OTP Greets County Commissioners for Lunch & Learn

Art by Ukranian artist Yulia Parabina (purchased on ETSY)

As I wrote about in past blogs, government officials in North Carolina have decided to allow each county’s commissioners to decide how to spend the opioid settlement money. They set a framework of priorities for this money, but the commissioners will have final control of how it’s spent. Also in past blogs, I wrote about how other physicians have tried to educate their county commissioners about evidence-based treatments for opioid use disorder.

I talked to my opioid treatment program’s program director about how we could have a discussion with our county’s commissioners. She thought we could invite them to come for lunch, a tour of our facility, and maybe a short education presentation by me about opioid use disorder and evidence-based treatment.

I thought this was an excellent idea. Food always helps.

She invited them, we worked out a date that worked for everyone, and it happened just last week.

It went very well.

We invited all five county commissioners, but three of them are rotating off service this year. The two active commissioners came to our event. We also invited other people in our area with whom we work: the head of Project Lazarus, a local non-profit agency that offers a variety of help and services to our patients and other people; the head of the county’s Health Coalition; and the leader of R3 Recovery Services, which also assists our patients – and others – with a variety of needs such as needle exchange, housing, peer support, and other things. We had a few other city officials, so in addition to our twenty or so staff members, it was a good-sized group.

I’ve given presentations about medications for opioid use disorder dozens of times. I’ve presented at Addiction Medicine conferences, at conferences for social workers, for nurses, and even for federal probation and parole officers. I’ve given this presentation to our county probation officers and to our county’s EMS works. I’ve given this presentation to hospital labor and delivery nurses, and probably a few other places that I don’t recall.

As always, I spent time updating my presentation, then pruned it to make it lean but full of information. In my presentation I described what opioid use disorder is, and how its course is like other chronic illnesses. I defined “evidence-based treatment” and how it differs from treatment fads. I commiserated about how they have been handed a large responsibility: deciding how to spend the opioid settlement money in a way that benefits the most people with the illness. I went on to tell them which treatments are ineffective, such as ultra-rapid detox and short-term detox- only treatments, which both increase patients’ risk of death.

Then I spent the bulk of the time describing treatment with methadone at an opioid treatment program, and treatment with buprenorphine products at both office-based programs and opioid treatment programs. I ended by giving them information about depot naltrexone injection as a treatment option.

I felt anxious before I started because I was so eager to make myself understood. I don’t enjoy public speaking, but I do it when asked because I need to do my part. I’m not a great speaker; I stammer and often phrase things awkwardly. But when I forget about myself and focus on the material, the words flow more easily and that’s what I did. My audience listened in respective silence, and one county commissioner took notes during my presentation.

I was thrilled.

Then we had a brief time for questions. I could tell by the questions they asked that they understood the information and were trying to understand how the settlement money could be spent effectively. I sensed they were intent on making good decisions. I was glad other recovery resource people were in the room, because we talked about patients’ biggest needs after treatment fees. We talked about the importance of housing and transportation, to name the biggest barriers to staying in treatment, along with childcare options and employment.

I was delighted. I felt like this short session was a big hit, and I felt like I had a chance to say what I needed to.

If you are a counselor, nurse, patients, doctor, or therapist, please consider reaching out to your county commissioners and give them information. Tell them what you see or what your experiences have been. Help them get the information they need to spend this opioid settlement money wisely.

Increased Take Home Doses for Patients at Opioid Treatment Programs: What’s the Risk?

Digital art downloaded from ETSY – by Ukranian artist Julia

The pandemic led to loosening of regulations on take home medications for patients being treated at opioid treatment programs, dosing on either methadone or buprenorphine. As I blogged about in my 12/1/21 post, SAMHSA has proposed guidelines for continuing extended take homes. Now there’s more evidence to support benefits of this approach.

Last week there was an article in the Journal of the American Medical Association (March 1, 2022, pp. 791-886), by Gomes et al., outlining results of the looser restrictions.

The authors concluded, after examining the study data, that increased take home dose schedules were associated with significantly lower rates of patients dropping out of treatment, without any increase of opioid-related overdoses, during the six months of follow up.

This is great news and supports the current popular viewpoint that more take home doses for patients at opioid treatment programs (OTPs) can be given without a reduction in safety.

This study was done in Ontario, Canada. Of course, I was concerned that Canadian take home schedules were already different from the U.S., but the authors say that both countries have similar take home schedules pre-pandemic. However, in Canada, patients can get some doses from pharmacies as well as OTPs. Treatment in Canada tends to be less centralized in the U.S

This study was large, including a total of over twenty-one thousand patients enrolled in opioid use disorder treatment programs.

The study divided these patients into four groups, depending on the number of take-home doses they were receiving pre-pandemic. Group one consisted of patients who dosed on methadone with no more than one take home dose per week. Similarly, Group Two dosed with buprenorphine/naloxone with no more than one take home per week. Group Three patients dosed with methadone and had up to a week of take-home doses just before COVID hit, and Group Four dosed on buprenorphine/naloxone and got five or six take homes per week pre-COVID.

To be included in the study, every subject had to have had at least one physician visit between 3/22/2020 and 4/21/2020.

Then the study divided each of the four groups of patients into “exposed” or “non-exposed” based on whether they received extra take home doses. For example, in the first group of patients, dosing daily on methadone, some of these patients received up to a week of take-home doses and some remained daily dosers, depending on decisions made by their physicians. For the patients in groups 3 and 4, which were made up of patients getting 5 or 6 take homes per week, they were either “exposed” to approximately two weeks’ of take homes or they were “non-exposed” to the extra take homes and remained on weekly schedules.

