Posts Tagged ‘opioid addiction’

The Opioid Summit

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Last week I went to a conference in Statesville, NC, called the Opioid Summit. It was hosted by Partners Training Academy, which is part of Partners Behavioral Health. This is an agency that provides mental health and substance abuse treatment for part of North Carolina.

I did not have extraordinarily high expectations for this conference. I’ve gone to plenty of such conferences around the state. The state-wide meetings are good, and regional meetings are decent, too. But I saw they had Dr. Thomas McLellan as a lunch speaker on the topic of integrating addiction care into mainstream medicine, and I wanted to hear him. Besides, it’s nice to socialize with people in this field I haven’t seen for a while.

My expectations were far exceeded.

We had five breakout groups in session at the same time, and on a whim, I went to the one titled, “Law Enforcement Innovation.” I told my friends I was headed to that one, and they thought it was odd. “Why? You know law enforcement doesn’t like MAT!”

But I knew there had to be a reason he was on the schedule, and I knew the speaker. He and I served on the North Carolina Board of Nursing advisory committee at the same time a few years ago, and I thought he was a pretty good guy, and knowledgeable. He was our state’s SBI Special Agent in Charge of drug diversion crimes back then.

Now he’s retired from the SBI, and is working for NC’s Harm Reduction Coalition, heading their LEAD program in Wilmington, NC. The presentation he made to a room full of social workers, drug addiction counselors, doctors, and policemen and women was excellent.

Mr. Varney explained the Harm Reduction Coalition’s new program in Wilmington, NC, called LEAD, which stands for Law Enforcement Assisted Diversion. This is a pre-arrest program that diverts people caught committing low-level crimes to drug addiction treatment and other services, based on their needs. This shunts them away from incarceration. These people are given a chance to avoid jail time and a criminal record if they want to undergo an evaluation by a case manager. The case manager decides what services are needed, and arranges the referrals. They are directed to drug addiction treatment including MAT, mental health services, housing assistance, food pantries…whatever they need.

Of course, the biggest drug addiction challenging our state and our nation is to opioids. According to Mr. Varney, North Carolina had around thirteen hundred drug overdose deaths last year, and 25% of those were from heroin. He didn’t give a breakdown of how many LEAD participants had opioids as a main drug of use, but it’s likely to be a majority.

Mr. Varney pointed out that it costs taxpayers $65 to incarcerate one person in minimum security for one day. That’s almost $24,000 per year. For comparison, the daily cost of the LEAD program is about $29 per day for the most intensive treatment, but then drops to around $17.50 per day for continuing participation. Most incarcerated people have committed low-level crimes to support drug use and drug addiction. In North Carolina, around eighteen thousand are incarcerated per year.

LEAD differs from drug court because LEAD participation starts before arrest, while drug court monitors people after they plead guilty. Since it’s spear-headed by the Harm Reduction Coalition, the program adheres to harm reduction principles. This program is intended to be non-judgmental and non-coercive, and is intended to offer a way to reduce the harm done to individuals and their community from drug use or drug addiction.

LEAD also differs from other programs because it requires the cooperation, participation, and communication from many organizations. First, law enforcement officers in the field must believe in this program to be willing to talk to the people they encounter in their job. Then, case managers help match each participant with needed resources. Representatives from those resources meet with case managers several times per month to discuss each participant’s progress.

I know what you are thinking…that’s great, but will it allow patients to enter medication-assisted treatment with buprenorphine and methadone? Yes. Mr. Varney specifically identified medication-assisted treatment as a necessary component of this program, particularly since so many of the would-be arrestees have opioid addiction.

Sometimes I hear what I want to hear, and I can’t remember his exact words, but regarding MAT, he said something like, “I’m not here to debate the science of medication-assisted treatment with methadone and buprenorphine but take it from me, it has to be part of this program to help these people.”

It was all I could do to keep from shouting “Hallelujah!”

I was delighted to see a top cop, the ultimate law enforcement officer, endorse treatment with methadone and buprenorphine. I sat in the audience grinning for several minutes.

The program in Wilmington, NC, is just getting started, but similar program in Seattle and Santé Fe have had success with LEAD programs.

Santé Fe had the highest overdose death rate in the nation, and since they started a program similar to LEAD, people who finished a treatment program had markedly less recidivism.

All parties benefit from having LEAD available. The person facing arrest gets an opportunity to get his needs assessed and be connected with needed help, instead of going to jail and getting a criminal record. Police benefit because they turn over an individual to a case manager instead of spending three hours arresting that person. Society benefits because it costs less to treat than incarcerate.

Everyone wins.

