Book Review: “The Opioid Epidemic: What Everyone Needs to Know,” by Yngvild Olsen and Joshua Sharfstein

This is The Book. This is the one you need to read for evidence-based information on opioid use disorder, its treatment with medications, and what we can do to address the epidemic.

The prose is lean and easy to understand without talking down to readers. Published by Oxford University Press in 2019, it’s still relatively up to date. It’s a substantial read, at 344 information-packed pages.

I know of one of the authors, Dr. Olsen, from presentations she’s given at national ASAM meetings (American Society of Addiction Medicine). In fact, I just listened to a recorded presentation from spring of 2022 where she was one of the main presenters about how treatment regulations changed both before and after COVID 19. She’s been a leader in the field of Addiction Medicine, holding key positions in both federal and state organizations.

She knows what she’s talking about.

Her co-author, Dr. Sharfstein, is also a standout in the field. He teaches courses at Johns Hopkins’ Bloomberg School of Public Health, giving this book a depth of information not seen in others on the same topic.

The book, written in a question-and-answer format, starts at the first chapter by defining what opioids are and how they work. The authors make clear the difference between addiction and physical dependence, which is so often misunderstood. In that first chapter, the book also answers another common misperception: why using methadone or buprenorphine is not “just replacing one addiction with another.” The authors accomplished this so deftly that I knew the book was a winner.

In the second chapter, they describe how opioids are used for pain, and in the third chapter describe how misuse of opioids can start. Chapter 4 discusses what opioid addiction (opioid use disorder) is.

Chapter 5 covers what opioid overdose is and how it can be treated with naloxone. The authors dispel more myths in the chapter, like the one that says people using opioids will use more if they know naloxone is available to save them.

Chapter 6 does the heavily lifting of describing what is and is not effective treatment for opioid use disorder. The authors do a great job of describing treatment both in office-based practices and at opioid treatment programs. They cover methadone, buprenorphine, and naltrexone. They even touch on use of kratom and ibogaine as purported treatments with little information to recommend their use.

Chapter 7 covers treatment for pregnant patients. I was so happy to see their discouragement of the use of the phrase “addicted babies” as an outdated and improper term. Chapter 8 discusses use of opioids in teens and recommended treatments for this age group.

Chapter 9 focuses on questions that families of people with opioid use disorder often have. The book encourages the families while still warning them that opioid use disorder is a chronic illness. They discuss the term “enabling” and why allowing a family member to “hit rock bottom” may not be the best thing to do.

Chapter 10 talks about the supports people in recovery need, specifically housing and other essentials. They talk some about peer supports as well, and about 12-step meetings and how in some cases, 12-step meetings can be confusing for people new to recovery on MOUD.

Chapter 11 gives the historical perspective of the opioid epidemic in the U.S., going all the way back to just after the Civil War, and up to the age of fentanyl.

Chapters 12 through 16 are possibly the most helpful sections of this book, describing evidence-based policies that can help us in the areas of prevention, treatment, and harm reduction of opioid use disorder. There’s also a chapter about our failed war on drugs, explaining how we could better use law enforcement to help people enter treatment instead of jail.

I found myself in the “Amen!” corner while reading this book, excited to see evidence-based treatment options discussed so eloquently in a book.

I would recommend this book to any person who wants scientific information about opioid use disorder and its treatment. It’s an appropriate book for public health officials on all levels: federal, state, local, counties, etc.

It is as up to date as possible given its 2019 publication date, and I hope this is the first of many editions of this book. Things change quickly in the arena of opioid use disorder and its treatment, so we should be ready for a second edition soon.

Patient Impairment

Ukrainian art from ETSY: Alex Gru

Patients on MOUD (medications for opioid use disorder) need to dose daily for stability unless they are on depot-release forms of such medications such as Sublocade. We encourage patients to dose daily around the same time whether it’s from a take home dose or at our facility. Patients taking consistent and sufficient doses have reduced rates of overdose death, improved mental and physical health, and better employment.