The study wanted to see if the patients who received the extra take homes in the four groups had worse outcomes than the ones who didn’t get the extra take homes. The primary outcomes that were observed were fatal or non-fatal opioid overdoses, interruption in treatment for opioid use disorder, and discontinuation of treatment. The interruption of treatment was defined as a gap in treatment of 5 to 14 days, and termination was defined as a gap of more than 14 days.

The study subjects were followed for 180 days.

The data is surprising and supports the use of more take home doses for patients.

 In group one, the group of patients dosing daily on methadone, the patients who were given extra take home doses had significantly lower risk of opioid overdose. They were also less likely to have an interruption or termination of their methadone treatment than the patients who remained on daily dosing schedule.

So…getting extra take home doses decreased the risk of having an opioid overdose. I would not have expected this. I wasn’t surprised that those patients were less likely to have disruption of treatment.

Buprenorphine/naloxone patients who were dosed daily prior to COVID but received extra take homes with the new guidelines were not significantly more likely to have opioid overdose. They  were less likely to have interrupted or terminated treatment, compared to those patients who remained at daily dosing.

Similarly, when they looked at groups 3 and 4, composed of patients already getting a week of take-home medication, the patients who were “exposed” to two weeks of take homes were less likely to have interruption of treatment.

Why were these results so good? Was it because the physicians were exceptionally wise when they decided which patients were safe to get extra take homes and who weren’t? That might be one explanation, and the explanation that would made me happy, but I can’t tell that from the data.

I looked at the article to see if there were specific factors that were associated with extra take home. I looked to see if some factors were associated with NOT getting extra take homes. The article says physicians making the decisions did have guidance from a document from the Canadian Centre for Addiction and Mental Health: “COVID 19 Opioid Agonist Treatment Guidance.” It discouraged advanced take homes for patients with recent overdose, unstable psychiatric illness, or use of illicit substances in ways that were considered high risk. This article says that it appears physicians used this guidance when deciding about take-home status. Patients who didn’t get advanced take homes tended to have higher rates of mental illness and medical problems related to alcohol use disorders

The authors say their study should be interpreted with caution, since there are some factors that may not have been captured by this clinical data. They say that the decision to allow more take homes was affected by complex characteristics that could confound the outcome of the study. They also say that overdoses may have been under-counted if they occurred out in the community and if the victims weren’t transferred to a hospital.

Even with its possible limitations, this study presents good news about the extra methadone doses and buprenorphine/naloxone doses that were given in Canada during the first months of COVID. More patients were maintained in treatment with no increase in overdoses. This study’s conclusions are supported by other articles in scientific literature that support the safety of extending take home doses for patients on both methadone and buprenorphine/naloxone. (Amram et al., 2021; Levander et al., 2021.

I do wish there was additional information about the physicians’ decision- making process regarding extra take home doses.

An Example of Lowering Barriers to Treatment

I’m lucky to work with many wonderful and caring people at the opioid treatment program. Usually counselors and nurses (and medical providers) do the visible work to help patients, but in this blog, I wanted to relate an inspiring example of how our receptionist lowered a barrier to treatment for a desperate patient seeking help.

Our opioid treatment program opens at 5am, but I don’t get there until 7am, which allows time for new patients to see a counselor and a nurse.

That morning, I settled into my office and went to the front office to see which patients were ready for me. One of our receptionists, named Trish, pointed at the patient list and said, “You’ve got to take of this one. He’s special.”

A little taken aback, I said, “I take care of all of them. They’re all special. But how is he special?”

She told me that he really was anxious to get into treatment and that she’d done some work to get him ready. I asked her to explain.

All new patients must have state-issued photo ID. I think this is mandated so we can make sure the patient isn’t enrolled in another opioid treatment program, and of course to make sure we are treating who we think we are treating. This requirement isn’t usually an obstacle. Most people have photo IDs, such as driver’s license or other documents. But once in a great while, a prospective patient doesn’t have such an ID, as was the case with this patient.

When the patient arrived at 5am, Trish discovered the patient didn’t have any ID. She sent him home to bring back all the ID that he possessed. Unfortunately, none of them were state-issued picture identification. It looked like he was going to have to make a trip to the DMV to get a photo ID before he could be admitted and start treatment.

But Trish’s heart went out to this patient, who was feeling bad from withdrawal. He wanted help and didn’t feel like taking a detour to the DMV. This is where Trish got creative. She asked if he’d ever been arrested because inmates get photo identifications made. He said yes, but it was in another county. With the patient’s permission, Trish called that county jail but quickly discovered they didn’t have photo ID available for him.

So then Trish asked the patient if he was sure he hadn’t spent any time in our county jail, and he said yes, he did stay one night in our county jail. Again, with the patient’s permission, Trish called our county jail and asked if they had a photo ID of him. They said no, it had been too long ago, and they didn’t have it in their system, but she might get it from the sheriff’s office.

So she called the sheriff’s office. They put her on hold and eventually told her she’d have to talk to a supervisor.

By this time, Trish was losing hope. She didn’t expect great cooperation from a law enforcement supervisor at six in the morning. But she was forwarded to him, and he told her he would look to see if they had such a document and call her back.

Trish didn’t expect much from this so she was pleasantly surprised when he called her back after about 20 minutes, saying he had a photo ID that the patient could come pick up. Pushing her luck, Trish asked if it would be possible for the supervisor to fax that copy to our office, to eliminate further wait time, and the supervisor agreed.

Several minutes later the patient had a photo ID in his chart and was ready to see me.

The patient was effusive with his gratitude for Trish’s actions. He told me, “I can’t believe how nice she was. She didn’t have to do any of that. She could have just sent me on my way and told me to come back when I had a photo ID.”

I agreed with him. I told him yes, she really wanted to see him get help as soon as possible, and I was also thankful she went the extra distance to help him. We did his intake and he entered treatment that morning and has come every day since.

This is a little example but such a big illustration of how a spirit of compassion can lead workers in the addiction treatment field to provide that something extra.

