Book Review: “Dopesick: Dealers, Doctors, and the Drug Company that Addicted America,” by Beth Macy

Dopesick, by Beth Macy

This well-written book has it all: compact information about how the opioid epidemic started, how our nation failed to act early to mitigate the damage of the epidemic, and how the epidemic shifted into our present predicament. The author did a great deal of research and talked to experts with vital information, but she humanized this data with personal stories about people affected by the opioid epidemic. She told this story not only from the view of the person with opioid use disorder, but also illustrated the grief of families who lost loved ones. The prolonged grief of families who have lost loved ones to opioid overdose deaths is rarely examined as well as it is in this book.

This is a book that will be staying on my shelf for a re-read.

The author is a journalist who works for the Roanoke Times newspaper, so this book focuses mostly on events in the western part of Virginia.

Avid readers on this topic will recall the book “Painkiller,” by Barry Meier, who also covered rural Western Virginia. Ms. Macy’s book picks up where Mr. Meier’s left off. They talk about many of the same communities and the same treatment providers, fifteen years later.

Mr. Meier’s book, published in 2003, could have been an early warning to the U.S. healthcare system. Unfortunately, the book wasn’t widely read, so few people took any note of what was going on, other than those of us already working in the field. I understand Mr. Meier wrote a second edition of “Painkiller” this year, and I plan to read and review it.

The most remarkable theme of Ms. Macy’s book is how the opioid use disorder epidemic grew worse over the past fifteen years. After physicians finally stopped prescribing so many opioid pain pills, these pills were less available on the black market. Many people with opioid use disorder switched to cheap and potent heroin.

In Ms. Macy’s book, she tells the experience of a rural physician, Dr. Art Van Zee, who was also interviewed for Barry Meier’s book. He was one of the brave people who stood up at conferences and raised the question about the ethics of Purdue Pharma, manufacturer of OxyContin, when it wasn’t easy to question anything about that drug company. He’s the first physician I can recall who actively sought answers about his perceived over-prescribing and mis-marketing of OxyContin.

This isn’t in the book: I remember Dr. Van Zee at an Addiction Medicine conference called “Pain and Addiction: Common Threads,” that I attended in 2003 o4 2004. I bought the recordings of the conference, because I was so excited to learn more about Addiction Medicine. I remember a recorded session where Dr. Van Zee asked a question after a lecture, asking – as I remember it many years later – why Purdue Pharma was still peddling their OxyContin as a relatively harmless opioid for chronic pain, while he was seeing patients with lives destroyed by this drug.

It was one of those moments where all you hear are crickets. His question wasn’t answered, but rather he was reprimanded by the speaker. He was cautioned to remember our conferences were sponsored in part by Purdue money, and that appropriate prescribing of OxyContin was a huge benefit to patients. He was told it wasn’t the drug, it was the prescribing that needed to be fixed.

Fast forward to 2007. As described in “Dopesick,” Purdue Pharma pled guilty to fraudulent marketing of OxyContin, which was a felony misbranding charge. Purdue paid $600 million in fines. Its top three executives pled guilty to misdemeanor versions of the same crime, and ordered to pay a total of $34.5 million.

So yes, inappropriate prescribing was a big part of the problem, but Purdue deliberately misinformed physicians about potential dangers of the drug, which contributed to inappropriate prescribing. From a 2018 perspective, that speaker’s answer to Dr. Van Zee seems disingenuous at best.

Dr. Van Zee’s perceptions, based on his clinical experiences, were correct. Around that same time, I was seeing the same thing in rural Western North Carolina. I remember having twenty to thirty new patients show up on admission day, all of them were using OxyContin, almost exclusively. This drug was easy to crush to snort and inject, and Purdue knew it.

Purdue Pharma testified before congress in 2003 that they were nearly ready to release a new formulation of their OxyContin pill that was more abuse resistant. As it turns out, that new formulation wasn’t released until 2010. With that change, people with opioid use disorder changed to other opioids, easier to misuse, such as Roxicodone and Opana. Eventually Opana underwent reformulation to a less abused form.

But I digress; back to the book. The author’s first few chapters summarize the history of opioid use disorder and the factors that lead up to the release and promotion of OxyContin. It related how this drug crept into the social fabric of Southwestern Virginia, and how early attempts to sound an alarm about its abuse were met with contempt from drug company representatives.

Chapter Three tells of the “unwinnable” case brought against Purdue Pharma by Virginia attorney general John Brownlee. He went up against the famous Rudy Giuliani, who was one of the lawyers who represented the drug company, and successfully negotiated the eleventh-largest fine against a pharmaceutical company. This chapter contrasts this legal victory with the devastating grief of parents who lost their children to overdose death with OxyContin. The book describes the creation of the “OxyKills.com” message board, which became a sort of a database for overdose deaths. The chapter after that contains depressing descriptions of how Purdue Pharma’s corporation executives and the owners, the Sackler family, distanced themselves from the profound harm caused by their medication and criminal mis- marketing.

The next several chapters contain the tragic stories of people who became addicted to opioids, and their journeys through the criminal justice system, the addiction treatment system, and the pain their families felt, every step of the way. The author illustrates the ridiculousness of our patchwork system of care for people with opioid use disorder, and how ineffective treatments are often pushed as first-line options.

Then the book details efforts to pursue the heroin ring that sprang up in Virginia, and how the ringleader, a man named Ronnie Jones, was eventually arrested, charged and convicted of trafficking heroin from Baltimore to the Roanoke suburbs. Many of Jones’ drug runners were addicted young adults, many female, from Roanoke’s suburbs. Families were shocked when they found out their children were involved with the drug trade. Heroin used to be an inner-city drug, but times have changed. Heroin is now plentiful in suburban and rural areas, as this book illustrates repeatedly.