However, sometimes it’s not safe to dose a patient. This can be due to a medical crisis that must be resolved, or due to impairment from sedative medication. It’s relatively rare for patients to arrive at their opioid treatment program with impairment, but it does happen, and physicians and providers need to be prepared for how to handle these events.

Sedatives like benzodiazepine (Xanax, Valium, Klonopin, and the like), alcohol, and other sedatives do not mix well with opioids. Both opioids and sedatives affect the part of the brain that tells us to breathe when we are asleep. People can die from single large doses of opioids, and they can also die if they mix sedatives and opioids. They go to sleep, stop breathing, and die from lack of oxygen to the brain, heart, and other important organs. This can happen quickly, as with a potent dose of fentanyl, or it can take much longer, perhaps hours, with longer-acting sedatives and opioids.

Before the patient gets to the unconscious stage, there’s often a period of impairment, when the patient doesn’t act or sound like their usual alert selves.

Impairment is defined, for these purposes, as a decline in mental function over baseline. Instead of being alert, the patient may be drowsy or inattentive. Instead of having clear speech with appropriate content, the patient may have slurred words, rambling or incoherent speech. There may be loss of control of motor function, leading to unsteady gait, stumbling, or even falling.

Impairment happens on a continuum; at one end a patient can be so impaired that he’s unconscious and needs to be revived with Narcan and CPR. At the other extreme, impairment might be so light that clinicians can’t detect it.

Part of our job at an OTP is to evaluate risks and benefits. If a patient is impaired, the risk of dosing her that day might outweigh the usual benefit of that dose.

Impairment must be evaluated by medical personnel. While receptionists, security guards or counselors can alert medical staff about a potential problem, the medical evaluation must be done by medical personnel.

This evaluation is done by the physicians or physician extenders unless there are none on site. In that case, an RN can gather data and evaluate for impairment. He or she can decide about the safety of dosing or may call the program physician for help with the decision. In our state of North Carolina, the Board of Nursing has said while RNs can work independently, LPNs cannot. LPNs can collect data but then must consult an RN, physician extender or physician to decide about the safety of dosing.

At our opioid treatment program, we take the patient to a private area. We don’t want to embarrass any patient in front of other people. I walk with my patient to my office, observing gait and balance. I try to be friendly and compassionate, realizing that the patient may be feeling fragile.

Once in my office I ask them how they are feeling, and about recent drug use or new medications. I listen to the content of what they tell me and to the delivery of their information. I listen for slurred speech or softening of consonants, speech content, and flow of conversation.

It’s helpful to get vital signs: temperature, blood pressure, heart rate, and respiratory rate. I add a pulse oximetry reading too. If these readings are abnormal, it can indicate a physical health problem as a cause of impairment. This can be serious and requires immediate medical investigation, usually at the local emergency department.

After talking to the patient, I turn to my computer and take my time typing data. While I do this, I watch the patient too. If she nods or falls asleep during conversational lulls, it’s probably not safe to dose her.

We have several tests we can ask the patient to do to test for motor impairment from sedatives. There’s the tandem gait test, which is what policemen do when they ask motorists to walk in a straight line. There’s the finger to nose test where the patient extends both arms, closes their eyes and brings the index finger to touch their nose.

My favorite is to ask my patient to stand on one foot for thirty seconds. It’s easy to do and I do it with them, so they won’t feel so put on the spot. Most people wobble a little but can keep their balance without touching down with the free foot or reaching for furniture.

We can also look for nystagmus of the eyes. This simple test, often misinterpreted by non-medical people, involves asking the patient to look to their extreme left or right. Then the examiner watches for slight bouncing of the eyes back and forth as the subject tries to keep their eyes in the extreme lateral position. Normal people can have one or two beats of nystagmus, but patients who have taken sedatives such as alcohol or benzodiazepines will have continued movement of their eyes.

Medical providers must remember that some medical crises can look like impairment from sedatives. A few months ago, a patient checked for impairment had a blood pressure of around 70/40 with an irregular heart rate into the 150’s, obviously in atrial fibrillation. We called the ambulance to take him to the hospital and he ultimately recovered.