Trish didn’t have to do all of what she did, which took well over an hour of her time. Thankfully there was a second receptionist who cheerfully took over the daily chores of greeting patients, checking them in, taking payment, and everything else that the front office does. Thankfully our OTP adequately staffed the front office to be able to handle complicated intakes along with the daily routines.

I’m thankful Trish saw our prospective patient with eyes focused on helping him rather than turning him away. That day, she reminded me what a servant’s spirit is and what it looks like in real life. She reminded me how much benefit we can see when we go the extra mile to help another person.

She sets a great example. She inspires me to keep a willing and helpful attitude towards patients and all other people.

This patient may not stay in treatment. He may not have used his last illicit opioid. However, he will always remember the special effort and care that our receptionist put forth to get him into treatment. Maybe that will help him continue to work on making the life changes he seeks.

What is “Low Barrier” Treatment?

Also called “low threshold” treatment, these terms refer to the idea that getting into treatment for opioid use disorder should be as easy as possible. Since only around 20% of the people in the U.S. with opioid use disorder are getting help, we need to improve treatment accessibility.

DATA 2000 was passed to make treatment more accessible. Before that piece of legislation, opioid use disorder was only treated with methadone which was only available at opioid treatment programs. DATA 2000 made it possible to get treatment at doctors’ offices.

Or at least that was the idea. Primary care physicians and other providers haven’t rushed to fill the treatment void as quickly as we might have hoped, but progress is being made.

So now experts are talking about other barriers to treatment and how to eliminate them.

Jakubowski et al., in their article “Defining Low-threshold Buprenorphine Treatment,” (Journal of Addiction Medicine, 2020, Mar-Apr 14(2), pp95-98.) published ideas about this concept.

First, they advocate for same day admission into treatment. The hope and desire for change can be fleeting, so getting people into treatment the same day they are ready is essential. Many people fear the unknown, and when they work up the courage to ask for help we need to make it available as soon as possible. It’s too easy to drop back into old behaviors if people meet with discouragement. Same day admission into treatment is the ideal.

Second, the article’s authors advocate for a harm reduction approach to treatment. At the most basic level, the article’s authors state this means improving patients’ quality of life and reducing overdose risk. What this looks like in a practice setting can include many things.

For example, it includes trying to keep people in treatment once they have started. It means we don’t kick patients out of drug use disorder treatment for drug use. If treatment is benefitting patients in some way, keep them involved, even if they are using other drugs. Harm reduction can also mean encouraging patients who still use drugs intravenously to use new needles and safer injection practices.

Harm reduction also means – and this should go without saying but I’m saying it anyway – treating people with warmth and empathy. Patients with opioid and other substance use disorders deserve kindness just like patients with any other illness. We shouldn’t minimize our patients’ complexities by seeing only their addiction. We always need to remember they are more than just their addiction.

Hopefully all treatment environments make patients feel comfortable and supported with no judgment.

I don’t understand treatment facilities that tolerate bad attitudes by employees charged with helping patients. Our patients can sense attitudes of judgment or distain even when they are transmitting non-verbally. A tone of voice or a sour expression can do as much damage as outright hostility. Providers must be vigilant for these problems in every employee from the receptionist to the physicians.

Third, the authors talk about the importance of flexibility in meeting the patients’ needs. Treatment shouldn’t be an obstacle to life’s other obligations like work and family. Hopefully office-based buprenorphine practices can offer a variety of appointment times.

The study authors recommend against making intensive counseling mandatory. They aren’t saying counseling isn’t needed or that it is not part of a recovery program. They are saying we shouldn’t let the ideal counseling program be the enemy of what the patient is willing or able to do. If the patient can’t or won’t make daily counseling appointments, be satisfied with weekly or monthly sessions.

The authors also say that monthly appointments with providers are adequate for many patients, and that patients should be offered which ever buprenorphine preparation appeals to them: sublingual tablets, films, or depot monthly injections.

Fourth, the authors advocate to make treatment available close to where patients live and work. The authors talk about non-traditional settings which might include mobile vans, homeless shelters, and other places. Of course, as mentioned above, primary care offices can be an ideal place to offer treatment since many people access medical care there.

I was talking to people in the opioid use disorder treatment sphere about how I felt opioid treatment programs can also be low-threshold, or at least low-ish threshold. I was met with some doubt, which I understand. After all, the nature of federal and state regulations on treatment are limiting.

However, since COVID, we’ve seen some positive changes. We’ve also seen much better funding available for patients who need help.

The Jakubowski article didn’t mention the cost of treatment, which is the biggest barrier among the patients I see. Private insurance does better at covering treatment costs than they did ten years ago, but it can still be challenging to get them to pay. Thankfully Medicaid covers treatment at opioid treatment program.

What about the vast numbers of people who have no insurance and don’t qualify for Medicaid? These working poor don’t get insurance where they work, which are often blue-collar jobs. For the past few years, the state has been able to pay for treatment, first under what was called the CURES grant and now under the SOR (State opioid response) grant.

Our opioid treatment program has more than two hundred and fifty people who get free treatment under these grants. The grants removed their biggest barrier to treatment.

Do office-based buprenorphine programs offer anything similar? Not the ones in my area, because we often get patients transfer to our program when their ability to pay for treatment runs out at an office-based practice.

So it appears OTPs have lower financial barriers then OBOTs, at least in our area.

Let’s look again at some of the Jakubowski criteria above.

The same day admission into treatment is important, and at the opioid treatment program where I work, we do same day admitting four days per week. I don’t do intakes on Fridays or the weekend. But Mondays through Thursdays, patient can walk in and ask for admission from 5am until around 10 am and we will do their admission. We also make appointments for intakes, so patients have their choice.

