is meant to be a program of complete abstinence from all drugs, people at this meeting have no issue with this statement. They know there is a difference between using drugs and taking medication. Surely the founders of NA never meant for members to be completely abstinent from all medications!

These members know the Third Tradition of Narcotics Anonymous says, “The only requirement for membership is the desire to stop using.” The assumption is that this means using drugs, not medications. At this meeting, members make their own decisions about their “clean date.” For most, the clean date is the day after their last illicit drug use.

At this meeting, the Fifth Tradition of Narcotics Anonymous is felt to be of the upmost importance, and should be a main guiding principle of every meeting: “Each group has but one primary purpose: to carry the message to the addict who still suffers.” No clean time distinctions are made. This still-suffering addict may be a newcomer, or it may be a member with twenty years of recovery. Suffering is suffering, and the group is there to support suffering members.

If a participant shares about taking medication, no one clutches at their pearls and gasps. No one  tut-tuts and asks them to shut up and talk to someone after the meeting. These people are given the same esteem as all other members. The others listen in respectful silence, and sharing continues after that person is finished.

Participants don’t often share about medication, except in passing. Most share about how they are feeling and how their emotions affect their recovery. They talk about situations that could cause a relapse, and they share gratitude for achievements big and small. They talk about how to handle the guilt from their actions in active addiction, or about how they want to do a better job raising the children.

In other words, an observer couldn’t tell this meeting was any different from any other NA meeting where recovery is underway.

This meeting is a tiny candle, spreading just a flicker of light into a small corner of one community darkened by the opioid use disorder epidemic.

But what if this light spread…what if more 12-step meetings welcomed people on methadone or buprenorphine with open arms, with hugs and unconditional love instead of judgment and put-downs?

Then 12-step recovery could be ablaze with the light of changing lives.

That’s my prayer.

 

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Older Patients at Opioid Treatment Programs, Part 2

 

 

Co-occurring medical issues complicate treatment of our patients at any age, but are more common in older (over fifty) patients.

Any of our older patients who report chest pain need an immediate workup for coronary artery disease (CAD). Since almost all our patients smoke or have smoked, CAD occurs frequently. Few of them know if they have high cholesterol or not, though most know if CAD has occurred in close family members, or if they have a personal history of diabetes or high blood pressure, which are other risk factors for CAD.

Some of our patients have used stimulants, which can cause certain types of heart disease including palpitations from cardiac arrhythmias. Long-term stimulant use can also cause cardiomyopathy, a disease that permanently weakens the heart muscle.

Methadone, but not buprenorphine, can cause a certain type of heart problem known as prolongation of the QT interval. To simplify, prolongation of the QT interval involves the electrical system of the heart. An extreme prolongation can put patients at risk for a potentially fatal heart rhythm problem. Patients with heart disease may need an EKG before and during methadone treatment to look for this specific problem. Minor heart ailments like mitral valve prolapse, or a murmur with no underlying structural problems may not be influenced by methadone at all. When in doubt, it’s easy to get an EKG.

Since my background is Internal Medicine, I feel comfortable reading and interpreting EKGs, as I did in primary care. I refer to cardiologists when there’s a problem. Most often, the cardiologists say that the benefit of methadone outweighs the risks of QT prolongation. That’s helpful, because my patients and I need information about the risk versus benefits of medication, to decide how to best move forward. Each patient is different, the patient must be part of the discussion of risk. Some patients don’t mind the extra risk, while others can be very bothered by it.

Respiratory problems can be made worse by methadone. Buprenorphine can also affect breathing, but to a lesser effect. However, almost always, these two medications reduce the overall risk of death when compared with uncontrolled use of illicit opioids in patients with respiratory problems.

The more severe the respiratory problem, the trickier methadone administration can be. Since opioids, including methadone and buprenorphine, can reduce respiratory drive, COPD with retention of carbon dioxide is one of the most worrisome conditions.

Patients who retain carbon dioxide have such severe obstructive lung disease, most often caused by cigarette smoking, that the patients have problems expelling carbon dioxide, a waste product of respiration. The CO2 accumulates, giving a chronically elevated level. This happens slowly, so that patients’ bodies make accommodations to keep the blood pH normal. Normal patients breathe faster when the body accumulates carbon dioxide, but patients with severe COPD can no longer do this. When respiratory depressants like opioids are used by these patients, there’s a danger that breathing will slow more, causing a potentially fatal build-up of carbon dioxide. In these fragile patients, it is best to use a much lower starting dose of methadone than usual, and to increase more slowly than usual. It’s also much more important to limit other sedative medications (like benzodiazepines, pregabalin, and others) that could further slow breathing.

Patients with kidney failure generally don’t need to have their dose adjusted. Methadone has no active metabolites, and is mostly metabolized by the liver. Less than one percent of the blood concentration of methadone is removed by dialysis, so the patient can dose daily as usual, with no adjustments needed after dialysis. However, the patient with end-stage kidney disease may be debilitated in general by their illness, so physicians need to be cautious when starting methadone, and follow the adage “start low, go slow” with dosing.

Methadone is stored in the liver and metabolized there, but it doesn’t harm the liver. However, if liver function is impaired, the metabolism of methadone may be slowed. This can cause a potentially fatal accumulation of this medication, so any patient with new-onset acute liver failure needs to be monitored more closely. In these patients, we may want to ask them to return to our OTP three hours after dosing, when the methadone level will be at its peak, to assess for sedation. Trough blood levels can be helpful in these patients too.

We used to worry that buprenorphine damaged the liver, and recommended patients with liver disease avoid buprenorphine. However, some big studies didn’t show any worsening of liver function in patients on buprenorphine, so again, the benefits outweigh the risks in most cases.