Patients who are deemed to be impaired by medical providers often say they didn’t get any sleep the night before. This may be true, but lack of sleep shouldn’t cause slurred speech or problems with balance, unless they’ve been without sleep for days, in which case they probably need to go home and sleep before they get their next dose anyway.

It’s difficult for me to tell a patient they can’t be dosed that day. I know it will upset them and make them angry. I just keep trying to tell them that I’m refusing to dose them due to safety concerns, and that I’d rather they be angry with me but still alive.

Medical providers should expect a great deal of anger and should not take it personally.

We also try to get a urine sample for drug testing, thought that test won’t tell us if the patient is impaired. A urine drug screen only tells us if a given drug has been used in the recent past. Patients can be impaired with a negative drug and can be alert and fine to dose with a drug screen positive for multiple things.

Alcohol breath testing is the only drug where levels correlate with blood levels. Depending on the alcohol breath test, we can determine if the patient is under the influence of alcohol or not. The legal limit is .08, but patients on MOUD may be impaired at a much lower alcohol level, due to alcohol/drug interaction. We don’t dose patients if alcohol is detected.

After determining a patient to be too impaired to dose, I ask for help from the patient’s counselor. We must find a way to get them home without allowing the patient to drive. In big cities, public transportation takes care of this, but in our rural community, everyone drives everywhere because there is no public transportation. This can be difficult.

Also, we want to get permission to call a friend or family member to stay with our patient to watch them. We want to educate this person to call 911 if the patient becomes unresponsive and can’t be wakened, and make sure they know how to use Narcan, while waiting for EMS.

Anytime a patient can’t be dosed due to impairment, the physician must meet with the patient the next day, or as soon as possible. Impairment might be a warning that the patient has so little control over drug use that an inpatient treatment setting is indicated, at least temporarily.

Above all, it’s important to encourage the patient and let them know we care about what happens to them. We remind them part of our job is to make treatment as safe as possible. More than that needs to wait until the patient is clear and not impaired.

As I said in the beginning of this blog, impairment events are rare. Most of our patients never have such an episode. But when we do have a patient with impairment, we must be ready to intervene with compassion and good judgment about what is in the patient’s best interest.

My Hopeless Patient

 

 

(Details have been changed to protect patient identity)

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

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

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

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

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

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

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

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

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

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

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

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

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

I saw what he meant.

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

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

I do get that. Even at the best OTPs, byzantine rules frustrate patients.

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

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

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

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

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

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

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

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

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

He gradually transformed into a productive member of society.

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

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

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

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

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

Who Should NOT Be in Medication-Assisted Therapy with either Methadone or Buprenorphine?

I spend much time and effort explaining how medication-assisted treatment for opioid addiction works for many addicts. It occurred to me that I should explain who isn’t a good candidate for such treatment.

I enthusiastically support medication-assisted treatment (MAT) of opioid addiction, but no treatment works for everyone. MAT doesn’t work for every opioid addict. Here are some reasons a patient may not be suitable for MAT:

1. The patient isn’t addicted to opioids. That seems obvious, but occasionally I encounter an addict who wants to be started on methadone even though he’s not addicted to opioids. Rarely, an addict using cocaine, benzodiazepines or other drugs will come to the OTP after they have heard how well it worked for other (opioid) addicts. After I explain that buprenorphine (Suboxone) and methadone only work on opioid addiction, some of these patients have become angry.

One patient accused me of discriminating against her because of the type of drug she used. I said yes, but only because methadone doesn’t treat cocaine addiction. (I tried to refer her for more appropriate treatment.)

2. The patient takes opioids for pain, but has never developed the disease of addiction.
Such a patient may be physically dependent, but lacks the hallmark indicators of addiction, such as misuse of medication, obsession and compulsion regarding opioids.

Opioid treatment programs, (OTPs) have stringent regulations put on them by both federal and state government, because OTPs are designed to treat patients with addiction. These patients have lost the ability to control their intake of opioids, so the OTP regulates a maintenance dose of either methadone or buprenorphine to keep the patient out of withdrawal and able to function normally.

