Posts Tagged ‘Addiction Medicine’

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.

 

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Tidbits

 

 

 

 

 

 

As I promised several weeks ago, in this blog I’m writing about some of the studies published in the latest issue of the Journal of Addiction Medicine, the journal published by ASAM (American Society of Addiction Medicine). All of the following articles were in the last issue, May/June of 2017.

The opioid situation in the U.S. has temporarily claimed a big chunk of our attention, but elsewhere in the world, amphetamine and methamphetamine use disorders are more common than heroin and cocaine use disorders combined. In fact, amphetamine and methamphetamine are second only to marijuana worldwide as the most commonly used illicit drug.

Many scientists have been working to find a medication that will help in the treatment of patients with this disorder. Thus far, only psychosocial treatments have been helpful, including individual and group therapies using motivational interviewing, cognitive behavioral therapy, 12-step therapy, relapse prevention, and contingency management strategies. These treatments do improve outcomes, but are at best only moderately effective.

In Runarsdottir et al., extended-release injectable naltrexone was studied in 100 subjects with amphetamine use disorder in a randomized, placebo-controlled study done in Iceland.

This authors of this study postulated that the opioid blocker naltrexone could block the opioid receptors and thus the pleasurable effects on any endorphin-mediated dopamine release resulting from methamphetamine use. Preliminary studies in rats, primates, and healthy human volunteers suggested naltrexone could be effective, so this study on human subjects with methamphetamine use disorders was undertaken.

Subjects in one arm of the study were randomized to the usual psychosocial treatments plus placebo injection, and the other arm got the same psychosocial treatments plus active extended-release naltrexone injections.

Unfortunately, in this study, extended-release naltrexone did not show any statistically significant benefit over placebo. Both groups had high rates of drop-out at around 50%, which hampered the study results. However, the study’s authors postulated that their selection criteria for the study may have pre-chosen subjects with more severe use disorders.

This study’s results were disappointing. We would love to have a new and effective was treatment for amphetamine and methamphetamine use disorders, but this study didn’t show benefit from extended-release naltrexone for use in this disorder.

 

Another article was about a newer product containing buprenorphine: the rapidly-dissolving buprenorphine/naloxone sublingual tablet (brand name Zubsolv). It’s been on the market for a few years, and previous studies showed it works as well as other sublingual buprenorphine products on the market.

This study took patients from the previous studies and extended their treatment with this product for twenty-four more weeks, to evaluate the safety of longer-term treatment. As a secondary goal, study subjects were evaluated for their quality of life, opioid cravings, and their addiction severity.

Of the 665 patients who entered this second-stage study, only 44% completed the 24 week extension study. So that’s not great – we would like to see patients retained in treatment. The authors say patients withdrew due to being lost to follow-up, patient nonadherence to medication, and patient request for discontinuation.

But of the 44% of patients who finished the 24 week extension study, improvements were seen in their addiction severity, in their quality of life, in their employment status, and other measures. This means that the rapidly-dissolving buprenorphine tablet was found to be as safe as other similar products on the market, and the benefits of continued treatment persisted throughout this prolonged study period.

The high rate of discontinuation is concerning, but certainly not unusual. In fact, this drop- out rate was similar to studies done on other sublingual buprenorphine products.

I see this at my work. We use both buprenorphine and methadone at the OTP where I work, and drop-out rates are higher for patients on buprenorphine. They tend to bounce in & out of treatment more often than methadone patients do. I believe, but can’t prove, that the milder withdrawal gives patients less incentive to make sure they dose daily.

Patient drop-out is undesirable for all concerned. When a patient drops out of treatment at an MAT, relapse rates are very high, and risk of death may increase as much as eight-fold.

From that point of view, I might be tempted to regard methadone as a superior treatment. However, I know some of our buprenorphine patients would never consider starting methadone, often citing the difficulty of tapering off methadone as the reason. So offering buprenorphine attracts patients who may not enter treatment otherwise.

 

 

Another article in this copy of the journal, titled, “Methadone-Induced Hyperhidrosis Treated with Oxybutynin, by Hong et al., was a case study of a patient with pronounced sweating caused by methadone.

Pronounced sweating from any cause is termed “hyperhidrosis.” All opioids can cause this, including methadone. As the author points out, we think this may be caused by muscarinic receptor activity in the part of the brain that controls body temperature.