I don’t do same day admissions at my office-based practice, and I don’t think most OBOT practices are able to do same-day admissions, at least in my area. I’m only in my own office one day per week, and my schedule is tight.

So again, some opioid treatment programs do better with same day admissions than many office-based programs, including my own.

What about using harm reduction policies?

In North Carolina, we have a weekly teleconference open to all providers who work at opioid treatment programs in our state, moderated by a fellowship-trained addiction medicine physician and supported by our Governor’s Institute. Over the past few years, consensus of this group has changed a great deal. After heroin with fentanyl became the most used opioid statewide, most of the providers no longer kick patients out of treatment for using stimulants like cocaine and methamphetamine. Most of us try every option we can think of to get patients using alcohol or benzos (dangerous with methadone) into more intensive treatment while continuing to treat with methadone (or buprenorphine). We don’t kick patients out of treatment for using THC.

However, we get many patients transfer from local office-based buprenorphine programs who have been discharged because they had repeatedly positive drug screens for other drugs besides opioids. We are happy to have these patients, and I don’t fault these providers. Usually, the providers were worried they weren’t doing a good job by “allowing” patients to use other drugs. They dismiss the patient because they think that’s what they think a good physician would do.

Many office-based buprenorphine providers aren’t familiar with harm reduction principles, and our OTP is happy to have these patients until providers become more comfortable with harm reduction ideas.

 However, it would be much better if they did a warm handoff to us rather than dismiss the patient.

Some regulations make full adherence to harm-reduction policies impossible, of course. OTPs must get at least eight observed drug screens per year, and there’s mandated minimum of individual counseling sessions that must be done at the opioid treatment program. Particularly with methadone, we have state and federal rules about take home doses.

Even so, I can’t think of any patient – over the last twenty-one years I’ve worked at assorted opioid treatment programs – who has been dismissed from treatment because they refused counseling. OTPs usually try to meet people where they are.

There are outliers – opioid treatment programs who insist their patients get intensive outpatient group treatment as a condition of also getting medication to treat opioid use disorder – but they are in the minority.

The ideal is to offer intense treatment to those who want it, but not to withhold medication if they decline.

Federal and state rules about daily dosing at opioid treatment programs has been a barrier to patients in the past. However, those rules have been relaxed since COVID. The response of patients has been so positive that changes are proposed to allow take home doses much more quickly. I just blogged about these positive changes in my blog posted December 1, 2021.

As far as Jakubowski’s urging to get treatment where the patients are, I’m not sure how OTPs can meet that recommendation, unless they take advantage of newer regulation changes around mobile vans. I’ve also blogged about this (see May 23, 2021).

Anyway, both OBOT and OTP treatment programs can do more to lower the barriers for patients to enter treatment and to stay in treatment. Providers need to examine current protocols and habits around admissions and treatment.

I’d love to see an era where treatment is as easy to get as drugs.

I Am an Outraged Dinosaur

This blog isn’t directly about opioid use disorder and its treatment, but it has some indirect comment on healthcare costs.

I had my yearly wellness physical done in November. My lackluster, outrageously expensive Blue Cross Blue Shield insurance plan is supposed to pay for this, as an incentive to get me to take care of minor health issues before they become major ones.

My old primary care physician retired, so I saw her partner this year. Atrium Health out of Charlotte bought this practice recently. My new doctor is a nice, competent young women in her early years of practice, and all went well. The whole thing took maybe a half -hour and she did a good job. I then had to go to an Urgent Care owned by Atrium to get my blood drawn since they had no phlebotomist at that practice.

Yesterday I got a bill in the mail saying I owed $224.25 to Atrium Health.

I started using creative curse words directed at my insurance company, thinking they made a mistake and hadn’t covered the wellness physical charges as they promised that they would.

Then I looked at the bill.

Atrium Health charged me $689.00 for the half-hour my doctor spent with me. My insurance paid all but $194.71. Notice I did not say my doctor charged me this. I know she’s getting a fraction of this money for the half-hour she spent using her medical skills to make sure I stay healthy. Atrium Health, a “non-profit” healthcare entity, will get the bulk of this.

My routine lab charges came to $758.70. My insurance paid all but $29.54. It could have cost much more, but I got rebellious when my doctor said she wanted to get a Vitamin D level. I told her my Vitamin D level had been low for ten years and remained low despite Vitamin D supplementation and sun exposure and I think it is safe to assume it is still low and besides there’s no good evidence to show Vitamin D supplementation benefits patients.

Thus, the grand total for my free wellness physical, with labs, totaled $1,447.70.

This is crazy. I am a relatively healthy middle-aged woman with a few chronic medical problems such as elevated cholesterol and mild hypertension.

I called Atrium Health’s billing department to see if perhaps they had made an error in my bill. A  nice lady representative answered my call. She listened to my concerns, then said that since my physician had to send prescriptions for me, it was no longer a preventative visit. Under these circumstances, she explained, Atrium Health billed for both for a regular office visit and a preventive health visit.

Wait, what? Atrium Health billed two office visits for the same day? I pointed out that a patient cannot be charged two separate office visits for the same visit. She said this was the usual way Atrium Health billed for preventive physicals.

I was confused, and muttered something like, “Well OK, we’ll see how that turns out for you,” and got off the phone. There was no point in arguing or being mean to her. It wasn’t her policy; it was her employer’s.

Next I called BCBS to see if they cared that they had paid for two office visits for my one office visit. I talked to a service representative who agreed to look at my bill that they had paid. After viewing the bill, she agreed it was unusual to be billed twice for office visits on the same day, and opened a case investigation for further review. I’ll find out in a few weeks if BCBS thinks Atrium Health made a mistake to bill two office visits. I was thankful she didn’t dismiss my concerns.