If a patient has only pain and no addiction, there’s no reason to enroll in an opioid treatment program, because patients without addiction are still able to take opioid medication as prescribed. Pain medication can be prescribed by any doctor with a DEA license.

Opioid treatment programs aren’t intended to treat chronic pain, but if a patient with both addiction and chronic pain finds methadone also helps with pain, it’s a nice benefit. Many of these patients do find they have less pain once they’re out of the miserable cycle of intoxication and withdrawal. So less pain is a happy side effect of addiction treatment.

3. The opioid addict presenting for treatment has been physically dependent for less than one year.
Methadone is difficult to get off of, and federal and state regulations say it cannot be prescribed for opioid addicts with less than one year of addiction (daily use or near daily use). This is a somewhat arbitrary cut off, and the OTP physician can ask for an exception to this regulation if needed. Even if the OTP wants to treat the patient with buprenorphine (Suboxone), which is usually much easier to taper off of than methadone, permission must be sought from state and federal authorities before enrolling a patient who has used opioids less than one year.

If buprenorphine is prescribed in the office setting, the prescribing physician can use her best judgment about who is appropriate for treatment, without needing government approval.

4. The opioid addict has the ability to go to a prolonged inpatient residential treatment program for his addiction.
This is controversial, because some doctors think medication-assisted treatment should be given to everyone because of its success rate compared to abstinence-only treatments.

But who gets the best of medical treatment in our country? Possibly it is medical professionals like doctors and dentists, airline pilots, politicians, and celebrities. They usually get the gold standard of treatment for whatever disease ails them.

If such people have opioid addiction, they are treated with inpatient medical detox, using buprenorphine to ease withdrawal, followed immediately with prolonged inpatient residential drug addiction treatment. I know doctors and dentists who spent six to nine months in treatment. After treatment, they must sign monitoring contracts with their licensing boards in able to go back to work. These contracts usually involve a mandated number of group sessions per week and random drug testing. With this kind of support and accountability, these medical professionals have excellent outcomes. Studies show that more than 80% are still off all drugs and alcohol at five years after entering treatment.

If only everyone could get that kind of treatment!

If this kind of treatment is available to the addict…take advantage of it. But most opioid addicts can’t access this kind of treatment, with post-treatment accountability. Insurance companies might pay for a one-week stay in detox, which won’t help. Even if the addict gets a few weeks of inpatient treatment, it’s usually not enough. What I’m talking about is months of quality inpatient treatment.

5. An opioid addict who is also physically addicted to alcohol, benzodiazepines or other sedatives. These drugs can be deadly when mixed with methadone or buprenorphine. I prefer such patients enter a medical detox unit to get off these sedatives prior to entering treatment in an OTP.

Of course this is a complex issue, and there may be times when starting methadone or buprenorphine can be done, perhaps keeping the patient at a relatively low dose, while the patient undergoes a gradual taper from benzos. The OTP physician should be free to use her best judgment about how to treat these complex and high-risk patients.

6. The opioid addict also has acute, severe mental illness. An actively suicidal patient is too sick for an outpatient opioid treatment program. So is an acutely psychotic patient who is having hallucinations and delusions. These patients often can’t to understand what is real and what isn’t. Ideally these patients need inpatient treatment at a facility that will treat both mental illness and addiction. Sadly, it’s getting ever harder to find such facilities for patients who need them.

7. A patient has behavior that interferes with treatment.
OTPs have an obligation to all their patients to maintain a safe and orderly treatment environment. Patients who start physical fights, threaten staff or other patients, or sell drugs shouldn’t be kept in treatment. I know that sounds harsh, but OTPs have a hard enough time maintaining good standing in their communities without having to face accusations about illegal behavior on premises.

Patients need to be emotionally stable enough to conduct themselves in a non-threatening manner to be able to remain in treatment. Some patients, after being counseled about acceptable behavior, are able to comply with requests for behavioral changes. Some patients have erratic behavior due to mental illness, and shouldn’t be blamed, but their behavior still may be too disruptive for the OTP setting.

8. The patient has serious co-existing physical health problems.
Actually, I can’t think of any physical health problem that would make the treatment of opioid addiction with methadone riskier to the patient than untreated opioid addiction. We know for sure that untreated opioid addiction produces high risk of death and disability.