Two specific types of co-occurring medical problems challenge opioid treatment program staff regarding patient take home status: changes in mental status and mobility issues.

Let’s take mental status issues first.

Cognitive decline is always problematic with aging patients, and perhaps doubly so in patients with substance use disorders. Watching a patient who has done well on methadone for years become more forgetful and scattered in their thinking is so sad. Underlying causes vary. The decline could be due to a reversible cause, from onset of Alzheimer’s disease or other dementia, or other medical problems.

Because we see our patients so often, opioid treatment program staff – nurses, counselors, physicians, and physician extenders – may notice slight changes in cognitive function before their other medical care providers. It’s then up to us to convince patients to go to their primary care provider for a medical workup. We always hope a reversible cause will be found.

Medications can cause changes of mental status in our patients. The classic drugs of misuse have typical signs and symptoms, but sometimes mental impairment can be caused by other medications: toxic levels of anti-convulsants, bingeing on drugs like gabapentin, pregabalin or muscle relaxants, or interactions between medications. Benzodiazepines are infamous for causing mental slowness and even associated with increased risk of dementia.

Patients diagnosed with chronic mental decline, like that seen with dementia, are most difficult to manage. With these patients, take home doses are a quandary.

A patient with dementia may gradually lose the ability to manage take home doses appropriately. Sometimes our first clue that something’s wrong with a patient can be when they come to dose days earlier than they are supposed to. They are confused about what happened to their take home doses, or why they came back to the facility early.

This is such a dilemma. We don’t want the patient to feel as if we are punishing them by revoking take homes, but we can’t in good conscience allow them to walk out of our OTP with take homes if they can’t remember if they’ve dosed today. It’s a safety issue.

Patients with significant memory problems must come to the facility to dose every day, which can be a hardship. If their mental decline has been accompanied by physical decline, problems are compounded. Sometimes patients have dependable relatives living with them who can help them take their medications at the appropriate times, but that’s not always possible.

If patients’ illnesses worsen to the point they can no longer be taken care of at home, what do we do? How can we continue their care while in a nursing facility? That gets tricky. If the facility or a relative is willing to bring the patient each day, we can do that. If that’s not practical due to physical frailty, sometimes the nursing home is willing to dose our patients, but regulations say OTPs can only dispense medication to the patient for whom it is prescribed. That is, a relative or personnel from the nursing home can’t come to pick up the patient’s dose and take it to him, as can be done in a pharmacy.

Finding solutions which are practical and workable that don’t violate any OTP regulations can be problematic.

Even getting patients on methadone and buprenorphine into assisted living facilities can be complicated. Last month on the AT Forum website (http://atforum.com ), an article was referenced that recounted the difficulties of finding nursing facilities willing to accept patients on buprenorphine or methadone. [1]

This article said some facilities have policies against admitting patients being treated for opioid use disorder with buprenorphine or methadone. The article said this stance was probably based on a bias against MAT in favor of abstinence-based approaches to treating opioid use disorder. Some experts believe this is illegal, because it violates the Americans With Disabilities Act.

Mobility issues from falls, broken bones, orthopedic conditions, or recent surgeries sometimes collide with my assessment of the patient’s stability from opioid use disorder. What if a patient deemed too unstable (or too new to treatment) for anything other than one take home per week has a sudden medical issue that limits his mobility? This situation occurs more than you might imagine.

We used to be able to dose patients in their cars if it was difficult for them to walk into the facility. Now, the DEA opposes this, worrying a nurse carrying a dose of methadone to a car in our parking lot could be intercepted by someone with criminal intent. I agree this could happen, but the rare occasions when we’ve had to dose patients in their cars, we sent two staff: one nurse to carry and administer the medication, and a witness (usually the patient’s counselor) to witness it being given to our patient and no one else. This also protects our nurses against accusations they mishandled the dose in any way. But the DEA says we can no longer do this.

Some OTPs take a hard line and say if you can’t walk into the OTP, you are not appropriate for treatment. That seems unkind, particularly if a patient has done well with us in the past, and is now having a temporary medical issue limiting mobility.

I think the best approach is to get input from the patient’s physician and try to decide action that’s in the best interest of the patient.

First, I talk to the patient’s physician for specific recommendations of the patient’s mobility. Then I talk to the patient, usually with a counselor, and we ask about family members who could help the patient take extra take home doses as directed. We can ask for state and federal exceptions for extra take homes, so long as we do all we can to ensure patient safety, and describe the situation to officials, to give a better idea of our thought processes and safety concerns.

Sometimes I am surprised, and the other physician wants the patient to get up and walk around, particularly after surgery, for a better outcome. If that’s the case, no extra take homes need to be provided.

Some patients are so debilitated that being around other people presents a health hazard. We had a patient on heavy cancer chemotherapy. When her white blood cell count was extremely low, her doctor recommended she avoid crowds. This occurred during the height of cold and flu season last year, so we requested extra take homes for her, to keep her from having to come to our OTP and sit in a waiting room with other patients.

Her oncologist and I had to weigh the risk of extra take homes against the risk she could contract a simple viral illness that could kill her in her immune-suppressed state.

These types of situations will occur with frequently given the overall aging of the U.S. population, and the aging of patients on medication-assisted treatment. We need to remember this aging is a good thing – patients getting help with MAT are surviving, and living until old age

  1. https://www.statnews.com/2018/04/17/nursing-homes-addiction-treatment/

 

Medication-assisted Treatment in An Aging Population

 

 

Patients prescribed medication-assisted treatments with buprenorphine, methadone, and naltrexone are getting older…as we all are. This is wonderful, because it means our patients are surviving, making it to old age. Methadone has been prescribed for the longest of the three, so we tend to see more older patients on it.