I know I’m a dinosaur in the medical field. I finished my Internal Medicine residency in 1990. I worked in primary care in the 1990’s, before I got interested in Addiction Medicine. The cost of medical care back then was much cheaper than now. I don’t think doctors are making that much more money, so where’s it going?

More non-medical middlemen take a good chunk of it, and places like Atrium Health shift costs of caring for the uninsured to those with insurance…I know the commonly spouted reasons given for the high cost of medical care. I have no good solution, other than advocating for universal healthcare coverage.

I am fortunate that I can afford to pay $224.54 for my “covered” yearly wellness physical. For many people, this would be an economic hardship for which they weren’t prepared since their insurance company advertises free wellness physicals. But I don’t blame BCBS (this time), and I’m surprised they paid as much as they did.

I plan to switch from an Atrium Health physician even though I like my new doctor. I think Atrium’s charges are excessive, even in our present-day runaway health costs.

There. I feel better.

What’s the use of having a blog if I can’t air a personal grievance occasionally?

Opioid Settlement Money Part 2

This blog entry is a continuation on some of the ideas presented in my last blog, mainly that the opioid settlement money being granted to each North Carolina county’s commissioners needs to be spent wisely.

The guidelines that our state government has put forth can be found in this pdf: https://www.ncacc.org/wp-content/uploads/2021/04/Opioid-Litigation-Settlement-Overview-202109.pdf

These plans include very reasonable ways to fight the opioid epidemic, embracing prevention, treatment, and plans for additional services. I have thoughts regarding a few specific topics.

Housing

Housing is a problem for many people with opioid use disorder in my area. There’s not enough low-income housing available in general, but people with substance use disorders have unique problems with housing. For example, if a person seeking recovery lives with other people who use drugs, as often happens, they encounter a constant trigger for relapse. They need to move, but where can they go?

We do have recovery houses in our area, but they don’t accept patients on methadone or buprenorphine. Last blog, I explained how some medical practices and facilities have been found in violation of the Americans with Disabilities Act (ADA) if they exclude people from services because they are on prescribed methadone or buprenorphine. I don’t know if this law applies to recovery houses, but the bottom line is that there are no recovery houses available in our area for people on medications for opioid use disorder. We need this is our area and around the state.

Over the past few years, our area’s homeless population has grown. I think there are several reasons for this, including a rise in methamphetamine use disorder, which often co-occurs with opioid use disorder. Methamphetamine use seems to lead to people getting kicked out of their housing. Also, our homeless shelter closed a few years ago, pressured by a community that didn’t want “those people” present in their community. Thankfully, a church opened a temporary homeless shelter, but people can only stay there for fourteen days per year.

Ironically, the closed shelter was located very near our OTP. Since that shelter closed, “those people” formed a tent city in the woods behind our OTP, at least during warm months. I’ve admitted some of them into treatment for their opioid use disorder, and at least they can get to our OTP daily since they live in our backyard. However, most also struggle with methamphetamine use and are triggered by others in this homeless camp. As most of my blog readers know, there’s no medication that has been proven to help patients with stimulant use disorder. We try our best to engage them in counseling, but they need safe housing.

At one point I estimate there were ten or fifteen people living there, though only a handful were our patients. Several churches in the area brought food to these patients regularly, and our OTP had clothing and blankets which we provided when we could.

In an ideal world, recovery homes for patients in treatment on medications for opioid use disorder would be wonderful.

Transportation

I’d like for our state to spend part of the opioid settlement money on the transportation of patients to treatment. The nature of our outpatient treatment program means patients must come for dosing and counseling daily, at least until they stabilize.

Transportation is a barrier to treatment for patients in our rural county. We have no public transportation for people without Medicaid. Thankfully patients with Medicaid can ride vans that bring them to and from our opioid treatment program to dose daily, but it’s not feasible for patients without Medicaid.

Since requirements were loosened for take home doses during COVID, patients can get take homes much earlier than in the past. But new patients starting methadone still need to come daily until they get to stable doses. Some patients take longer than other to get to a stable dose and stop using fentanyl and other opioids. If they miss days, it interferes with dose increases and they spend longer in induction, placing them at higher risk for a bad outcome.

I’d like for someone to invent dependable transportation for our patients.

Of course, a mobile unit would be ideal but so far there’s no talk of starting this at the OTP I work for. It could work well, particularly in rural areas.

Fund Treatment

Of course, the most obvious need in patients with opioid use disorder is funding to pay for treatment. As I talked about in my last blog, the opioid settlement money should pay for evidence-based treatment.

The state opioid response grant (SOR) has paid for treatment at opioid treatment programs for indigent patients. To qualify for the grant, patients need to have an income below a certain cut off and have no health insurance or Medicaid. This grant has been a lifesaver for many patients. We have around two hundred patients now getting their treatment paid for by this grant at the OTP where I work.

The Opioid settlement money could be administered in a similar way, except I wish even patients with health insurance could get grant money. Right now, having health insurance disqualifies patients from the grant, but many of those patients can’t get their health insurance to pay for treatment. It’s not quite as bad for office-based buprenorphine treatment, but similar.

As I wrote about last blog, county commissioners need to take care not to give money to unproven treatment providers.

Just last week, WRAL in Raleigh ran a piece about a ten-million-dollar grant to combat opioid use disorder to a pastor running a non-profit organization called Hope Alive. Critics say this agency has no experience treating opioid use disorder. To make matters worse, WRAL did some research and found that this pastor served time for seven counts of embezzlement 1992 through 2004. [1]

Defenders of the grant decision say there’s no other providers of treatment in rural Robeson County, and the pastor’s criminal record was a very long time ago.

The last part of that I’ll agree with completely. Perhaps the pastor had a substance use disorder himself, leading to the criminal charges. Perhaps his past has made him a more effective person to lead a recovery service. I believe people can grow and change, or else I wouldn’t be working in this field.