Issues like severe lung disease and specific heart rhythm problems do increase the risk of medication-assisted treatment, especially with methadone. I try to contact the patient’s other doctors and consult with them before the patient goes above a low dose of methadone.

Ideally, I’d like to talk to the other doctors on the day of admission, before methadone is started, but that can’t always be done. With the time pressures doctors are under, it’s getting ever harder to claim some of their time for a patient consultation.

Some of these patients could be started on buprenorphine instead of methadone, which is safer with these health conditions, and has fewer medication interactions.

9. The patient has transportation difficulties.
Some patients can’t get a ride to their treatment program every day, which interferes with delivery of quality treatment. With buprenorphine, federal requirements for daily dosing were lifted, but states still have varying regulations. With methadone, the patient must come for treatment daily. During the first two weeks of stabilization, it’s important for medical personnel to be able to evaluate the patient every day, to assess the effects of dose increases.

10. A patient who enters treatment expecting to be completely drug free in the near future.
I try to make sure patients entering treatment with methadone or buprenorphine understand that I am not switching them from illicit opioids to these medications because tapering off of them is easier. Particularly with methadone, it is not. But both methadone and buprenorphine are so long-acting, they can be dosed once per day, giving the patient a steady level of opioids. This allows the addict to function normally, without withdrawal or impairment, once the dose has stabilized.

Both medications give the opioid addict time to regain physical and mental health. Once on a stable dose, the recovering addict can make changes in his life, with the help of counselors and other OTP workers. The addict can get back to work, stop a life of crime, form better relationships with his family and himself, and recover a better quality of life.

Will that addict ever do well off methadone? There’s no way to be sure about this. Some patients can taper off methadone, as long as they address all of their issues prior to the taper, and if they bring the dose down slowly enough that they don’t feel intolerable withdrawal. Some, perhaps most, recovering addicts find they will do better if they stay on methadone.

All this is to say that the goal of entering an opioid treatment program isn’t necessarily to
get off the treatment medication.

So if a patient seeks to enter methadone treatment but also expresses a desire to be off buprenorphine or methadone within weeks to months, I tell them their expectations aren’t realistic. These medications don’t work like that. If the patient wants to get off all medications quickly, they need referral to an inpatient program. This way, patients can’t later say they were mislead, and they feel like they have liquid handcuffs, chained forever to methadone, with its many regulations for treatment.

Urine Drug Screens for methadone and Suboxone (buprenorphine)

Many patients who are prescribed methadone or buprenorphine (better known to some as Suboxone) are concerned about their employment drug screens. Because of the stigma attached to opioid addiction and its treatment with methadone or buprenorphine, patients don’t want their employers to know about these medications, and thus about their history of addiction.

Most companies who do urine drug screening hire a Medical Review Officer (MRO), who is a doctor specifically trained to interpret drug screen results. This doctor is a middle man between the employer and the employee, and though this doctor may ask for medical information, and information about valid prescriptions, this doctor usually can’t tell the employer this personal information. The MRO reports the screen as positive or negative, depending on information given to her.

Most employment urine drug screens check for opiates, meaning naturally-occurring substances from the opium poppy, like codeine and morphine. Man-made opioids like methadone, buprenorphine, and fentanyl, to name a few, won’t show as opiates on these drug screens.

A few employers do drug screening that specifically checks for hydrocodone or oxycodone. This is infrequent. It’s rare for employers to screen for methadone, and they almost never screen for buprenorphine, unless the patient is a healthcare professional being monitored by a licensing agency. The screen for buprenorphine is pricey, so the only doctors who tend to screen for it regularly are the ones prescribing buprenorphine. These doctors want to make sure their patients are taking, not selling, their medication.

Patients ask if they should tell their employer they are on methadone or buprenorphine. In general, that’s probably a bad idea, unless it’s a special situation. So long as you can do your job safely, your medical problems aren’t any of your boss’s business.