Aging in our patients can present specific challenges; research literature shows high rates of physical and psychological illness in opioid users in general, meaning as this population ages, we can expect to see even more co-occurring illnesses.

When looking for information about aging MAT patients, I was appalled to see a journal article define “older adult” as those fifty and above. I’ve always thought of “older” as being, well, older than me. I’m no longer pushing fifty – I’ve been pulling it behind me for nearly seven years, so I felt a little resentful on behalf of my patients.

Anyway, the article was titled “Older Adults Prescribed Methadone for Opiate Replacement Therapy: A Literature Review,” and the author said that the U.S. had 1.7 million people over age 50 in 2000 who needed substance abuse treatment. That number is expected to rise to 4.4 million by 2020. [1]

This article said the numbers of patients over 50 years old who are on MAT is expected to rise, and this group of patients has special needs. They say these patients tend to age more quickly (physiologically) due to past lifestyle.

I see that in my patients. Around 90% are smokers, and cigarettes cause a whole host of medical issues. Some patients have had poor dietary habits since childhood, from a combination of factors. Many patients haven’t had the time or energy for self-care, prior to entering recovery, and this takes a toll.

A New York study of older OTP patients on methadone [2] sampled 156 patients enrolled in OTPs. Twenty-nine percent were age 55 or older (45 patients) These patients, as compared with their younger counterparts, were significantly more likely to have been in treatment longer, less likely to be using heroin currently, but more likely to have an alcohol use disorder.

The older patients were less likely to be impulsive or hostile, but more likely to have chronic medical problems and more likely to be on medications for those problems. Older patients were more likely to be on more liberal take home schedules, due to less illicit drug use compared to younger patients. Despite having more chronic medical issues, older patients’ scores on life satisfaction scales weren’t different from younger patients.

Improving the health of our older OTP patients is a challenge, and I have a few suggestions to help.

Get them to a primary care provider. Some OTPs are fortunate enough to be able to offer primary care to their patients. That’s wonderful, but if, like me, you work at an OTP that can’t do that, patients will need to be referred. This should be easy, but it’s not, at least in some areas of this country My patients tell me when they call for an appointment as a new patient, they are told they can’t be accepted if they have a history of substance use disorder or treatment for chronic pain. They say they’ve called all the practices in the area and none will accept them.

Could this be exaggeration by patients? Maybe, but I’ve heard this over and over. Some patients say the receptionist who answers the phone takes their name and birthdate, then calls back to say they can’t be accepted. The patients think it’s because the prospective physician sees they have past histories of filling controlled substances on North Carolina’s prescription monitoring program. I hear the same things from patients with private insurance, Medicaid, and self-pay.

I’ve never heard any physician to admit to doing this, since it would unethical, and probably also a violation of the Americans With Disabilities Act.

Federally Qualified Health Centers (FQHCs) will take these patients. We have a center that does an excellent job with our patients; however, it’s an hour’s drive away. Some patients have difficulty getting transportation for that distance.

Medicaid patients should be assigned to a doctor or practice, and it’s printed on their Medicaid card.

Health maintenance can’t be neglected.  

Often a patient says something to the effect of, “I didn’t expect to live this long. I never thought of doing those things.” This is called a “sense of foreshortened future,” meaning the person senses he will not live to an old age and is destined to die young. It’s seen in people who have experienced trauma in their lives and can be a symptom of post-traumatic stress disorder (PTSD). But now here he is, over 50, and not accustomed to taking care of himself.

And yes, it also means that rite of passing age 50: the screening colonoscopy.

Our patients need routine PAP smears, mammograms, prostate exams, and vaccinations. They need their blood pressure and cholesterol profiles checked when appropriate. We need to encourage our patients to keep up with these simple measures.

After patients get into recovery, it takes time and effort to adjust thinking, and accept the idea that good self-care can extend the quality and length of life.

Opioid treatment programs, like all other medical practices, should keep an updated medication list and updated problem list.

That should be easy to accomplish, but at my OTP, our present software system has no provision to document this essential information. I’m left to figure it out with paper charts, which isn’t ideal, but workable. But I can only see that data if I’m in the office with the chart in front of me.

Methadone has interactions with many medications. The list is long, and difficult to remember, so I use a smart phone app that will tell me about drug interactions. There are many out there: Epocrates and Medscape are but a few. If you work in an OTP, get this phone app. It will save you time and effort.

See complicated patients more often.

This applies to older patients, but also to younger ones if they have a complicated medical history. Sometimes it’s hard to convince patients they need to see me if they are doing well. Particularly if they have their own doctor, and they are doing fine, why should they waste their time? Of course, I think it’s time well-spent, but I understand their thinking. I delay seeing my doctor too. Life is hectic and that’s never at the top of my list.

I’ve started “warning” new patients with more than a few medical issues that I will want them to see me every 3 months. We can flag this in our computer system, along with flagging when they will be due for a yearly physical.

I count diseases like heart disease, diabetes, COPD/emphysema/asthma, and other chronic conditions as complicating illnesses. There are dozens of others, and I also count chronic mental illnesses, even though they are treated by psychiatrists. Many of those medications can have interactions with methadone, making it prudent to see these patients more often.

More than anything else, keep talking to patients about quitting smoking. Smoking-related illness is the number one killer of people in recovery. It’s not easy, but keep encouraging and supporting them. My state has a quitline to help anyone wanting to quit at: https://www.quitnow.net/Program/This is sponsored by the American Cancer Society, for no cost to the patients.