But the first part…just because there’s no other programs in Robeson County doesn’t mean spending money on ineffective or unproven treatment will help anyone. Shouldn’t the treatment facility be vetted, to make sure it adheres to evidence-based treatment, before the state awards ten million dollars?

In order for agencies and programs to receive settlement money, there should be some standard process to prove that they use evidence-based programs or medications.

Treatment for incarcerated people

Our state’s county jails and state prisons don’t often offer medication-assisted medications to treat opioid use disorder in incarcerated people. They usually won’t continue treatment that a patient has been getting. There’s a pressing need for this to change. I was happy to see this added as a priority for how NC planned to spend the opioid settlement money.

Litigation around the nation has been decided in favor of people who were denied their usually prescribed medications of buprenorphine or methadone while incarcerated. I’m happy about this because the threat of a lawsuit motivates organizations to change quickly.

I wish the public knew how much suffering our patients endure in these county jails when they are denied their treatment medication. A patient dosing for months on methadone at 120mg could be locked up for unpaid traffic tickets and spend five days in jail going through hellish withdrawal. If a nurse can be found, the patient might be given their “detox protocol:” a single bedtime dose of clonazepam .5mg. Healthy adults usually don’t die from opioid withdrawal if dehydration is treated in a timely fashion with intravenous fluids. However, medically fragile patients can die from sudden and severe opioid withdrawal.

I’ve blogged about this before. I tell all my patients who have been through such an awful experience that they can contact the NC chapter of the American Civil Liberty Union, to ask about filing a lawsuit for being denied appropriate medical care. Such lawsuits have been won in other states.

But North Carolina’s plan looks farther than continuing legitimate medical care for people already in treatment. It also envisions screening of newly incarcerated people to start appropriate medications. That’s a wonderful idea. After all, we know that studies show reduced criminal activity in patients who start in treatment with buprenorphine or methadone, so it makes financial sense as much as medical sense.

The logistics of providing this care will be difficult, but some prisons already have such protocols. We can learn from them how to set up good programs that benefits incarcerated people with opioid use disorder and our communities.

  1. https://www.wral.com/church-nonprofit-with-zero-track-record-of-providing-drug-treatment-awarded-10-mil-from-state-to-combat-opioid-crisis/20072234/

Opioid Settlement Money: Who Gets It?

By the term “opioid settlement money,” I’m talking about the $26 billion agreement reached in mid-2021 with the opioid manufacturer Johnson & Johnson and the big three opioid distributors: McKesson, Cardinal Health, and Amerisource Bergen. The settlement was reached between these parties and the organizations and agencies that sued them, which were over three thousand opioid-related suits nationwide.

Some states opted out of this settlement, preferring to continue to pursue lawsuits.

The settlement does not include other opioid manufacturers such as Purdue Pharma, Indivior/Reckitt-Benckiser, Teva, Mallinckrodt, or any of the pharmacy chains such as Walgreen’s, CVS, Walmart and others.

The agreement is more complicated than I’m able to explain in a brief blog, so if you have specific questions, I’ve found this is a great website: https://www.opioidsettlementtracker.com/globalsettlementtracker

States participating in the settlement now must decide how best to spend their money. Will it be a free-for-all like the tobacco settlement of previous years, or will the money go towards helping people who were harmed by the opioid epidemic?

I was pleased to learn that my state of North Carolina has a plan in place to distribute the money. According to an overview document, [1] North Carolina plans for 15% of the money to go to the General Assembly, to be spent on “…a wide range of strategies to address the epidemic.” The largest chunk, 80%, will go to local governments to spend. The last 5% will be used as incentive money to urge counties and municipalities to sign on to the agreement.

The state has set up oversight to make sure the money gets spent on these things: evidence-based addiction treatment, recovery support services, recovery housing, employment-related services, early intervention programs, naloxone distribution, post-overdose response teams, syringe exchange programs, criminal justice diversion programs, addiction treatment for incarcerated persons, and re-entry programs.

It’s a little more complicated than this, since counties have other options too, but all the options look like legitimate uses of this money, with potential to help the people who have suffered the most: people with opioid use disorder.

North Carolina’s plan is to allow county commissioners of each county decide how to spend their money, which could lead to some difficulties.

For example, what if one county’s commissioners want to spend it all on detoxification? They might not know that detoxification alone, when not paired with FDA-approved medications to treat opioid use disorder, has dismal fail rates. Detoxification provided to patients with opioid use disorder show relapse rates of more than 90%, with an increased risk for overdose death shortly after leaving detox.

I’ve said on other blogs that if treatment with this fail rate and increased risk of death were provided to people with any other chronic illness, malpractice lawyers would leap into action to sue the providers. They might even drop from helicopters like malignant spiders. But when detox treatment fails – as one would predict from fifty years of data – to benefit people with opioid use disorder, the patients are blamed for not wanting recovery badly enough.

However, detoxification results may improve if patients are started on long-acting naltrexone before they leave the detox facility. Its brand name is Vivitrol, and it is given as a monthly injection.

Of course, relapse rates would drop if detox facilities used methadone or buprenorphine, but we don’t often need inpatient facilities to accomplish this. It can be done safely as outpatient treatment, and more cheaply too.

What about the traditional abstinence-only based facilities who provide detox, then 28 to 42 days of inpatient rehabilitation? Should they get any share of the opioid settlement?

One of my colleagues got into some hot water lately when he voiced his opinion at his county’s Drug Overdose Prevention Coalition. He told the audience that in his opinion, several local abstinence-based residential programs, both of which bar patients on methadone or buprenorphine, shouldn’t be allocated any of the opioid settlement money. They both discriminate against patients on medications (buprenorphine and methadone) which are heavily evidence-based for the treatment of opioid use disorder.

 I admire his bravery, and everything he said was science-based…but not well-received.