I was most interested in the author’s description of available treatments. Usually I dread reading writers’ summaries of treatment for opioid use disorder. If they describe medication-assisted treatment at all, it’s often couched in negative terms. However, this author did her homework.

She describes the accurate reasons why medication-assisted treatment with buprenorphine and methadone is the gold standard of treatment, and even writes about some of the success stories. However, she also writes about the more common public perception of buprenorphine: “shoddy” prescribers located in strip malls who don’t mandate counseling or do drug testing patients. She writes about the poor opinion of Virginia law enforcement officials, who criticize doctors for not weaning people off the drug, and for allowing patients to inject the drug & sell it on the street.

However, it’s clear the author was able to grasp harm reduction principles, and latest research findings, since she said (on page 219) the unyielding opposition to MAT was the single biggest barrier to reducing overdose deaths.

I felt gratified to read this in print. I underlined it.

She also pointed out how some states’ refusal to expand Medicaid when given the opportunity kept many people with opioid use disorder from being able to access treatment. That’s more perceptive than I expect from a writer who isn’t trained in public health or substance use disorder treatment.

But my favorite part of the book was on page 221, where an addiction counselor named Anne Giles said of the opioid overdose death epidemic: “We should be sending helicopters!”

I underlined this too.

She pointed out that if the same number of people dying from opioid overdoses were dying of Ebola, the government would be sending helicopters of medical help to rescue people and contain the epidemic, and she’s right. We ought to be sending helicopters….helicopters loaded with emergency medical personnel and treatment medication. (By the way, per most recent data from NIDA, over 49,000 people in the U.S. died from opioid overdose in 2017. That’s one-hundred and thirty-four people per day. If they were dying from Ebola…helicopters for sure.)

So I heartily recommend this book to anyone interested in this topic. Even if you aren’t interested, it’s so well-written that it will entertain you. I particularly appreciate the author’s talent at describing so many facets of this opioid epidemic and the obvious scope of her research.

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Tapering Off Suboxone: Three Patients’ Success Stories

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This year I’ve had three long-term patients taper off the buprenorphine products I was prescribing. All three are doing well and are happy with their treatment outcome. Since tapering off buprenorphine products can be challenging, I thought I’d share their stories, to help other people who wish to taper off buprenorphine. (Note that when I say buprenorphine, I mean to include all the brands and generics: Suboxone, Zubsolv, Bunavail, generic combination product buprenorphine/naloxone and the generic monoproduct buprenorphine.)

The first patient had been on buprenorphine for over ten years. She saw one of the first physicians to prescribe buprenorphine, and I inherited her from this prescriber after he retired.

When she started Suboxone, which at that time were only available in tablet form, she stabilized at eight milligrams. She stayed on that dose for about four years. She saw her prescriber monthly for the first year and a half, then every other month. By the time she started seeing me, she had cut her dose to 4mg per day without too much difficulty. When the suboxone films were available, we switched to those, both because that’s what her insurance would pay for and because I thought she could taper more easily with films.

Over the first year with me, she brought her dose down to 2mg per day, reducing by a half milligram every three or four months. I then switched her to the 2mg films, and she continued to cut off more and more from her films. I gave her some guidance, but she largely managed her taper on her own.

After a year or two, she asked me to prescribe only fifteen films per month, since she was taking half of a film per day. A year later, she had dropped to only a forth of a film per day, and needed only eight films per month. This slowly progressed until she had brought her dose down to one-sixteenth of a two milligram film which she took every other day.

That’s right…she was taking .125milligrams every other day. Her urine drug screen still showed positive for buprenorphine at her visits. I told her I thought she could stop taking that dose and not have any withdrawal symptoms, but she told me she still felt withdrawal if she missed her every other day dose. I didn’t push her; I didn’t mind prescribing only one 2milligram film per month!

She continued at this dose for over a year. When she missed a visit earlier this year, I asked my staff to call her. Sure enough, she forgot to take her dose for several days, and didn’t feel any withdrawal. I offered to see her one more time, to talk about relapse prevention and options to give her insurance against a relapse (Vivitrol), but she didn’t want another visit. I congratulated her and told her if she had questions or problems in the future to call us.

During her last year or so, we talked regularly about relapse prevention. We made plans for what to do if she had a catastrophic medical problem that required pain medication (broken bone, surgery, etc.). We discussed other big relapse triggers, such as strong negative emotions, and being around people who had opioids or other drugs.

This patient was very involved with 12-step recovery. Even after so many years of recovery, she went to three or more meetings per week. She had a sponsor and served as a sponsor to newer members. She had relatives in 12-step programs, and most of her friends were members of 12-step recovery groups.

The second patient also tapered her dose over years. I knew her for around fifteen years, first as a patient at an opioid treatment program, where she dosed on methadone. She did well from the start, though she had some slips with non-opioid illicit drugs.

She didn’t care for the restrictive nature of the opioid treatment program, so when she’d been doing well there for several years, I told her about the new option of buprenorphine treatment through an office setting. She decided that was what she wanted to do, and proceeded to taper her methadone dose, slowly.

Once she was down to 30mg, which took about six months, she made an appointment with an office-based physician, who started her at suboxone 16mg per day. When that physician retired less than a year after she started Suboxone, she transferred to my office-based program.

By the time she transferred to my office-based program, she was down to 12mg per day. Just like the first patient, she steadily tapered her own dose. She reduced her dose by an estimated milligram of Suboxone every four months.

I say estimated because cutting the Suboxone films is largely guesswork, and the manufacturer says there are no studies to show buprenorphine is evenly distributed over the film. While that’s true, buprenorphine is so long-acting that I wonder how much variation patients get in their blood levels, even with uneven distribution.