This case study is of a patient who stabilized on methadone 100mg for the treatment of his opioid use disorder, but had severe sweating, to the point he had to change clothes multiple times per day. This patient went to his internist, who prescribed oxybutynin, a medication also known under the brand name Ditropan. It’s used for overactive bladder disorders, and works through its anti-muscarinic activity.

The patient had resolution of his excessive sweating within two days, so the treatment was a success in this case.

I think I will start recommending to my patients with excessive sweating see their primary care providers for a trial of oxybutynin.

There are some pitfalls…it can lead to urinary retention, of course, and that’s always vexing when we ask patients to give urine drug screens.

 

 

De-stigmatize the Doctors

 

 

 

 

As our opioid addiction epidemic rumbles on, carrying an avalanche of overdose deaths, people are asking why doctors who are authorized to prescribe buprenorphine are not doing so. Many of these physicians, interested enough to take an eight-hour course in how to prescribe buprenorphine in an office-based setting, don’t implement buprenorphine prescribing into their practices.

My last blog entry was about the obstacles identified by scientific studies as reasons why physicians don’t prescribing buprenorphine for their patients with opioid use disorders.

This blog entry is about my opinion, not about hard data. I think there are unspoken reasons why doctors don’t treat patients with this disease, the biggest being stigma.

Stigma keeps physicians from treating substance use disorders.

Starting in 1914, it was illegal for physicians to prescribe any opioid for the purpose of treating opioid addiction. Doctors went to jail for doing this. Since then, physicians have absorbed the same cultural messages as the rest of the U.S. population: addicts are bad, and doctors who want to treat addicts are probably unscrupulous. It’s difficult to reverse the attitudes of generations of physicians over a few years.

I don’t blame physicians for thinking that way, since I carried that same attitude, until I knew more about medication-assisted treatment for substance use disorders.

Most physicians don’t know about the proven, extensive benefits not only to patients but also to families and communities when addiction is treated. They must be educated, if treatment of substance use disorders is to become mainstream in primary care.

Physicians need to know that addiction medicine is now a recognized medical subspecialty, with a specialized body of knowledge, with specialized training and a board certification exam. Addiction medicine became recognized only last year, long after other specialties like allergy & immunology, preventive medicine, nuclear medicine, and genetics had recognition as specialties. I don’t point out those areas of medicine out to demean them, but to illustrate that substance use disorders affects many more patients and their families than these, yet it took many more years for recognition. I think the reason for the delay was stigma.

Physicians who want to work with patients with substance use disorders need to know they will be supported, not judged, for working in this field. At many conferences, we hear from experts from DHHS, SAMHSA, and CDC about how important it is to recruit good providers to treat patients with substance use disorders. This is helpful and encouraging, but it’s not enough.

I think it’s going to take public statements of support from state licensing boards and professional organizations for office-based treatment of opioid use disorder for physicians to be reassured that they aren’t doing something wrong or shady by treating opioid use disorders with buprenorphine.

Physicians must feel they won’t be under unfair scrutiny because they treat people with opioid use disorder.

Many physicians who might like to treat opioid use disorder with buprenorphine worry about being judged, and feel like they don’t need that kind of stress when there are so many perfectly “normal” patients with chronic disease that they can help. When I talk to them, some of them say things like, “I don’t need the extra hassle,” viewing this type of medical care as more trouble than it’s worth.

Doctors already feel a little wary. Mind you, not twenty years ago, doctors were scolded for under-treatment of pain. We were told to regard pain level as the “fifth vital sign.” We were told the risk of addition from being prescribed opioids for months to years was only about one percent. We were told by pain management experts that due to tolerance, high doses of opioids are often required, and are safe. Physicians were told they should believe what a patient said about their level of pain, and were told they had an obligation to get rid of pain.

Some of that was wrong, as it turns out. Now we know the risk of creating opioid use disorder from long-term prescribing of opioids is somewhere in the range of nine to forty-eight percent. We know that patients on higher doses of opioids are at higher risk for death.

Some doctors now find themselves reprimanded by their licensing boards for over-prescribing opioids. These doctors feel they’ve been prescribing in the exact manner recommended by the so-called pain management experts of fifteen to twenty years ago. Now they are told opioids should rarely be prescribed for chronic non-cancer pain, and that prescribing opioids at high doses isn’t good medical practice.

You can’t fault doctors for being a bit wary about any new attitude or practice that isn’t steeped in medical tradition.

You also can’t fault physicians for worrying about extra regulatory scrutiny when treating substance use disorder because there is some extra scrutiny for physicians who treat substance use disorders.