He got angry letters from these two facilities, who wrote long letters about the benefits of their programs. Interestingly, the letters did not directly address the most pressing issue: is it fair or even legal to deny treatment services to people who are prescribed methadone or buprenorphine?

In fact, at one point in their letter, one facility says, “…at multiple points prior to admission, we are clear that we do not utilize addictive substances as part of our treatment milieu.”

They doubled down on their position that they not only can deny treatment to patients on buprenorphine or methadone, but that they consider them addictive substances. This may be why only 18% of their patients have a diagnosis of opioid use disorder (their data). I suspect most patients were discouraged during the admission process and abandoned their efforts to get help.

Courts across the country are deciding that patients denied medical services because they are prescribed either methadone or buprenorphine are being denied their rights under the Americans with Disabilities Act (ADA).

For example, in 2018, the Department of Justice found a medical practice violated the ADA when they refused to provide primary care and specialty services to patients who were legitimately prescribed MOUD (this abbreviation stands for medications for opioid use disorder, meaning methadone or buprenorphine). The medical practice agreed to a settlement where they paid a hefty fine and agreed to educate their staff and change their policy of discrimination against these patients. [2]

At least five nursing homes have been cited by the Department of Justice for violating the ADA when they refused to accept patients on MOUD. All the facilities agreed to change their policies, train their personnel, and some paid substantial fines as penalties for their behavior.[2]

The DOJ also investigated an orthopedic surgery practice in New England because they were turning away patients for orthopedic care who were prescribed buprenorphine. The practice made a settlement agreement with the DOJ to pay $15,000 to each person reporting discrimination, and the practice agreed to implement a non-discriminatory practice. [2]

Even Massachusetts General Hospital was found to have violated the ADA after investigation by the DOJ. They denied a patient a lung transplant because he had opioid use disorder treatment with MOUD, a decision which ended in an agreement for MGM to pay the patient and his family $250,000 for emotional distress and out of pocket expenses. [2]

With these legal precedents, is it legal to bar admission of patients on buprenorphine or methadone to residential treatment facilities, if these patients wish to remain on their MOUD? Is refusal to admit these patients a violation of the ADA?

Let’s assume for the sake of our discussion that these facilities don’t violate the ADA or any other law when they deny admission of patients with opioid use disorder who are on MOUD. Let’s say these facilities have the right to provide only the treatments they think are effective. Does that mean they should get money from the opioid settlement? What if the treatment they provide has poor rates of success, just like the detox-only providers? Is that the way we want to spend money meant to benefit people damaged by the opioid epidemic?

In other words, should there be a measure of effectiveness of treatment before money is granted by each county? Should treatment providers need to show how their program benefits people with opioid use disorder before the county grants money to them? Or can any charlatan with a good patter get dollars from the opioid settlement, if they talk a good game to county commissioners?

MOUD has the most evidence to show it reduces the risk of dying, improves physical and mental health, and other positive measures for patients. Yet I fear agencies and facilities that do not use MOUD will try to claim the opioid settlement money. How do we negotiate this?

I was forwarded a great commentary published in the Raleigh News and Observer recently, and here’s a link: https://edition.pagesuite.com/popovers/dynamic_article_popover.aspx?artguid=f0ca7281-4cf1-4369-b352-fc781dc82465

The authors raise good points. As a society, we need to decide how to move forward to spend this settlement money wisely, and the commentary provides food for thought.

I plan another blog post looking at other aspects of this issue, soon.

  1. https://www.ncacc.org/wp-content/uploads/2021/04/Opioid-Litigation-Settlement-Overview-202109.pdf
  2. https://www.lac.org/assets/files/Cases-involving-denial-of-access-to-MOUD.pdf

A New Drug on the Scene: Isotonitazene

As if fentanyl and its derivatives weren’t killing enough people, we another opioid to worry about. It’s isotonitazene, sometimes called “Iso” or “Nitazene” for short. it’s related to etonitazene and has similar drug effect profile.

This drug, which is not approved for medical use anywhere in the world, is a synthetic opioid with high potency. It has been identified in drug seizure analyses by the DEA on a regular basis since 2019. In 2020, the DEA issued a temporary order to schedule isotonitazene and its isomers as Schedule I controlled substances, with all the civil and criminal sanctions carried by this designation.

This drug has a high potential for addiction and causes respiratory depression in a dose-related fashion. Some reports suggest this drug may be worse at causing respiratory depression than other opioids, making it more dangerous. Its effects can be reversed by naloxone, though some sources say it might take a higher dose.

Since this drug is sold illicitly, buyers get it through unregulated sources, so the purity varies widely and inconsistently, adding to the danger of this drug.

A recent article by the Washington Post goes into more detail about how the drug and its analogues have been found in the District of Columbia’s drug supply: https://www.washingtonpost.com/local/dc-politics/new-opioids-more-powerful-than-fentanyl-are-discovered-in-dc-amid-deadly-wave-of-overdoses/2021/11/29/680afb2c-4d43-11ec-94ad-bd85017d58dc_story.html

This article says that according to experts, isotonitazene analogues are more potent than fentanyl. Deaths from analogues, mostly protonitazene, have occurred in Tennessee, Texas, New Jersey, and Iowa, among other states. Overdose deaths have also been seen in Europe and British Columbia, Canada.

There have been some reports of overdosed patients presenting to the Emergency Department with respiratory arrest, which is a common mechanism of death with opioids, but also with no heartbeat. With other opioids, respiratory depression or arrest is often accompanied by slow heart rhythm (https://www.forensicmag.com/581896-NPS-Alerts-New-Synthetic-Opioid-and-Unusual-Overdose-Symptoms/ )

This all sounds pretty bad. Several doctors in my state have seen patients who mentioned this drug among the types of opioids they are using, so I plan to start asking patients about it.  I don’t know of any drug test available commercially to detect this drug, further complicating treatment.