Just like with the first patient, we switched her to the 2mg film once she got to a 2mg per day dose. She continued to reduce on her own. She would cut her dose and wait for a month or two before going down again. I saw her only every two months, given her stability. She had negative drug screens, always kept her appointments, and lead a productive life. I gave her as much advice as I could, but I was impressed that she was able to listen to her body and taper only as fast as she was comfortable.

Once she was taking one-eighth of a 2 milligram film (.25mg), she stopped her medication. I saw her for one last planned visit, and we talked about how she felt. At that point, she’d been off buprenorphine for four weeks. She noticed aches and pains more intensely than in the past, but said it wasn’t anything ibuprofen or Tylenol couldn’t fix. It took a little longer to get to sleep, but she was still functioning well as a mother to her four children. She was ecstatic to be finished with medication-assisted treatment, and she knows that – heaven forbid – if she does relapse, to call quickly and come to see me to get back on buprenorphine.

Again, we had been discussing relapse triggers for months. We also discussed naltrexone, available as a once monthly shot called Vivitrol, as insurance against a relapse but she decided against it. She felt she didn’t need it.

She did individual counseling while she was a patient at the opioid treatment program, but hasn’t done much counseling recently. She saw a therapist many years ago, after a traumatic life event, but didn’t feel she needed to continue with this. She tried 12-step recovery but didn’t feel it was right for her.

Initially I worried she wouldn’t make progress in her recovery without continuing to see a therapist, but when I saw how well she was functioning in life, I decided not to push the issue. The only counseling she got was with me, during our 20-minute office visits. I’m not a trained therapist, but I like to think I have developed some skills over the years.

Her life changed completely over the past ten or so years she’s been on medication-assisted treatment. Early on, she let go of drug-using friends and acquaintances. She became focused on what was important to her: her young family and her extended family. She got a part-time job after her youngest child started school, to afford some extras for the family. Her husband is in his final stages of taper from buprenorphine, and she hasn’t rushed him, letting him take his own time, just like she did.

Drug use holds no allure for her; she hasn’t had any cravings or desires for any sort of drugs for years.

My third patient to taper off this year just saw me several weeks ago. It’s been over eight years since she used any illicit drugs. At her last visit, she declared this to be her last visit, saying her last buprenorphine had been taken six weeks prior, and that she felt fine.

She has been at a dose of less than 8mg for about two years, and less than 2mg per day for at least the last eight months. She tapered on the generic combination tablets, buprenorphine/naloxone 2/.5mg, cutting them into quarters. Once she got to one-quarter per day (.5mg), she took one of these quarters every other day for several weeks and then stopped completely.

Again, we’ve been discussing relapse prevention for literally years. Again, she decided against starting naltrexone as a safety net against relapse, feeling she didn’t need this medication. She was happy and smiling and was very kind when she thanked me for helping her these past years. I told her it was truly my pleasure, and I was honored to be even a small part of her success.

These three patients have common themes in their successes. All three had very support families who didn’t rush them to get off buprenorphine or shame them from being on it. I also didn’t pressure them. I said I’ll do everything I can do to help you taper off this medication, but there’s nothing wrong with staying on it either, if that’s what you prefer.

This left the decision in their hands. All three said this was important, since they had control over when/if/how they tapered. Once I told one of these patients to listen to her body, since she was the expert on her body and how it felt. This resonated with her, and she thanked me for saying that. She felt that took the pressure from her to try to meet someone else’s expectations.

These three patients all tapered their dose very gradually, over periods of not days or weeks, but months and years. While such slow tapers can be frustrating, not to mention expensive, to people who want a quicker exit off medication, maybe slow tapers allow the body more time to adjust to changes in dosage.

Two of the three patients exercise regularly at a gym. The third is also active, and walks nearly daily. Exercise usually helps us to feel better, both physically and emotionally. I wonder if exercise also boosts endorphin, our body’s own opioid. I’ve started recommended patients start a reasonable exercise program in advance of starting a dose taper.

All three of these patients have faced serious adversity in the past and survived it. This tells me they have skills they can use in their recovery. All three had tremendous resolve to do what was necessary to get their lives back. They kept at it, accepted the few setbacks that came their way as part of the process, and kept moving forward, even though progress was slow at times.

I admire all these patients. All have excellent prognosis, and we’ve talked about how opioid use disorder is a chronic illness. They need to be on guard against relapses the rest of their lives, and if relapse happens, I think they will know what to do.

I have another crop of patients who are dosing at 4mg or less of buprenorphine per day, all in the process of tapering. I’ll update my blog with those stories after they taper.

 

Idle Time and Our New PMP

 

 

 

 

 

 

Usually I stay busy when I work at the opioid treatment program (OTP). Every August, however, things slow down. We see fewer people presenting for admission. I don’t know why this is, but I’ve seen it happen every year for the past seventeen years I’ve worked at OTPs.

This August was no exception. Our admissions dropped down significantly, giving me chunks of time that I otherwise dedicate to doing intake admission histories and physicals. My new challenge was staying busy.

My staff knows I must be kept busy. Otherwise, I tend to Get In To Things.

For example, once when we were slow, I went on a fact-finding mission about why our toilets have no blue dye in the water. Blue dye reduces the risk of adulterated urine obtained for drug screens, yet we had no blue dye. As it turned out, the answer to my question was: it’s complicated. Our toilets have a bladder system that holds water instead of storing water in the back of the tank…well, that’s not important. But it wasn’t under my control to fix, and I only managed to interrupt people with more pressing work to do.

Another time when I wasn’t busy, I wanted to know why there were five WTA vans in our parking lot at the same time. WTA is the transport service that picks up our Medicaid patients to bring them to the OTP for treatment. We’ve asked them to stagger their arrival time, so that we don’t have multiple vans disgorging five to eight people arriving to dose at the same time. This causes a delay in dosing for all of the patients, and no one likes that – not the patients, staff or our dosing nurses.