Yesterday I completed the latest form that I must submit yearly to register with my state’s department of health and human services in order to prescribe buprenorphine. I don’t think any physicians have to do that when prescribing opioids for any other disorder. Physicians with no “X” DEA number who prescribe buprenorphine “for pain,” with a wink and a nod, don’t have to submit this form.

Office-based providers of care for opioid addiction can be inspected by the DEA at any time, and we have to register with the national Department of Human Services every three years. I’m not saying this is wrong, but it is a level of scrutiny not required when physicians use controlled substances to treat other diseases.

Hassles don’t always take the form of licensing boards. Let’s not forget the phone calls from

hostile and uneducated pharmacists.

I respect pharmacists. Most are my allies, and most want to do the best thing for their patients. But I’ve received the nuttiest phone calls from pharmacists about buprenorphine prescriptions. Some pharmacists insisted I tell them exactly how long I planned to prescribe buprenorphine for a particular patient. Others say I have to put a diagnosis code on the prescription. Others won’t fill a half- day early.

My latest weird call was from a CVS pharmacist, who questioned whether my patient actually had opioid use disorder. She was worried the patient was lying to me, since the patient had never filled an opioid prescription before, per data on our state’s prescription monitoring program data.

I told the pharmacist that opioid use disorder can occur with opioids obtained from sources other than prescribed for the patient in question. Sometimes these patients use other people’s medication, or buy it on the black market. Then the pharmacist said she just had to make sure I wasn’t prescribing this buprenorphine product for pain. I said that since I used the “X” DEA number, that confirmed I was prescribing for opioid use disorder, and the “X” number was the only DEA number I wrote on this patient’s prescription.

Then the pharmacist told me I didn’t need to get an attitude with her, and that she was just trying to do her job…

I’m guilty of bad attitudes sometimes, but this wasn’t one of those times. I didn’t have a derisive tone, and was genuinely trying to educate her (so I wouldn’t get another phone call from her in the future asking these same questions). So I think she was the one with a bad attitude, towards me and my patient.

People who treat people with opioid use disorders with MAT sometimes need thick skins, much like the people with the actual disorder.

Dozens of times, when asked by another doctor what kind of medicine I practiced, I’d say “Addiction Medicine” and get a blank look. “What, you treat drug addicts?” would be the doubtful reply. Often the next question is something like, “So are you a real doctor, an M.D.?” and I have to assure them that I am.

One physician in my area tells our shared patients that I’m a legal drug dealer. I’d be tempted to discount one such report, but dozens tell me the same thing about the same doctor, so I tend to believe it’s true. Yet the few times we’ve met face-to-face, this physician says nothing to me. Sometimes I wish he would – it could open a dialogue. I have information he needs.

I’ve been judged very harshly by a few people in the 12-step community. I’ve had ex-patients, for whom I’ve prescribed methadone or buprenorphine, come up to me after they’ve entered 12-step recovery and tell me what an awful thing I did by treating them with medication. On a few occasions, those people returned to my practice to re-enter medication-assisted treatment. I do the right thing, and admit them, but it makes me feel twitchy.

Some physicians have ideas about what people with opioid use disorders are like, and worry they will bring a criminal element in their practice. In fact, recently, when I asked one doctor why he didn’t use his “X” number to treat patients with opioid use disorder, he answered that the first two patients he attempted to treat threatened his life, and he felt it was too dangerous.

I thought to myself that either this was the unluckiest doctor on the planet, or he had a terrible bedside manner. I’ve treated thousands of patients with opioid use disorders over the past fifteen years, and none have threatened my life. (I can’t say the same of my years in primary care. One soccer mom threatened bodily harm when I refused to prescribe a Z-pack for her viral respiratory infection of one day’s duration.)

I love my work because it is so rewarding. Patients actually get better, and some get better really quickly. It’s thrilling to be even a small part of their success. And they are nice people, nearly without exception. I wish I could show other physicians and providers how much fun working with people with substance use disorders can be.

Even considering the occasional hassle from pharmacists and other professionals, it’s worth it. Maybe I do have to fill out a few extra forms every year or so, and I need to be prepared for a DEA inspection at any time. Yet that’s a slight inconvenience when I see the progress my brave patients make.

Last week, a patient I’ve followed for years described his honeymoon to me. He found a well-paying job that he loves, met and married the woman of his dreams, and is working on starting a family. When I asked my usual question about his biggest source of stress, he said, “I don’t have stress. When I look back on how big a mess my life was six years ago, I have nothing at all to stress about now. I’m so blessed.”

That kind of thing makes my day.