Out of curiosity, I Googled the drug and how to buy it, leading to a depressing array of purchase options. One website based in China offers this drug for $450 for 10 grams, or $9000 for a kilogram. Of course, they offer a selection of other controlled substances to consumers. Who knows what would be shipped if anyone bought off this website – if anything at all. And it would be illegal, and subject to schedule 1 drug penalties if discovered, lest any of my readers feel tempted to purchase off the internet.

Some news articles say the drug dealers buy isotonitazene in bulk to add to whatever illicit opioid they are selling, to make it go farther. This practice led to series of deaths in some states.

In the Sept-Oct 2021 issue of the Journal of Addiction Medicine, Shover et al published an article titled, “Emerging Characteristics of Isotonitazene-involved Overdose Deaths: A Case Control Study,” in which they compared characteristics of 40 isotonitazene deaths with overdose deaths from other opioids. They found deaths from isotonitazene more often involved other drugs and were also more often found in combination with a designer benzodiazepine called flualprazolam.

 I suspect some dealer somewhere added this second drug to a bulk supply of isotonitazene, which was then sold on the street. This emphasizes the problem of knowing what a drug bought illicitly actually contains. Potent opioids, when taken with sedatives like benzos, are known to cause overdose deaths in the unsuspecting buyer.

So what do we do about Iso? I plan to ask new patients about their use of it, or if they’ve even heard of it. We need a cheap commercially available test for the drug to get better information about the extent of the problem. And we need to educate and warn patients and providers about the drug’s presence.

And keep giving out lots of naloxone kits.

Merry Christmas and Happy Holidays!

I hope all my readers have great holidays.

Here are some upcoming topics to be covered on my blog:

*The Opioid Settlement: Who Gets the Money?

*A New Opioid on Our Streets: Isotonitazene

“We will not regret, nor wish to shut the door on it…”

I know 12-step recovery isn’t for everyone. Some people tell of bad experiences with 12-step groups. And I know millions of people have been helped by these groups, too. So take what you like from this blog entry, leave the rest, and if you read something helpful, I’ll be happy.

I talk to many people recovering from opioid use disorder who voice regrets about their past. The stories vary; the patients’ main theme is regret for behavior during active addiction. I understand those feelings, and feel tempted to tell patients how to deal with these feelings… but I don’t say anything, for fear that I’ll sound too “preachy.” Who am I to tell someone that they can examine past regrets, learn from previous mistakes, make amends when needed, and face the future with a clean slate? Isn’t that a conversation for a priest, imam, rabbi, or pastor?

Yes, it is. And yet, this person is in my office. Many times my patients tell me they feel unworthy to join or rejoin a religious community, and feel judged by such groups. Some of my patients’ perceptions could be colored by their own shame, but I fear many of them are accurate in their perceptions. Addiction, the old word for opioid use disorder, is still regarded as a sin by some religious groups. Other groups know it isn’t a sin but a disease, which can cause us to do and say things we regret, which are contrary to our values

Twelve step groups like Alcoholics Anonymous and Narcotics Anonymous have mechanisms for dealing with past regrets and ruptured relationships. These groups didn’t invent anything new. They use the same approach as other spiritual and religious groups. This sound psychological advice can be found through other sources, but today I’m writing about how the 12-step programs offer a handy framework for handling regrets.

First, in Step 4, the recovering person assesses past behavior, called a “moral inventory” in recovery parlance.  That inventory is shared with themselves (ending denial), another trusted person, and the god of their understanding. Patterns of behavior emerge, giving information to be used in steps 6 and 7, where the person becomes willing to give up old behavior and ask the god of their understanding for help with this.

In step 8, the recovering person lists the people he has harmed while in active addiction. With the aid of a sponsor or trusted spiritual advisor, in Step 9 the recovering person makes plans for how best to make up for past behavior.

Amends can be as simple as saying, “I’m sorry,” to someone for past bad behavior, or amends can be more extended, like resolving to be fully emotionally present for loved ones. Some amends can be made in a moment and others take a lifetime of changed behavior.

Sometimes direct amends aren’t possible, if the person has moved away, died, or unable to be located. A more general amends can be made instead. For example, if a person shoplifted to support their addiction, it may be impossible to remember where and what was stolen. Part of the amends process is not to repeat the old behavior, but a more general amends may involve volunteering in the same community to help society in some way, like donating to a food bank or giving time to help a child in need.   

If the recovering person feels guilty about stealing money, amends may include apologizing for the past behavior, and making a plan of re-payment. For example, I know a person in recovery for over twenty two years who sends a check for $25 each month to a governmental agency to whom he owned money after a criminal conviction. He may never get the full amount paid off, but he’s taking action to fix what he broke.

Substance use disorders taught harsh lessons that came at exorbitant prices, so we should try to learn from past mistakes. Recovering people can move forward by planning amends for past actions, but also should consult a sponsor or spiritual guide for help. For example, if a person in recovery from opioid use disorder stole money from a drug dealer, it should not be paid back, especially if it puts the recovering person at risk. In some situations, the best amends may mean having no contact with the other person.

Some recovering people have long lists of bad behavior to make amends for, and other recovering peoples’ lists may contain only a few family members. Many people harmed only their immediate family, by not being completely emotionally available to their spouses or children during their addiction. Some recovering people feel just as bad about that as others feel about committing armed robbery for drug money.

The point of amends isn’t how bad the behavior was, but how the recovering person feels, and how he can leave behind guilt and shame and move forward.

Substance use disorders, like some other diseases, affects behavior. Rather than living with regrets, recovery means facing regrets, learning from them, fixing what we can, and then moving on. It doesn’t matter what you call it: making amends, cleaning your side of the street, getting right with the god of your understanding, or some other term.