Apparently, our request to WTA was a river too wide, a mountain too high. I can’t remember the last morning when I’ve arrived at work at 7am when there were fewer than three WTA vans. Their drivers chat amiably amongst themselves while tempers flare because of dosing delays due to a clump of patients arriving all at the same time.

I know I can be annoying when I’m not kept busy, so yesterday I kept going to the lobby to ask if anyone needed to see me. I got to see five or six people this way, a good use of time.

During the other free time, I looked at patients on our state’s new prescription monitoring program.

While I recognize I’m never good with new technology, I have some complaints about our new system.

Last week, I settled in on a Thursday evening to look at the reports of the office-based buprenorphine patients I had scheduled to see in my private office the next day. Every time I entered the patient’s first name, last name, and date of birth, I got an error message.

When technology fails to work for me, I become enraged. Many times, it turns out to be my own fault, which enrages me all the more. But this time, the new system clearly wasn’t working.

There was a phone number listed on the web site to call for problems. Since it was after hours, I expected a machine, but a human answered. I told him of my problems, and he said, “Try entering just the first three letters of the first and last name, and check the boxes that indicate partial name.”

I did so, and it worked. My short-term problem was fixed. However, feeling a little crotchety with this delay, I asked him how any provider could know it only works with the first three letters of first and last name, unless they made the effort to call the help number.

He said as long as it worked, it was good enough. In my mind, I pictured all those “There, I fixed it” photo memes often seen on the internet. I grumbled a little more, but ended with a thank you. To be fair, since then, the system has been working with the full names again.

On our old system, we could adjust our search to allow for an error in the date of birth. That is, we could select the exact date, or options for one to two years surrounding this date. You’d be surprised how many times the date of birth is recorded wrong in our charts or by the pharmacy. With this new system, the date of birth data entry must be entered exactly by the pharmacy and by the physician searching the system.

I also don’t care for the first page of this report, dedicated to overdose death risk and MME of the patient. MME stands for morphine milligram equivalents. This gives an “overdose score” which may be helpful to some prescribers.

But it annoys me, since it gives big scores to patients who are only filling prescriptions for buprenorphine products. Buprenorphine isn’t translatable into MME numbers, and MMEs were never meant for this purpose. In the fine print, the MME score for patients on buprenorphine is zero, but there’s still a high overdose score. This glitch doesn’t cause any harm so far as I can see…except for the annoyance it causes. I want my patients to get credit for being on buprenorphine, arguably one of the safest opioids in existence.

This mess of data on the front page, in large type, makes it harder to find what I’m looking for, which is the actual printout of all controlled substances filled by the patient, the date they are filled and the prescriber. While the front page must have that overdose score in a font of twenty-six, the actual data is printed in – I’m not making this up – in ten font.

I’m on the shady side of my fifties, and ten font is unsatisfactory to me.

We’ve also encountered another problem, which is that the patient’s name is only listed on the first page. Some of these reports can run to six or more pages, even with the ten font. It’s a real problem to figure out which sheets go with which patients. It’s not a huge problem at my home, where I’m the only person printing. But at work, my papers can get shuffled by other personnel getting their printed papers. I’ve had loose sheets with no name on them, which had to be discarded because I couldn’t tell for sure to which patient they belonged.

No system is perfect, and the new system has some improvements – I can print the page I’m viewing, rather than the two-step process of the past, when I had to select the option to create a pdf, then go back in a second step to print that pdf file. So it’s not all bad. Plus, we can search more states. Now providers can select our own state, plus all of our bordering states. We can select a total of eighteen states.

As August turned into September and then into October, my brief problem with free time resolved. We are busy again, though not as busy as we will be later in the year. Being busy is a good thing for everyone; more patients getting admitted to treatment means more people are getting their lives back. That’s always an awesome thing to observe.

And I am prevented from bothering staff members with more important things to do than figure out how to put blue dye in the toilets.

 

Update

 

 

 

 

 

 

I have an update to my blog of September 16. The patient, who was hospitalized with life-threatening endocarditis (infection of the heart valve), was finally granted the right to have visitors – about fourteen days into his hospital stay. Mission Hospital administrators gave no reason for the change of policy, but I have reason to believe they were feeling some heat from the many people advocating for the patient.

Since this was the patient’s second admission for endocarditis, the chart said cardiovascular surgeons were not going to do a second heart surgery, per hospital policy, because the patient had continued to use drugs intravenously. The patient was told no other hospital would accept him in transfer because he had no insurance. The palliative care team was called in to manage his case, which appears to mean his physicians thought he was going to die without surgery.

Thanks to the efforts of several very tenacious providers at the opioid treatment program where the patient had just been admitted, this case got the attention of many people. Emails flew about the state. The outrageousness of this case got people involved, who got other people involved. Besides the patient’s providers at the OTP, advocacy efforts were undertaken by personnel at the NC State Opioid Treatment Authority (SOTA), the Medical Director of DHHS in NC, the General Counsel for DHHS, and out-of-state help from a lawyer with the Legal Action Center in New York. Patient advocacy groups were helpful, and several other people whom I won’t list by name but know who they are.

Thanks to advocacy efforts, the patient was transferred to Chapel Hill last week, to be evaluated for surgery of his infected heart valve.

I have good reason to believe Mission Hospital had complaints filed against it with the Joint Commission. The Joint Commission is an independent, not-for-profit organization that gramts accreditation to hospitals if they meet certain standards. Accreditation is important, because it affects payment from payers, including Medicare and Medicaid.

I have also heard that a complaint was filed with the Department of Justice, reporting that the hospital violated the patient’s rights under the Americans with Disabilities Act.