The only exceptions to this are if you work in a “safety sensitive” job. This includes medical professionals, transit workers, pilots, and the like. These jobs may require disclosure of medical issues to protect public safety. For example, to get a commercial driver’s license (CDL), you have to be free from illnesses which may cause a sudden loss of consciousness behind the wheel.

The Dept. of Transportation still says that if you are taking methadone for the treatment of addiction, you can’t be granted a CDL. However, most of the studies done on methadone-maintained patients shows their reflexes are the same as a person not on methadone, so there’s no real scientific reason for the DOT’s decision. (1, 3, 4) Besides, since the urine drug screen for a driver’s physical doesn’t include methadone, they won’t know unless you tell them.

Patients can be impaired, and unable to drive safely, if they have just started on methadone, haven’t become accustomed to it, or are on too high a dose. These patients shouldn’t be behind the wheel until they are stable, even in a car, let alone an 18-wheeler. Methadone patients are likely be impaired and unable to drive if they abuse benzodiazepines. They shouldn’t drive any kind of vehicle. Ditto for alcohol. (2, 5)

1. Baewert A, Gombas W, Schindler S, et.al., Influence of peak and trough levels of opioid maintenance therapy on driving aptitude, European Addiction Research 2007, 13(3),127-135. This study shows that methadone patients aren’t impaired at either peak or trough levels of methadone.

2. Bernard JP, Morland J et. al. Methadone and impairment in apprehended drivers. Addiction 2009; 104(3) 457-464. This is a study of 635 people who were apprehended for impaired driving who were found to have methadone in their system. Of the 635, only 10 had only methadone in their system. The degree of impairment didn’t correlate with methadone blood levels. Most people on methadone who had impaired driving were using more than just methadone.

3.Cheser G, Lemon J, Gomel M, Murphy G; Are the driving-related skills of clients in a methadone program affected by methadone? National Drug and Alcohol Research Centre, University of New South Wales, 30 Goodhope St., Paddington NSW 2010, Australia. This study compared results of skill performance tests and concluded that methadone clients aren’t impaired in their ability to perform complex tasks.

4.Dittert S, Naber D, Soyka M., Methadone substitution and ability to drive. Results of an experimental study. Nervenartz 1999; 70: 457-462. Patients on methadone substitution therapy did not show impaired driving ability.

5.Lenne MG, Dietze P, Rumbold GR, et.al. The effects of the opioid pharmacotherapies methadone, LAAM and buprenorphine, alone and in combination with alcohol on simulated driving. Drug Alcohol Dependence 2003; 72(3):271-278. This study found driving reaction times of patients on methadone and buprenorphine don’t differ significantly from non-medicated drivers; however, adding even a small amount of alcohol (.05%) did cause impairment.

Suboxone, the “Miracle” Drug

The patient quoted in the Suboxone success story, printed in this blog over the last few days, obviously has a healthy recovery on buprenorphine, and plans to continue his present recovery program. He goes regularly to Narcotics Anonymous meetings, has a sponsor, works the twelve steps of recovery, and contributes to NA by sponsoring people and doing other service work. He had such a good outcome, because he didn’t neglect the psychological aspect of his recovery, even after Suboxone took away the physical withdrawal symptoms.

For the patients I treat with buprenorphine, the most challenging part is coaxing, coercing, and cajoling patients to get some sort of counseling. Whether they go to an individual counselor, pastoral counselor, or to 12-step meetings doesn’t matter to me. I’d love to be able to send them to local intensive outpatient treatment centers, but as will be discussed later, most of these centers require the patient be off buprenorphine completely, before they can enter treatment, which can create a curious circle of relapse. Fortunately, I know good counselors, knowledgeable about addiction and its treatments, willing to see my buprenorphine patients. They markedly benefit from this individual counseling, though group settings can give patients insights they won’t get any other way.

When buprenorphine was first released, the addiction treatment community and opioid addicts had very high hopes for this medication. Many patients say, “It’s a miracle,” on their second visit, after they‘ve started the medication. Most patients are surprised they don’t feel high, and don’t have any withdrawal symptoms.