Right now, funding is the biggest obstacle to developing programs like LEAD. Hopefully someday, after LEAD has more data to show it works, taxpayer money could be earmarked for similar programs. Right now, funding comes from grants and from the cities that have established these programs.

I am delighted to see such an innovative program start in North Carolina. Since it is operated by the Harm Reduction Coalition, I know it will be well-run. I’m eager to see data from this program after it’s been active a few more years.

And yes, Dr. McLellan’s presentation was excellent, as usual.

 

Case Study of an Opioid-addicted Patient: New England Journal of Medicine

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A doctor friend of mine sent me an article from the New England Journal of Medicine from November 13. 2014. I subscribe to the NEJM, but somehow overlooked this article, so I’m happy he brought it to my attention. My friend reads my blog and knows I have lamented how I was taught in my Internal Medicine residency to treat endocarditis (potentially life-threatening infection of a heart valve), but not the underlying cause, which was addiction (read in my blog post of December 7, 2014).

The journal article he sent me is a case study of a young woman with endocarditis from intravenous drug use. The case study begins in the usual way, describing her history and physical findings. Nothing was uncommon here: the patient told them she was a drug user, and she had track marks, fever, and a heart murmur. The history and physical findings screamed, “Endocarditis! “ A chest x-ray and then chest CT scan showed multiple septic emboli, commonly seen with endocarditis, sealing the diagnosis.

But this case wasn’t only about the diagnosis and standard treatment with antibiotics. To my delight, the first sentence describing the case management was “Methadone was administered orally.”

Huzzah!

But as it turned out, the patient was only put on a methadone taper while hospitalized. She was started on a protracted course of antibiotics and sent to an extended-care facility, where she quickly relapsed. This relapse illustrated the second point of the article: medication-assisted therapy must be continued to be effective.

As the case discussion points out, “As with other medications for chronic diseases, the benefits, at least in the short term, last only while the patient is taking the medication.” In other words, her relapse was predictable, and not due to failure on the part of the patient. The relapse happened because of failure to continue the medication by the doctor.

A little later in the case study I read these wonderful sentences: “Although making a diagnosis of endocarditis is a crucial first step (emphasis mine), understanding the root cause of the endocarditis is a key feature in the diagnosis and management of this patient’s illness. Endocarditis is only a symptom of her primary illness, which is an opioid-use disorder.”

I loved this case presentation for two reasons: it emphasized treating the entire patient, including the underlying disease of addiction, and it pointed out that short-term medication with methadone or buprenorphine doesn’t work, just like temporary treatments for other chronic diseases don’t cure anything.

This patient developed endocarditis again after her relapse, and needed a second hospitalization. This time, she left the hospital on buprenorphine maintenance. She relapsed again after two months, had a third episode of endocarditis, this time due to a fungus, and required a third hospitalization.

After that treatment was over, she was maintained on buprenorphine. At the end of the article, the authors reported that the patient had over a year of abstinence from drug addiction, was taking buprenorphine, and going to AA and NA regularly.

In the discussion of appropriate treatment of both the endocarditis and the opioid addiction, I read this delightful sentence::The opioid agonists methadone and buprenorphine are among the most effective treatments for opioid-use disorder.”

Can I get an “Amen!”?

The same paragraph goes on to describe the benefits seen with MAT, which include decreased opioid use and drug-related hospitalizations, and improved health, quality of life, and social functioning. This article also clearly states MAT will reduce the risk of opioid overdose and death. Many references are cited at the end of the article for non-believers in MAT.

This article also included recommendations about educating patients about overdose risk, and providing them with naloxone.

At the end of the article, the patient who was the subject of this case study discussed her perspectives regarding her treatment. She related how each time in the past, she was treated for whatever medical problem she had, and then sent on her way, with little effort to treat her addiction. She says she’s grateful for the second episode of endocarditis, because she met the doctor who treated the addiction and gave her hope that she had a treatable disease. Prior to that, she doubted she could stop her active addiction, because she saw herself as a bad person, not as a sick person.

This article ends with this patient’s words: “To be honest, I never thought I would be standing here, clean for over a year. I thought that I was going to die.” That effectually describes the hopelessness of patients in active addiction.

I hope such endorsement of medication-assisted treatment of opioid addiction by the prestigious New England Journal of Medicine will help convince more doctors of the legitimacy of MAT.

During my training in the 1980’s, I didn’t learn how to treat the underlying cause of the endocarditis. I am delighted and encouraged to find the New England Journal of Medicine has published an article that does just that. This article clearly and overtly states the importance of treating the real problem, not just symptoms of the problem. Today’s doctors have a valuable opportunity to change the lives of many of their future patients.