A big meeting was scheduled for October 2, with hospital administrators and the patient’s many advocates, people who were upset with their handling of this patient’s case. Unfortunately, the day before the meeting, Mission administrators canceled, saying it hadn’t been put on their schedule, by some oversight.

By this time, I felt those administrators lacked credibility.

I hope this case gets the attention of hospital leaders. I hope the time has come where hospitals will be held accountable for their mis-treatment of patients with opioid use disorder (OUD). OUD is a completely treatable chronic illness, not bad behavior that deserves the death penalty.

 

 

What I Do With My Day

Dr. Cat

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Some of my friends and family still don’t understand what I do for a living. When I was working in primary care, they understood. Now that I work with patients with substance use disorders, they are unsure. I tell them I do the same thing I’ve always done: I take care of sick people.

“Yeah, but they’re not sick sick, right? Not like people who usually go to the doctor.”

“Um, sometimes they are.”

For them and anyone else who wonders what an addiction medicine doctor does all day, this blog entry is a summary of a recent workday at the opioid treatment program where I work.

This was a Wednesday, which I dedicate to established patients. On Wednesdays, I talk to patients who are established in treatment about numerous issues, including adequacy of their dose, other medical problems, new medications, and other things. I also do yearly history and physical exams on patients who have been with us for a while.

In the following, I have changed the patients’ characteristics to protect their identity, while still conveying the essence of our interaction.

My first patient has been with us for several years and has done very well. She was seeing me for her yearly exam. First, I asked about her if her dose was still working well for her, and she said yes. She has been on methadone 105mg for more than a year, and her drug screens have been positive only for only methadone and its metabolites, since shortly after her admission.

This is a nice quality of methadone. Most patients don’t develop a tolerance to the anti-withdrawal effects of their dose, allowing them to remain comfortable on the same dose for months or even years. Other patients have fluctuations in their dose requirements, for assorted reasons: changes in other medical problems, changes of other medications, or changes in activity level, to list a few.

My patient looked at her picture on our electronic record, taken at her intake nearly two years ago. “I hate that picture! It looks awful. Can I get a new picture?”

“Sure, just ask the receptionist or your counselor. You do look different now. You look like that person’s younger, happier sister. But maybe it’s good to keep that old picture, at least in your mind, to remind you what opioid use disorder took from you – your joy.”

We proceeded with her history and physical, and at the end, I told her I thought her biggest health issue was smoking cigarettes. She was now abstinent from illicit drugs for nearly two years, but was still smoking nearly a pack and a half per day. I asked her if she had considered trying to quit. She said she would like to quit but wasn’t yet ready to try. I told her I thought she could quit, because she was doing so well in her recovery already. I asked her if it would be OK for me to ask her about smoking cessation in the future, and she said yes.

It’s important to hit the right tone with patients on this issue. I don’t want to pressure her and demand she try to stop smoking right now, because – of course – that approach doesn’t usually lead to behavioral change. Instead, I wanted her to think about why quitting smoking would be best for her, and to support her efforts in any way I can.

I can’t ignore the smoking issue. Tobacco-related illnesses are one of the most frequent killers of people in recovery, and I would not be doing my job if I ignored such an essential health issue. I like my patients, and I don’t want them to suffer illness and disability from a preventable condition, especially since their lives have changed so dramatically already.

My next three patients all wanted dose increases. Two were on methadone, and both were on sub-therapeutic doses, as evidenced by late-day withdrawal symptoms. I examined both before they dosed, so I could see them when their symptoms were at their worst. Both had large pupils and sweaty hands, and I ordered dose increases for both.

The third patient was a little trickier. He was dosing on buprenorphine at 16mg, and said he felt withdrawal symptoms of sweating with muscle aches and runny nose, which started at around 1pm each day. Since he doses at around six-thirty in the morning, his withdrawal symptoms started around six hours after dosing.

I didn’t think increasing above 16mg would cover the patient for a full twenty-four hours. I talked to the patient about switching to methadone, since unlike buprenorphine, there’s no ceiling on its opioid effect. As a full opioid, the more you take, the more withdrawal blocking effect.

He was reluctant to switch. He said he heard bad things about methadone, about how it gets in your bones and rots your teeth, and he didn’t want that to happen.

Inwardly, I sighed. Such ideas are still all too common in this region of the country. There’s still more stigma against methadone than against buprenorphine. While I’d love it if all my patients felt normal while dosing with buprenorphine, that’s not the case. There will never be one medication that’s right for everyone, and methadone is a life-saving medication too.

I corrected his mistaken impressions about methadone, without downplaying the real risks of methadone. I told him it was easy to overdose on methadone if he used benzodiazepine or alcohol while on it. I acknowledged that methadone does appear to be more difficult for most people to taper off of, but since he was early in treatment, we weren’t anywhere near close to considering any kind of taper.

He agreed to the switch, and I wrote an order to stop buprenorphine and start methadone. When patients switch from buprenorphine to methadone, I usually start methadone at a lower dose, at around 20-25mg on the first day. If they are older, on many medications, or have serious medical conditions, I may need to start lower than 20mg on the first day. I planned to see him again in a few weeks to see how he was doing.

My next patient had been admitted to the hospital for exacerbation of COPD, and the day I saw her was her first day back at our OTP. She usually doses on methadone at 80mg per day. The hospital didn’t call to confirm her dose with us, so I was very worried that she had gone without methadone for the five days she was in the hospital, on top of the COPD exacerbation.

When I (finally) got her records, I saw she was dosed at 80mg per day, because that’s what she told them she was taking.

I’m glad they dosed her. But it seems to me they should confirm that with her treatment facility before dosing her at that amount. Nearly all our patients will tell their other physicians the truth, but what if the patient, in a misguided attempt to feel better, exaggerated her dose and said she was on 110mg per day?