However, it’s really not a miracle drug. It’s still an opioid, and though it’s weaker than other opioids, some patients have extreme difficulty when they try to taper off of this medication. One can read postings on internet message boards that describe the difficulty some patients have.

In my own practice, I’ve had some patients who stopped buprenorphine suddenly, and claim they had no opioid withdrawal symptoms. At the other extreme, I’ve had patients who wean to Suboxone one milligram per day and say they get a terrible withdrawal, if they go a day without even this one milligram. I’ve had many patients who gradually cut their dose on their own, until they take the medication every other day, and gradually stop it.

Patients appear to differ widely in their abilities to taper off buprenorphine. Some patients are dismayed to discover it’s just as hard to taper off of Suboxone, and stay off opioids, as it is to taper off methadone and stay off opioids.

If it’s appropriate to consider tapering a patient off of buprenorphine, best results are seen if the taper is done slowly. In the past, I have informed patients who wished to taper completely off buprenorphine that addiction counseling improves outcomes, and reduces relapse rates, but this may not be true.

Information presented at the American Psychiatric Association’s 2010 conference calls that advice into question. In a study of over six hundred prescription opioid addicts, relapse rates were remarkably high when patients were tapered over the course of one month, after two months of stabilization. (2) The addition of fairly intensive addiction counseling didn’t improve relapse rates. In the treatment as usual group, prescription opioid addicts met weekly with their doctors, and after their taper, ninety-three percent had relapsed within four weeks. Even in the group getting doctor visits plus twice- weekly one hour counseling sessions, ninety-four percent relapsed within the first four weeks after buprenorphine was tapered. This was the largest study done so far, specifically on prescription opioid addicts, as opposed to heroin addicts. The overall message from initial results of this study seems to be that adding fairly intense drug counseling doesn’t improve patient outcomes, if the buprenorphine is tapered off within the first three to four months.

Once a patient is on buprenorphine and doing well, he or she often becomes very reluctant to participate in counseling, or even 12-step meetings. Once patients feel physically back to normal, they begin to minimize the severity of their addiction, and don’t think they need any counseling.

Some patients admit they need counseling, but say they can’t afford it. This is a valid excuse, because counseling sessions can cost around a hundred dollars each. Private counselors usually like to see their patients weekly, so that’s an additional four hundred dollars per month that patients need to pay. Even patients with insurance are allowed only a limited number of sessions. Those without insurance have great difficulty affording counselor fees on top of all the other expenses, like doctors’ visits, drug screens, and medication. Patients have fewer valid excuses for not participating in Narcotics Anonymous or Alcoholics Anonymous, since they’re free, and located in nearly every city or town. I have more patients who will go to these meetings.

1. Amass L, Bickel WK, “A preliminary investigation of outcome following gradual or rapid buprenorphine detoxification” Journal of Addictive Disease, 1994; 13:33-45.
2. Weiss RD, The American Psychiatric Association 2010 Annual Meeting: Symposium 36, presentation 4. Information from the National Drug Abuse Treatment Clinical Trials Network Prescription Opioid Addiction Treatment Study, May 23, 2010, New Orleans, LA.