In my next blog, I’ll talk about some of the most challenging co-occurring problems in my patients: deteriorating cognitive function and limited mobility.

  1.  Doukas et al., and published in Addiction and Preventive Medicine, February 10, 2017.
  2. Rajaratnam et al., Journal of Opioid Management, 2009 5(1), pp 27-37.

 

North Carolina’s Addiction Medicine Conference

I had a great weekend.

I went to the annual NC Addiction Medicine Conference, held in April each year, in Asheville. This year, I took an extra day off work and went to the pre-conference workshops, which I haven’t done in the past, because of poor planning on my part.

I went to the workshop titled “Treating Women for Substance Use Disorder During the Perinatal Periods: Integrated Medical and Behavioral Health.” It was fantastic. Hendree Jones, PhD., lead author or the MOTHER study, was one of the main speakers. I’ve heard her talk before, and not only does she present information in a straightforward way, she epitomizes the empathy that providers should have towards their patients. Dr. Mishka Terplan, MD, was the other presenter, and was equally eloquent and gifted lecturer. During the workshop, we broke into small groups to interact with other participants about topics.

Here are the latest ideas I heard: it’s ok – really, it is ok – to treat pregnant women with buprenorphine/naloxone combination products. We don’t have to switch them to the monoproduct. I already knew a pregnant woman shouldn’t be switched from methadone to buprenorphine, but I learned a pregnant woman shouldn’t be switched from buprenorphine to methadone, either.

I learned the depressing news that screening and brief intervention for substance use disorders are less likely to be done in women than men, and when their screen is positive, women are less likely to receive any intervention. Also, physicians aren’t good at diagnosing substance use disorders in women who are on either end of the age spectrum.

I learned about the social determinants of health that influence the outcome of pregnancies and substance use disorders the same as they influence all of health.

I learned that split dosing in pregnancy can be helpful with buprenorphine, same as it is with methadone. I have been splitting the dose of pregnant patients on buprenorphine nearing the end of their pregnancies, but wasn’t sure there was data or expert opinion that supported doing this. There is.

These lecturers talked specifically about the Bell study – that pesky study out of Tennessee that concluded taper of medication-assisted treatment during pregnancy was a reasonable idea. Even Bell’s own data didn’t support that conclusion, since the incidence of neonatal abstinence wasn’t decreased with a taper (or cold turkey withdrawal in jail). Reduction of NAS is the main reason Tennessee physicians in TN and elsewhere taper the dose of buprenorphine/methadone during pregnancy.

I already knew these facts, but since I deal with some obstetricians who don’t approve of the use of buprenorphine/methadone for the treatment of pregnant women with opioid use disorder, it was nice to confirm my approach is based in facts and data. After so much resistance from local OBs, I start doubting myself, wondering if I’ve got it wrong because after all, I’m not an obstetrician. It’s a great feeling to have what I’ve been recommending confirmed by the experts.

The whole conference was great. On the day of the main conference, I gave a thirty-minute presentation about the state laws passed around opioid and buprenorphine prescribing. I think it went well. I was well-prepared, since I’d spent hours researching, then hours rehearsing my presentation. I hate speaking in public, and have jitters about it. The more I practice, the more confident I feel. I felt a flood of relief when it was over, and pleased I’d gathered the courage to do this.

Then I went to an outstanding presentation on LGBTQ patients. I learned a lot, and feel more confident that I can treat this population in a culturally competent way. That presentation was followed by one on peer support specialists. This is not necessarily a completely new idea, but now there’s funding available for such personnel. I know how valuable peer support specialists can be, since we have several who work with our patients. They can be a godsend.

It went on like this for the rest of the day and the next too. All the speakers I heard were outstanding.

At this (and similar) conferences, it’s not just the information I get, or the credit hours that I need to remain licensed. There’s also a delight in being around people with the same passion to help people with substance use disorders. Sometimes we argue. I don’t think a group of three hundred doctors will ever agree on everything. But we remember we have more in common than the few points about which we have disagreements.

It’s nice, being among providers who understand the joys and tribulations of caring for our patients.

Any provider interested in joining North Carolina’s Society of Addiction Medicine should go to these websites:

http://www.ncsam-asam.org/

https://governorsinstitute.org/

The advantages of joining the state chapter of Society of Addiction Medicine (and also the national organization, called American Society of Addiction Medicine, or ASAM) include reduced rates on conferences, access to other physicians interested in treating patients with substance use disorders, and access to online CME hours (ASAM).

And support. Lots and lots of support, because we have a job that can be challenging.

Additional resources for physicians include the Provider Clinical Support System (PCSS)

https://pcssnow.org/

Providers in North Carolina who want more data about providing office-based treatment of opioid use disorder using buprenorphine can join ECHO UNC, a program of weekly teleconferences that can be accessed by computer or by phone. This is free, and participants can get CME hours. The format is a case presentation, followed by questions and commentary about management options, then a short didactic session. Then the session wraps up with a second case presentation. It lasts 2 hours, and participants can join for all or part of the weekly conference. It’s held each Wednesday from 12:30-2:15 or so.

Interested providers can go to: https://echo.unc.edu/ to learn more and to sign up to participate.

Happy Anniversary to Me

 

 

 

 

 

 

This blog entry is about random thoughts careening through my brain today.

Last week marked the eight-year anniversary of this blog. I started it in 2010, to promote a book I had written. The book did OK, but it’s out of date now. Things happen rapidly in the field of opioid use disorder treatment.

My blog has turned into a bigger thing than I ever planned. I enjoyed writing it more than I thought I would, and people were more receptive to the type of information I presented than I imagined they would be. People tell me my blog filled a void by providing information about medication-assisted treatment of opioid use disorder.