What if this patient wasn’t even currently in our treatment program? Dosing a patient at 80mg per day who wasn’t already on methadone at that dose would be deadly. When the stakes are that high, why take that risk? I know our phone system has byzantine voicemail, but the 24-hour number is given at the beginning of the voicemail, so they should be able to reach an administrator at any time, who can get all needed information for them.

Anyway, my patient was feeling better, and had no gap in treatment since she’d been dosed while in the hospital. I made note of some new medications and applauded that she had five days without cigarettes and encouraged her to continue the nicotine patches she’d been started on.

I had asked to see my next patient for an odd reason: we got a call that this lady was injecting her methadone dose each day. The caller remained anonymous, which always makes me suspicious of the caller’s motives, but I felt I needed to check it out anyway.

It’s rare for anyone to inject methadone. For one thing, methadone has a high oral bioavailability, due to excellent oral absorption. With methadone, you can get around 90% of an intravenous dose just by swallowing that dose. But injection drug use is about more than just the physiology. Often there’s a psychological component. Patients accustomed to injecting drugs can get a rush of dopamine just with the ritual of injecting.

I didn’t think this patient I was seeing would be doing that, since she’d been in treatment for over a year. All of her urine drug screens were positive only for the expected methadone and its metabolites.

When I saw her, I told her we received reports that she was injecting her methadone, and that I was sorry to inconvenience her, but I needed to check for myself, for safety reasons. To my great surprise, I found track marks. I asked her about what caused the marks, and she denied any IV drug use of her methadone or anything else, but there was no mistaking what I was looking at.

I told her I was afraid to give her further take-home doses, and that she needed to dose with us on site from now on.

She was furious, and while I understood her anger, I was in a pickle. There was no way I was could give her take home doses, given what I saw. It wasn’t safe. Her explanations of how the tracks came to be there didn’t sound realistic at all (cat scratched her in the same place multiple times, repeated injury from a fishing hook in the same area multiple times). I tried to be frank with her, and told her I knew tracks when I saw them.

Some physicians might not be so confident. Early on in my career as a physician treating opioid use disorders, I might have been a little unsure. After seventeen years of doing this job, I know track marks when I see them.

She asked when she could get her take home levels back, and again I was stumped. How could I ever be confident this patient wouldn’t inject take home medication? I could keep a check on her arms, but of course she could use other sites, and do I really want to have to ask a patient to strip so I can be sure there’s no injection drug use? No, I’m not going to do that.

If I knew what happened, it would give us something to work with, but my patient was unwilling or unable to tell me, so she will have to dose with us daily.

The rest of the day continued like this, with patients asking for dose increases, some asking for recommendations about how to go about decreasing their dose, and others checking in because they were medically fragile. I like to see patients with significant medical issues every three to four months, so I can stay current about any new medications, and remain updated on the status of their other medical issues.

This is what I do during my work day. I love my job and feel like I can help people and make a difference in their lives. I’m better able to do that where I work now than I ever could during the years I worked in primary care.

I’ve got the best job in the world.

 

The Rights of Patients with Opioid Use Disorder

 

 

I’ve been notified of an alarming development that’s come to pass at Mission Hospital in Asheville, NC.

Recently Mission Hospital decided that patients with opioid use disorder will be unable to have visitors while they are hospitalized, and they will also be unable to have any electronic devices with them. The hospital will provide “sitters” to stay in patients’ rooms at all times, for patients with opioid use disorder. It’s unclear to me if this policy also applies to all patients with substance use disorders. It’s also unclear if their policy applies to all patients with opioid use disorder, or just those in early recovery.

These measures have been imposed to prevent hospitalized patients from using illicit drugs.

The first edict – that patients with opioid use disorders can’t have visitors – isn’t absolute. Apparently potential visitor candidates must be pre-approved by the Chief Medical Officer of the hospital.  I don’t know what criteria this CMO uses, but it would seem this policy would have the effect of isolating a hospitalized patient.

I’ve only been hospitalized once, with a broken leg, but without the presence and support of my fiancé, I would have been distraught and more frightened than I already was (and I’m a doctor!). And that’s just a broken leg, completely fixable. Imagine how much worse it would be for patients hospitalized with severe or life-threatening medical problems. Isolating patients at such a time is cruel, even if it may be legal.

Banning electronic devices also has the effect of isolating the patient. Think of it – no email, no cell phone calls, no Facebook, no surfing the net to pass time…this measure also seems unnecessarily harsh.

Mission Hospital’s administrators probably instituted these actions because visitors brought drugs to patients in the past. Of course this happens, and it’s vexing to staff and dangerous to the patients. But surely some sort of common-sense measure can be taken short of barring all visitors and banning electronic devices.

As far as having a sitter in the room – I, for one, would be most annoyed if the hospital where I’m paying to get treatment decided I needed the constant companion of an utter stranger.

Frightened hospital patients with life-threatening illness need to discuss treatment options with loved ones. A random person sitting in the room will not serve as a substitute. The wrong kind of person could even increase patient anxiety.

These new measures taken by Mission are likely to increase the risk of a patient leaving against medical advice (AMA). The cynical side of me wonders if that’s the hospital’s intent. Many people with substance use disorders don’t have insurance, and often need long hospital stays. Are these new measures, which isolate patients with substance use disorders, intended to get rid of these “bad” patients?

I hope not.

As good as their intentions might have been, Mission’s actions might be a violation of the Americans With Disabilities Act (ADA).

I saw a presentation at the spring American Society of Addiction Medicine (ASAM) conference, given by Elizabeth Westfall, an attorney who works at the Department of Justice (DOJ). The topic of her lecture was the new Opioid Initiative started by the DOJ. Right now, there’s a push to investigate and eliminate unnecessary and discriminatory barriers for patients with opioid use disorder who are in treatment and recovery. She said the DOJ was doing an outreach to stakeholders to spread information about what counted as discrimination, and to offer technical support when needed.