Suboxone Patient’s Success Story, continued

XYZ:My brother had enough faith in me that it was worth the risk of starting this business [that he has now] together. I spent hours setting up a company in a ten foot by twenty foot room above my house. My wife and I started on EBay, making and selling [his product], and slowly grew it to the point that, three years later, I’m going to do over two million dollars in sales this year, I’ve got [large company] as a client, I’ve got [large company] as a client, I’m doing stuff locally, in the community now, and can actually give things back to the community.
JB: And you employ people in recovery?
XYZ: Oh, yeah. I employ other addicts I know I can trust. I’ve helped some people out who have been very, very successful and have stayed clean, and I’ve helped some people out who came and went, but at the same time, I gave them a chance. You can only do so much for somebody. They have to kind of want to do it themselves too, right?
JB: Have you ever had any bad experiences in the rooms of Narcotics Anonymous, as far as being on Suboxone, or do you just not talk to anybody about it?
XYZ: To be honest, I don’t broadcast it, obviously, and the only other people I would talk to about it would be somebody else who was an opioid addict, who was struggling, who was in utter misery. The whole withdrawal process…not only does it take a little while, but all that depression, the body [feels bad]. So I’ve shared with those I’ve known fairly well. I share my experience with them. I won’t necessarily tell people I don’t know well that I’m taking buprenorphine, but I will let them know about the medication. Even though the information is on the internet, a lot of it is contradictory.
It’s been great [speaking of Suboxone] for someone like me, who’s been able to put a life back together in recovery. I’d tell anybody, who’s even considering taking Suboxone, if they’re a true opioid pill addict, (I don’t know about heroin, I haven’t been there), once you get to the right level [meaning dose], it took away all of that withdrawal. And if you combine it with going to meetings, you’ll fix your head at the same time. Really. I didn’t have a job, unemployable, my family was…for a white collar guy, I was about as low as I could go, without being on the street.
Fortunately I came from a family that probably wouldn’t let that happen, at that point, but who knows, down the road… I had gotten to my low. And that’s about it, that’s about as much as I could have taken.
It [Suboxone] truly and honestly gave me my entire life back, because it took that away.
JB: What do you say to treatment centers that say, if you’re still taking methadone or Suboxone, you’re not in “real” recovery? What would you say to those people?
XYZ: To me, I look at taking Suboxone like I look at taking high blood pressure medicine, OK? It’s not mind altering, it’s not giving me a buzz, it’s not making…it’s simply fixing something I broke in my body, by abusing the hell out of it, by taking all those pain pills.
I know it’s hard for an average person, who thinks about addicts, “You did it to yourself, too bad, you shouldn’t have done that in the first place,” to be open minded. But you would think the treatment centers, by now, have seen enough damage that people have done to themselves to say, “Here’s something that we have proof that works…..”
I function normally. I get up early in the morning. I have a relationship with my wife now, after all of this, and she trusts me again. Financially, I’ve fixed all my problems, and have gotten better. I have a relationship with my kids. My wife and I were talking about it the other day. If I had to do it all over again, would I do it the way I did it? And the answer is, absolutely yes. As much as it sucked and as bad as it was, I would have still been a nine to five drone out there in corporate America, and never had the chance to do what I do. I go to work…this is dressy for me [indicating that he’s dressed in shorts and a tee shirt]
JB: So life is better now than it was before the addiction?
XYZ: It really is. Tenfold! I’m home for my kids. I wouldn’t have had the courage to have left a hundred thousand dollar a year job to start up a tee-shirt business. I had to do something. Fortunately, I was feeling good enough because of it [Suboxone], to work really hard at it, like I would have if I started it as a kid. At forty years old, to go out and do something like that…
JB: Like a second career.
XYZ: It’s almost like two lives for me. And if you’re happy, nothing else matters. I would have been a miserable, full time manager, out there working for other people and reaping the benefits for them and getting my little paycheck every week and traveling, and not seeing my wife and kids, and not living as well as I do now.
I joke, and say that I work part time now, because when I don’t want to work, I don’t have to work. And when I want to work, I do work. And there are weeks that I do a lot. But then, on Saturday, we’re going to the beach. I rented a beach house Monday through Saturday, with just me and my wife and our two kids. I can spend all my time with them. I could never have taken a vacation with them like that before.
JB: Do you have anything you’d like to tell the people who make drug addiction treatment policy decisions in this nation? Anything you want them to know?
XYZ: I think it’s a really good thing they increased the amount of patients you [meaning doctors prescribing Suboxone] can take on. I’d tell the people who make the laws to find out from the doctors…how did you come up with the one hundred patient limit? What should that number be? And get it to that number, so it could help more people. And if there’s a way to get it cheaper, because the average person can’t afford it.
The main thing I’d tell them is I know it works. I’m pretty proud of what I’ve achieved. And I wouldn’t have been able to do that, had I not had the help of Suboxone. It took me a little while to get over thinking it was a crutch. But at this point, knowing that I’ve got everybody in my corner, they’re understanding what’s going on…it’s a non-issue. It’s like I said, it’s like getting up and taking a high blood pressure medicine.