I’m glad. This makes me happy.

While there are other blogs about Suboxone, most are oriented towards patient problems and questions. I hope my blog entries help patients and their families gather more information, but I also want to edify treatment professionals, including other physicians, nurses, therapists, and counselors. To be able to do this, I must keep reading the latest information and going to conferences in the field of Addiction Medicine. Since this field is my passion, that’s been no sacrifice to make; plus, it keeps me up to date for my own patients.

But the writing can be vexing. Sometimes writing flows like lava down the side of a volcano, but sometimes I write a sentence three times before I’m happy with it. This has improved with more consistent writing, but there are days that I still sumo-wrestle with sentences.

Terms we use in this field have changed over eight years. If I want to re-blog something from more than six years ago, I need to read it carefully before posting again. I’ve missed a few “opioid addiction” phrases and readers have pointed out my error with some enthusiasm. Fair enough. Language is important. The proper term now is “opioid use disorder,” and patients are not “addicts.” They are people with opioid use disorder.

Some blog entries are informational and don’t change, so I recycle them: how to treat insomnia without medications, how clonidine works, and the like. Other blog entries are out of date within in year, like statistics on opioid use disorders and overdose deaths, and state laws around opioid and buprenorphine prescribing.

Buprenorphine’s reputation has changed. In 2010, many fewer people knew what this drug was. Now we have internet memes about Suboxone, and plenty of websites with data and opinion. We’ve had some excellent news pieces about the medication buprenorphine, and some websites set up only to tell the world how awful buprenorphine is. Everyone has an opinion, it seems.

Diversion of buprenorphine products has become a frequent topic, fueled by the perception that much of this medication is making its way to the black market.

My own opinion about medications for opioid use disorder and how treatment should be organized have changed. I’ve become more avid about harm reduction, but more conservative about where patients start treatment. I’ve also come to believe most new patients with opioid use disorders should be started on medication at opioid treatment programs, then referred to office-based programs once they stabilize, like the Vermont hub-and-spoke model. I realize those two views aren’t consistent.

We have too many lawmakers trying to legislate the care provided at treatment programs, but I understand why they feel it’s necessary. Some treatment programs cry “harm reduction” as an excuse for sloppy patient care while making large profits. Medicine in the U.S. is a for-profit enterprise, and no doctor should be blamed for making a profit; however, there’s profit and then there’s obscene profit.

I’ve met some of the best, brightest, and most dedicated people in the world in this field of medicine. I’ve also met some real con artists and shady characters in this field, working only for personal prestige and money. It seems to draw people from both extremes, and I try to maximize my contact with the former and minimize my contact with the latter.

I’ve developed a thicker skin writing the blog. I don’t post the worst of the comments, like the woman who commented that I would burn in hell for prescribing medication for opioid use disorder. She’s entitled to her opinion, but it’s my blog and I don’t have to air her view, particularly since it seemed spew-y and irrational.

I don’t post comments insulting to people with opioid use disorder, unless it’s to educate readers about how much misinformation still exists in the world.

Patients sometimes write negative comments about their care providers, and I usually encourage them to talk to their physician. If they don’t get satisfaction with that, I tell them to vote with their feet and go elsewhere. The trouble is, there may be only one provider in their area. What does the patient do then?

We do need more primary care physicians prescribing buprenorphine, but they must be respectful of the patients they treat. If as a physician you can’t understand that some behavioral issues are associated with opioid use disorders, you shouldn’t be working in the field.

The nation must educate physicians in all fields about medication-assisted treatment for opioid use disorder. Treatment for opioid use disorder has for too long been in its own silo, far away from mainstream medicine. Most physicians don’t know anything about MAT, except that they are opposed to it. These physicians MUST be educated. Our patients must be able to get good medical care without judgment.

Negative comments from other physicians about MAT undermine our patient’s progress and their self-esteem. It also prevents my patients from getting good medical care from primary care providers, surgeons, and especially emergency department physicians.

Physicians must start referring people with the illness of substance use disorder for treatment, rather than telling these patients they are bad people because they haven’t stopped yet. They must be taught to give my patients the same understanding and forbearance as patients with other chronic medical illnesses with behavioral components.

I’m happy with all the attention that new outlets have been paying to opioid use disorder and its treatment over the past several years. I also wish this attention could have been started around fifteen years ago, before thousands died from this problem.

Opioids and Gabapentin: A Potentially Dangerous Mixture

 

A Canadian study, published late last year, showed co-prescribing of gabapentin and opioids was associated with significantly increased risk of opioid-related death.

I’ve had a few of my patients on methadone or buprenorphine misuse gabapentin, and even had one patient end up in the emergency room with an overdose from a mixture of buprenorphine and gabapentin, but I thought it was because the patient took way too many of the gabapentin. In the past I’ve thought of gabapentin as a “junior” substance of abuse. I thought most people with opioid use disorder wouldn’t deign to be interested in such a low-powered drug. I thought it might fall in the category with trazadone, Seroquel, or Benadryl…something young people might experiment with, but not what people with established opioid use would want to mess with.

After reading this study, I’ve changed my mind. Gabapentin with opioids is associated with increased risk of death. This is serious.

The Canadian study by Gomes et al., says gabapentin is often prescribed for pain, and obviously opioids are as well, resulting in many patients who are prescribed both. The purpose of the study was to discover if co-prescribing gabapentin and opioids resulted in higher risk of death from accidental opioid-related reasons.

Before describing the study, let’s talk more about this medication, gabapentin, sometimes marketed and sold under the brand name Neurontin.