She said the DOJ works with U.S. Attorneys across the country to look at these cases of discrimination. She says they can usually negotiate settlements where part of the agreement is to make sure discriminatory practices are ceased. If settlements can’t be agreed upon, the DOJ assists with litigation when needed.

Ms. Westfall told the ASAM audience that the ADA prohibits discrimination based on disability in different areas: employment, services from state and local governments, and public accommodations. She said that patients with opioid use disorder are protected under the ADA if they are not currently using illicit drugs.

That last part is what makes ADA claims tricky. Who is to say what is “current use?” Clearly, she told us that patients in medication-assisted treatment are not considered to be current users. These patients are taking medications prescribed by a physician for a specific purpose. These patients are covered under the ADA, so long as there is no current illicit drug use.

Elizabeth Westfall also gave information about how to file a claim with the DOJ. Of note, employment discrimination claims need to go to the EEOC, but even if you send them to the DOJ, she said they would be forwarded to the appropriate agency.

There is a specific case at issue right now. I will change some data to protect patient identity, but here’s the story: A patient entered medication-assisted treatment on methadone about two weeks ago. He did well, and got up to a dose at which he stabilized. Then he became ill with malaise and fever, and went to Mission Hospital’s emergency department. He was found to have a potentially life-threatening medical disorder, and was admitted for treatment.

He has not been permitted to have visitors, and his mother was apparently refused permission to visit him. He’s been isolated from any support network he might have, due to Mission’s new policies in place to prevent illicit drug use among their hospitalized patients.

Is this a violation of the ADA? Since I’m no lawyer (despite having watched every single “Law and Order” episode from the twenty years it aired), I don’t know.

Bu it doesn’t seem right to me, separating the patient from critical support during a life-threatening illness. I know the medical staff at the OTP he goes to has been talking to hospital officials, trying to negotiate a compromise.

Here is the information given at the ASAM meeting, should any of my readers know of a case of discrimination against patients with opioid use disorder:

File a complaint:
http://ada.complaint@usdoj.gov

Great website for further reading/information:
http://www.ada.gov

Pregnant Women with Opioid Use Disorder

 

 

 

 

Before I launch into my blog entry for today, I’d like to remind readers that my intent with my blog is to offer general information. My blog isn’t a substitute for real medical advice based on a face-to-face evaluation by a medical professional. In medicine, the devil is in the details, meaning one patient’s case could vary in some small way that would indicate a completely different approach to treatment. I have people write me for specific and personal medical advice, which I cannot provide. You will be disappointed with my answer, which is nearly always to see your own doctor.

Having said that, this blog entry is about my general recommendations to pregnant women with opioid use disorder:

Medication-assisted treatment with methadone or buprenorphine is still the gold standard of treatment for pregnant women with opioid use disorder. Despite some recent studies which indicate medically-supervised withdrawal in the fetus may not be as dangerous as we previously thought, relapse rates for the mother are still high.

There’s no conclusive evidence that medically supervised withdrawal of opioids during pregnancy reduces the incidence of neonatal opioid withdrawal (NOW), also called neonatal abstinence syndrome (NAS). [1]

That’s right…tapering a pregnant patient off methadone or buprenorphine doesn’t reduce the risk of NAS, probably due to high relapse rates.

In keeping with that information, at our opioid treatment program, our pregnant patients are continued on their life-saving medication. If a pregnant patient demands a taper, even after hearing all the current expert recommendations, I’ll honor her wishes, but only after she signs a form saying she’s been informed about possible harmful outcomes.

Due to the enormous stigma pregnant women with opioid use disorder face, I like to see these patients once per month. I can offer them support and remind then they are doing the right thing for themselves and their babies despite what other people tell them. I can also more closely monitor their medical issues and the adequacy of their dose of methadone or buprenorphine.

I try to address certain issues each month when I a see these pregnant women in our treatment program, to make sure they have all the data needed, and to make sure we have good peripartum planning.

In no particular order, here are the items I review at each visit. If I forget one, since I’m seeing the patient repeatedly, I’ll address it at the next visit.

  1. Recommendations for pregnant patients with opioid use disorder have not changed recently. The gold-standard, best treatment choice is medication-assisted treatment with either methadone or buprenorphine.

Many pregnant women are urged by their family, with the best of intentions, to taper off methadone or buprenorphine while pregnant. Sadly, even some obstetricians still recommend taper off medication-assisted treatment, lacking the information from experts in their own field.

Sometimes I can gently educate these physicians…and sometimes it doesn’t help.

Sometimes I ask the patient if they’d like to bring their significant other, or other relative, to one of our visits so that I can explain the importance of staying in treatment. Often, once the relative has more information, they don’t try to discourage my patients from remaining in treatment. I can only do this with patient consent, though.

2. The risk of withdrawal in the newborn isn’t related to the dose of the mother during pregnancy. It’s counterintuitive, but studies done over the past three to four decades don’t show a clear relationship between dose and risk of NAS. Given this fact, there is no reason to keep the mom’s dose lower than she needs. Since we know that the mother will be healthier and have a better outcome with adequate dosing, we need to titrate the mom’s dose to the point withdrawal symptoms are suppressed.

3. We expect a pregnant patient’s dose to need to increase during pregnancy. This is particularly true with methadone. Because of plasma volume expansion and faster methadone metabolism, the pregnant patient’s methadone blood level will drop during pregnancy, mostly during the last three months. Sometimes splitting the mother’s dose (giving half the dose in the morning and half in the evening) works better than increasing the overall dose. We also have some evidence that splitting the dose may reduce the risk of withdrawal in the newborn, so it’s win-win. Splitting the dose isn’t possible if the patient has an unstable home situation, or if she struggles with other drug use. It’s always a matter of balancing risk and benefit.