Gabapentin is a medication that is structurally similar to the neurotransmitter GABA, but gabapentin has no activity at the GABA receptor. Gabapentin appears to attach to calcium channels, but we don’t know the exact mechanism of action of its anti-seizure and anti-analgesic effects.

This medication isn’t changed into other compounds, meaning gabapentin is the active drug. It’s metabolized by the kidneys, and so the dose must be adjusted in patients with kidney failure.

This drug is odd because its bioavailability goes down as the dose goes up, which means that as the dose goes up, the amount available in the blood stream goes up too, but not by as much as one would expect, due to the decrease in bioavailability.

Its half-life is around 6 hours, and so it is dosed three times per day. It can be removed by hemodialysis.

Gabapentin can cause sedation and suppression of respiratory rate, both by itself and when combined with prescription opioids. In fact, the product’s monograph was changed in 2014 to emphasize the risk of suppression of respiratory rate when combined with opioids. This may be more important in patients with COPD, renal insufficiency, and older age.

Gabapentin can also cause dizziness, fatigue, and swelling of the lower legs. It is not categorized as a controlled substance because studies didn’t show it to be prone to misuse or addiction. In fact, it has been studied for use in alcohol and marijuana use disorders, with some evidence of benefit.

Gabapentin is prescribed for an assortment of reasons, and not all are FDA approved. Gabapentin is approved for the adjuvant treatment of partial seizures in kids and adults, which means it can be used as an add-on to main seizure treatment medications. It is also indicated for the treatment of pain after a bout of shingles, called post-herpetic neuralgia.

That’s it. There’s no FDA approval for the many other conditions for which it’s commonly prescribed, like fibromyalgia, anxiety, hot flashes of menopause, pain of diabetic neuropathy, or alcohol withdrawal symptoms, though there are studies that support its use for some of these conditions. There’s evidence gabapentin may help with restless legs syndrome and itching from kidney failure.

Use of gabapentin for other than FDA approved uses isn’t unusual and it isn’t necessarily bad medical practice. Many medications are used “off-label” which means they are used for purposes for which they don’t have FDA approval.

A newer version of gabapentin, called pregabalin, is marketed under the brand name Lyrica, and it is classified as a controlled substance because of its potential for addiction and misuse. It has FDA indication for treatment of neuropathic pain, post-herpetic neuralgia (pain from previous shingles outbreak), epilepsy, fibromyalgia, and diabetic peripheral neuropathy pain.

The article I’m describing today did not look at any data relating to pregabalin.

The study was a nested case-control study, which means each opioid user who died of opioid-related causes was matched with four control subjects, with age, sex, start date of opioids, and presence or absence of chronic kidney disease being similar for each index case and the controls.

This was a big study, with 1256 index cases and 4619 controls.

An analysis was conducted to see how many of the index cases, patients who died of opioid-related reasons, were also prescribed gabapentin within 120 days of the index date. The dose of gabapentin was further categorized as high, medium, or low dose.

The results showed that 12.3% of the people who died of opioid-related causes were prescribed gabapentin within 120days preceding death. Of the age and sex matched control patients who did not die, only 6.8% were prescribed gabapentin within 120 days.

This means that patients on opioids who were co-prescribed gabapentin had odds of an opioid-related death 49% higher than patients on opioids who were not prescribed gabapentin.

The authors also found a significantly increased risk with higher dose gabapentin than low or moderate dose.

The authors of the study used the same method looking at anti-inflammatory medication prescriptions, to see if those medications increased risk of opioid-related death, and found no difference in use of anti-inflammatories in patients who died compared to controls who did not die.

It’s important to note that patients with opioid use disorder who were being prescribed methadone were not included in this study. Patients with cancer diagnoses and who were in palliative care were also not included. The authors didn’t explicitly say why these patients were excluded, but patients in these groups may not represent general patient populations. Patients with cancer, getting end-of-life care, are likely to be prescribed much higher doses of opioids, due to a shifting of the focus of their care. At the end of life, comfort is of more importance that functioning.

As for patients on methadone, perhaps the authors thought patients with substance use disorders would be more likely to misuse their prescribed gabapentin. Maybe the authors thought including such patients would skew the data, and gabapentin would appear to be more dangerous than it is. This study was not done on people with substance use disorders; it was done on the general population.

This is a powerful study because it was so large, and it spanned sixteen years. Canada has a population similar to that of the U.S., so I think it’s safe to assume their data should be valid for patients in the U.S.

What does this mean for me and my patients? I don’t treat pain, I only treat opioid use disorders. But are my patients, for whom I prescribe buprenorphine and methadone, at increased danger if they are co-prescribed gabapentin by another doctor? Yes, by my interpretation of this data, they are at increased risk. For sure, if they take more gabapentin than prescribed, they are increased risk for death, but this study shows that even when taken as prescribed, this medication is associated with increased risk of death.

Association doesn’t always mean causation, but given what we know about how these medications who, a causal relationship is strongly suggested.

In the past, I had more of a “pick your battles” attitude. I was happy if my patients stopped drinking alcohol or using benzodiazepines. For the latter, we have good studies (for example, Park et al., 2015, BMJ, “Benzodiazepine prescribing patterns and deaths from drug overdose among US veterans receiving opioid analgesics”) that have shown a four-fold increase in the risk of overdose death when benzodiazepines are co-prescribed with opioids. Now I will add gabapentin and pregabalin to my list of medications that can harm my patients.

It’s tempting to issue a blanket policy against gabapentin. Blanket policies make life easier for the opioid treatment program, but such policies treat every patient the same.

For this issue, I think the best course is to talk to each patient, evaluate each patient, and ask them how much benefit they receive from gabapentin. I will advise them of the increased risks of this medication, and we will decide whether it’s best to stop or continue the gabapentin. Some patients may decide the benefit it worth the risk. Other patients may decide it’s better to stop taking gabapentin. Either way, I’ll document this in their charts, and re-visit the issue regularly.

I am grateful, as always, to the website sponsored by the North Carolina Governor’s Institute: http://addictionmedicineupdates.org/ for bringing this article to my attention. The tireless people at the GI support excellence in substance use treatment around the state.

  1. https://doi.org/10.1371.journal.pmed.1002396

 

Driving on Methadone

 

 

 

 

“How can you let those people get behind the wheel and drive after you shoot ‘em up with methadone?”

This question, frequently asked by law enforcement and other people, reveals key misunderstandings about the pharmacology of methadone. That’s OK; I don’t expect laypeople to know methadone pharmacologic principles. Oh, and we don’t “shoot them up.” We give them controlled oral doses of methadone measured to the nearest milligram of liquid, and observe our patients consume this medication on site.

While laypeople may not have a reason to understand medication-assisted treatment, I think it’s essential for law enforcement officers to understand. They need to know why our patients are not impaired when they leave our parking lots after dosing.

When patients on methadone (or buprenorphine) are dosing every day, they have a tolerance to the drowsiness that opioids cause opioid-naïve people. Our patients, assuming they have reached a stable dose and aren’t using any other drugs, have blood levels of medication that don’t fluctuate much through the day. Because methadone is such a long-acting medication, the blood level doesn’t even reach its peak until around three hours after dosing.

Because of the frequent misunderstandings and assumptions of law enforcement personnel, I’ve composed a sample letter that opioid treatment programs may forward to the law enforcement officer of their choice.

Dear Officer Zealous:

First of all, thank you for patrolling our streets and highways and for your efforts to keep them safe. I know you have a difficult job and I deeply appreciate your willingness to take on this responsibility.

However, please stop arresting my patients for whom I’ve prescribed methadone and buprenorphine (better known under the brand names Suboxone, Subutex, or Zubsolv). You mistakenly think all people taking these medications have no right to be driving, and you are wrong. I’m writing this letter to give you better information, so you can do your job more efficiently.

Our nation is in the middle of a crisis. Opioid use disorder is an epidemic, and too often its sufferers die of overdoses. Medication-assisted treatment with methadone and buprenorphine works very well to prevent overdose deaths, and it’s been proven to help patients have a betterquality of life in recovery.

I doubt you’ve been provided any information about medication-assisted treatment, so I want to offer data to you.

Methadone has been around for fifty years and has a proven track record. It’s been studied more than perhaps any other medication, and we know it does a great job of treating opioid use disorder. Buprenorphine has only been available in the U.S. for about 17 years, but has been used in Europe for decades with success.

With both methadone and buprenorphine, the proper dose of medication should make the patients feel normal. Patients should not feel intoxicated or high, and should not feel withdrawal symptoms as the day wears on. Methadone and buprenorphine are both very long-acting opioids, and can be dosed once per day. They both can provide our patients with a relatively steady level of medication, compared to short-acting opioids usually used for intoxication. Therefore, using methadone to treat opioid addiction is not “like giving whiskey to an alcoholic,” as has incorrectly been asserted. The valid difference lies in the unique pharmacology of methadone. Opioid addicts can lead normal lives on this medication, when it is properly dosed.

In addition, both of these medications block other opioids at the opioid receptor. When a patient is on an adequate dose of methadone or buprenorphine, if she relapses and uses an illicit opioid, the medication blocks the effects of the illicit opioid. The patient feels no euphoria, which reduces the urge to use illicit opioids in the future. Both methadone and buprenorphine work in this way to deter use of other opioids for the purpose of getting high.

Treatment of opioid addiction with methadone and buprenorphine is endorsed by the CSAT (Center for Substance Abuse Treatment) branch of SAMHSA, by the U.S.’s Institute of Medicine, by ASAM (American Society of Addiction Medicine), by AAAP (American Association of Addiction Psychiatry), and by NIDA (National Institute of Drug Addiction. In study after study, methadone has been shown to reduce the risk of overdose death, reduce days spent in criminal activities, reduce transmission rates of HIV, reduce the use of illicit opioids, reduce the use of other illicit drugs, produce higher rates of employment, reduce commercial sex work, and reduce needle sharing. Medication-assisted therapy is also high cost effective.

Indeed, the current debate of government officials at the highest levels has been how best to expand medication-assisted treatment with methadone and buprenorphine, not to make it less available. So please don’t do anything which may discourage opioid addicts from receiving life-saving treatment.

Over the years, many studies have been done on methadone and buprenorphine to see if patients are able to drive safely on either of them. In study after study, data show patients on stable doses of both medications can safely drive cars, operate heavy equipment, and perform complex tasks. Please see the list of references at the bottom of this letter if you wish to investigate for yourself.

I’m not saying, however, that patients on methadone or buprenorphine can’t become impaired. Impairment can occur if patients are given too high a dose of methadone or buprenorphine, which most often occurs during the first two weeks of treatment. For that reason, patients are warned not to drive if they ever feel sedated or drowsy.

Patients on medication-assisted treatment can also become impaired if they mix other drugs or medications with their methadone or buprenorphine. In fact, benzodiazepines (like Xanax, Valium, Klonopin) and alcohol act synergistically with maintenance opioids. They can cause impairment with smaller amounts of alcohol or benzos than expected. And of course, patients can still become impaired with other drugs, such as marijuana.