After delivery, we usually need to decrease the dose slowly, as the pregnant patient’s body gradually goes back to its pre-pregnancy state.

4. I try to help the mom stop smoking during pregnancy, since there’s good evidence to show smoking cessation reduces the risk of withdrawal in the newborn. This isn’t an easy thing, but very important for the baby’s health – and the mom’s.

5. It’s OK to breast feed while on either methadone or buprenorphine. Studies show only tiny amounts of either medication in the breast milk. Experts say the benefits of breast feeding clearly outweigh the risks. And it’s OK if the patient does not want to breast feed. Let’s not be “breast-bullies” and shame women who decide not to breast feed. Let’s support their decision no matter what.

However, if the pregnant patient has used other substances, particularly during the two months prior to delivery, the neonatologist may make a recommendation not to breast feed. Most commonly, the drug in question is marijuana. I tell my patients to heed the advice of the neonatologist.

6. I make sure the patient understands the plan for pain control during hospitalization. I want to continue the patient’s same dose throughout her hospitalization for the delivery of her baby. Patients can still have epidurals which will work well. After delivery, they can be prescribed short-acting opioids like any other pregnant patient, since the daily methadone or buprenorphine won’t be enough to treat acute pain.

I also make sure patients know the names of medications that are contraindicated with methadone and buprenorphine. If they are given one of the mixed agonists/antagonists like pentazocine (Talwin), butorphanol (Stadol), or nalbuphine (Nubain) they will go into immediate withdrawal. This is more problematic for patients on methadone than buprenorphine. Lately I’ve written the name of all three on a piece of paper and given it to the pregnant patient, determined to avoid therapeutic misadventures that have occurred in the past.

Several years ago, a new-ish obstetrician called me, concerned about one of our patients who had elevated blood pressure after delivery. She wondered if there was something in the methadone that caused this, as she had seen it in several other deliveries.

I was mystified. No, I said, I didn’t know of any data saying that methadone raised blood pressure. Worried, I combed the literature but didn’t find anything.

Then I got a copy of the patient’s hospital record. Shortly before the patient had elevated blood pressure, she got a dose of Nubain.

Mystery solved. The Nubain put the patient into immediate withdrawal, resulting in very high blood pressure and other miseries. I hadn’t considered this possibility before, because I had talked to this OB in the past about the need to avoid the mixed agonists/antagonists. She must have forgotten this.

So now, I give all pregnant patients a piece of paper on which I write the three medications, and tell the patients to tell their providers that they are allergic to all three medications. I hope this will prevent further episodes of precipitated withdrawal in patients.

7. I make sure our pregnant women know their babies will need to stay in the hospital for monitoring for six or seven days. I want them to be prepared for this, since it’s upsetting not to be able to bring the baby home immediately.

The baby must stay to be evaluated for withdrawal. Because of the very long-acting nature of both methadone and buprenorphine, the infant won’t have withdrawal as soon as it is born. Withdrawal, if it occurs, can be delayed up to six days. I tell the moms-to-be that the prolonged admission is for the baby’s safety.

Lately, more hospitals are encouraging “rooming-in” which means the infant and mother have a room assigned to them where the mom can keep the room dark and quiet, and either breast feed or cuddle with skin-to-skin contact that soothes the baby.

This newer way uses non-medical means to reduce the infant’s withdrawal symptoms. Sometimes it isn’t possible, obviously, if the baby has other major medical issues, and may have to be admitted to the intensive care unit. But when possible, rooming in is a wonderful option.

8. All drug use is of special concern during pregnancy. Ironically, we have more data about the harm caused by alcohol during pregnancy, yet it’s legal, and part of many social activities. If the mom struggles with use of alcohol or other drugs, we try to refer her to inpatient treatment programs, for more intensive treatment of her substance use disorders.

Our first choice is the state facility in Greenville, NC, called Walter B. Jones Alcohol and Drug Use Treatment Center. They do a terrific job, and admit pregnant women as a priority. They can provide prenatal care as well as maintaining the patient on methadone or buprenorphine. And they can address whatever other drug use has been a problem, providing a much higher level of support. Soon, that standard of care may be offered at other North Carolina ADATC programs, as they become certified as opioid treatment programs too

.Pregnant women on medication-assisted treatment can’t be admitted to many inpatient residential programs, because these programs won’t “allow” patients to dose daily with methadone or buprenorphine. This severely limits our choices for pregnant patients. I hope this will change soon, since those programs aren’t observing the standard of care for pregnant women.

Let me say a little about stigma and bias. We’ve seen too many sensationalistic stories in the media about “drug-addicted babies.” As a point of fact, babies aren’t born with addiction. They may be drug-dependent, but they aren’t addicted, since the definition of addiction requires mental obsession with the drug, and craving. Newborns obviously can’t formulate that mental preoccupation for substances.

Pregnant moms face a great deal of stigma for having substance use disorders. These disorders are defined by loss of control over the substance, yet if one of these women become pregnant, they are suddenly reviled for their lack of control. They are sometimes judged severely, and told they must not care about their babies or they would quit using drugs.

Substance use disorders are so much more complicated than that.

In fact, harsh confrontation of a pregnant woman predicts treatment failure, with worse outcomes in both mom and baby.

Best results are seen when the woman is treated with compassion, and motivated by hope.

All mothers want to have healthy babies, and moms who use drugs are no different. They want to be good moms, and they want to do the right thing for their babies. Sometimes pregnancy can be a positive thing, since it can be a strong motivator for patients to ask for help. Let’s support them in any way that helps.

  1. Jones et al, 2017 “Medically Assisted Withdrawal (Detoxification: Considering the Mother –Infant Dyad,” Journal of Addiction Medicine, Vol. 11, No. 2, March/April 2017)