As you probably know, a urine drug screen won’t detect impairment. The urine screen only tells you if a person has taken a given drug or medication over the last few days to weeks. Drugs are detectable in the urine long after the impairing effect wears off.

You can do blood tests, but these aren’t useful for patients on methadone. The dose required to stabilize one of my patients would impair or even kill a person who’s never taken opioids, so the meaning of the blood level depends on the patient’s experience and history.

My family and I drive these roads too, and I don’t want impaired drivers on our highways any more than anyone else. However, due to your desire to do a good job, you have mistakenly targeted patients on medication-assisted treatment for the disease of opioid addiction.

I know you have formed bad opinions about methadone and buprenorphine patients from seeing both drugs misused on the street. I hate that, because you probably rarely get to see our more typical patients on medication-assisted treatments.

The vast majority of my patients have jobs, families, and responsibilities that they meet, despite having this potentially fatal illness of opioid addiction. If you are fortunate enough to encounter one of my patients on a random traffic stop, please don’t give them a hard time. Please congratulate them on having the courage to find recovery from addiction, and tell them to do what works for them. In some patients, that means medication-assisted treatment.

Thanks for reading this long letter and thanks for all you do in the name of keeping our roads safe. If you want to know more about how we treat opioid use disorder at our facility, please call our program manager at xxx-xxx-xxxx and we would be happy to provide you with an after- hours tour and lots of information.

Sincerely,

Dr. XYZ

Medical Director, OTP

 

P.S. And please don’t attempt to intimidate patients from coming to get help for this fatal illness of opioid use disorder by parking your squad car just outside our facility’s entrance. Some of these patients may have old warrants, but by stalking them where they come for help, you discourage people who want to escape addiction and want to better their lives. If you do park near us, you should expect a staff member to approach you with a smile, a cup of coffee, and a pile of information about opioid addiction and its treatment.

ATTACHMENT:

Methadone and Driving Article Abstracts

Brief Literature Review

Institute for Metropolitan Affairs

Roosevelt University 2/14/08

  1. DRIVING RECORD OF METHADONE MAINTENANCE PATIENTS IN NEW YORK STATE

BABST, D., NEWMAN, S., & State, N. (1973). DRIVING RECORD OF METHADONE MAINTENANCE PATIENTS IN NEW YORK STATE. DRIVING RECORD OF METHADONE MAINTENANCE PATIENTS IN NEW YORK STATE,

When a comparison was made within specific age groups, it was learned that the accident and conviction rates were about the same for methadone maintenance clients as for a sample of New York City male drivers within the same period. The findings from other related studies discussed in this booklet are consistent with the results in this study.

2. The effects of the opioid pharmacotherapies methadone, LAAM and buprenorphine, alone and in combination with alcohol, on simulated driving.

Lenné, M., Dietze, P., Rumbold, G., Redman, J., & Triggs, T. (2003, December). Drug & Alcohol Dependence, 72(3), 271.

These findings suggest that typical community standards around driving safety should be applied to clients stabilized in methadone, LAAM and buprenorphine treatment.

3. Maintenance Therapy with Synthetic Opioids and Driving Aptitude.

Schindler, S., Ortner, R., Peternell, A., Eder, H., Opgenoorth, E., & Fischer, G. (2004). Maintenance Therapy with Synthetic Opioids and Driving Aptitude. European Addiction Research, 10(2), 80-87

Conclusion: The synthetic opioid-maintained subjects investigated in the current study did not differ significantly in comparison to healthy controls in the majority.

4. Methadone-substitution and driving ability
Forensic Science International, Volume 62, Issues 1-2, November 1993, Pages 63-66
H. Rössler, H. J. Battista, F. Deisenhammer, V. Günther, P. Pohl, L. Prokop and Y. Riemer

The formal assertion that addiction equals driving-inability, which is largely practiced at present, is inadmissible and therefore harmful to the therapeutic efforts for rehabilitation.

5. Methadone substitution and ability to drive. Results of an experimental study.

Dittert, S., Naber, D., & Soyka, M. (1999, May).

It is concluded that methadone substitution did not implicate driving inability.

6. Functional potential of the methadone-maintenance person.

Gordon, N., & Appel, P. (1995, January). Functional potential of the methadone-maintenance person. Alcohol, Drugs & Driving, 11(1), 31-37.

Surveys on employability and driving behavior of MTSs revealed no significant differences when compared to normal population. It is concluded that MM at appropriate dosage levels, as part of treatment for heroin addiction, has no adverse effects on an individual’s ability to function.

8. Influence of Peak and Trough Levels of Opioid Maintenance Therapy on Driving Aptitude. Baewert, A., Gombas, W., Schindler, S., Peternell-Moelzer, A., Eder, H., Jagsch, R., et al. (2007). European Addiction Research, 13(3), 127-135.

This investigation indicates that opioid-maintained patients did not differ significantly at peak vs. trough level in the majority of the investigated items and that both substances do not appear to affect traffic-relevant performance dimensions when given as a maintenance therapy in a population where concomitant consumption would be excluded.

9. The influence of analgesic drugs in road crashes.

Chesher, G. (1985, August). The influence of analgesic drugs in road crashes. Accident Analysis & Prevention, 17(4), 303-309.

Methadone, as used in treatment schedules for narcotic dependence, produces no significant effect on measures of human-skills performance.

10. Influence of narcotic drugs on highway safety.

Gordon, N. (1976, February). Influence of narcotic drugs on highway safety. Accident Analysis & Prevention, 8(1), 3-7.

A review of the literature on narcotic drug use and driver safety indicates that narcotic users do not have driving safety records that differ from age-matched individuals in the general population. Maintenance on methadone also does not appear to increase driving risk.