Posts Tagged ‘opioid addiction’

Comorbidity and a Sad Update


 

 

In 2011, I posted the following blog entry, and described an example of a patient from my office-based practice to illustrate:

Addicted patients are twice as likely as non-addicted patients to have mental illnesses such as mood disorders, anxiety disorders, schizophrenia, and attention-deficit hyperactivity disorder. The converse is also true: patients with mental illness diagnoses are twice as likely to have an addictive illness in addition to their mental illness.

Why is this? Is there a common factor underlying both types of disorders? Does one cause the other? For years, doctors and therapists have argued about this, and there are still no definite answers. However, why these diseases occur together isn’t as important to me as how to treat them most effectively.

We know patients get the best results when both diseases are treated at the same time, preferably under the same roof. That’s not always easy, but it’s the ideal.

To further complicate treatment, many times drug addiction causes the same symptoms as mental illness. For example, a person intoxicated on methamphetamine can look just like someone in the manic phase of bipolar disorder, or even schizophrenia. Another example can be seen in heavy drinkers, who are often depressed from the effects of alcohol, which is a depressant.

I rely on several methods to help me decide if drug use, abuse, or addiction is mimicking mental illness. First, I try to get information about what a patient was like during periods of abstinence from all drugs. If all of the mental illness symptoms went away during abstinence, it’s less likely that there’s an underlying mental illness. However, if the patient was still suffering with significant symptoms of mental illness even during a period of abstinence from drugs, the patient probably has a second diagnosis.

I ask about family history of mental illness, because if relatives have been diagnosed with these disorders, it’s more likely that the patient I’m treating will have mental illness in addition to addiction.

I ask my patient which started first, the symptoms of mental disorder or drug use? Often, symptoms of mental illness and drug use both started around the same time, at late adolescence/early adulthood, so that history often isn’t as helpful as I’d like.

Here’s an example of a case I saw recently: (identifying details have been changed):

A 24 year old female saw me in my office as a new patient. She wanted to be considered for my Suboxone program. She gave a history of illicit drug use for four years, and had used opioids daily for a year and a half, snorting up to 200mg of hydrocodone or oxycodone per day. She used marijuana three times a week, usually two cigarettes per day. She denied use of benzodiazepines or alcohol, and said her father was an alcoholic. She used cocaine heavily in the past, but stopped using it three years ago because of its expense. Besides, by that time, she preferred opioids. She acknowledged recent use of methamphetamine three or four days ago, and said she snorted methamphetamine when she couldn’t find any opioids, only to stave off withdrawal. Her answers about frequency and amount of methamphetamine used were vague and evasive, so I was unsure of her exact history.

When I asked about her mood, she said she was depressed because of all the bad things that were happening as a result of her addiction: she was broke, her boyfriend just broke up with her (he was her drug-using buddy) and her family wasn’t loaning her any money, so she was in withdrawal much of the time. She denied any period of abstinence from drugs since she started using drugs at age 15. Family history was significant for a maternal aunt with severe bipolar disorder, requiring psychiatric hospitalization on multiple occasions.

Her exam was worrisome for a very low body weight. At 5’6” she weighed 103lbs. (she denied any symptoms of eating disorders) She was tense, pleasant, intelligent, and well-spoken. She fidgeted in her chair to an extreme amount. She was in florid opioid withdrawal, with wide pupils that were briskly reactive, obvious runny nose, frequent yawning, sweating, and goose bumps visible on her upper arms.

Her mother, who paid for her treatment, came to the appointment with her. My patient gave me permission to talk with her mother, who had quite a bit to add to the story. Mom said her daughter often seemed paranoid, and last weekend she stayed awake all night on Saturday, peering out one window after another, and checking repeatedly to make sure they were locked. My patient’s weird behavior kept the family awake all night. My patient also claimed to be able to hear people talking just outside the windows, and was sure the government meant to take her from her family for a nefarious reason. The patient’s mother said this last weekend was the most severe paranoid behavior she had seen in her daughter, but she had seen similar conduct in the past.

At this point, I thought there was a good chance we were dealing with more than just addiction. I considered bipolar disorder with psychotic features to be the most likely diagnosis, or schizophrenia. I hoped her use of methamphetamine had caused these worrisome symptoms, since she shouldn’t have them once she stopped use of the drug and got out of opioid withdrawal.

With this new information, I changed my treatment recommendation, and thought an inpatient admission to a detoxification unit was most appropriate. Her psychiatric status could be closely observed, and she could be started on Suboxone. If the psychotic features resolved, great. If not, she could be started on appropriate medications, be stabilized and then come see me after she was discharged. I could maintain her on Suboxone after she was stabilized.

It was a great idea, but unworkable. The detoxification unit wanted a chunk of money up front, before admission, and she didn’t have that kind of money. It was also beyond her mother’s financial capability. This patient had no insurance and didn’t qualify for Medicaid.

The patient pleaded with me to start on Suboxone. She believed all would be well if only she could get out of opioid withdrawal. I had my doubts, but agreed to prescribe one week of medication with telephone contact. Her mother agreed to call me or take her daughter to the psychiatric emergency room if her mood or behavior deteriorated.

One week later, a calm, smiling young lady entered my office. She had gained seven pounds in one week, and was no longer restless. The change was remarkable. Her mom came with her and said she hadn’t seen any more paranoid behavior. Her mother started to cry, saying, “I have my daughter back.” I was thrilled at the improvement. I adjusted her Suboxone dose slightly, and made sure she had her first session with the addiction counselor in my office.

I’ve seen her every week for the past month. She goes to three Narcotics Anonymous meetings per week, which is fewer than I’d like, but at least she’s going. She’s met with the licensed addiction counselor in my office each week. She’s had negative urine drug screens for the past three weeks and continues to gain weight. She says her mood is good, and she just went back to work.

For now, I don’t see evidence on mental disorder, but I’ll keep watching for problems.

I have a sad update.

After about two years of doing extremely well in my office-based practice, this patient relapsed. She was taking Suboxone 8mg per day, and appeared to be enjoying a good recovery. She went to 12-step meetings, got a sponsor, worked the 12 steps of recovery, and did service work at her home group.

She also had some sessions with the therapist who works in my office, who is MINT certified and has LPC and LCAS certification. After the first six months, she didn’t see a need for this service, and I didn’t push the issue, since she appeared to be doing so well.

After nearly two years of recovery, she missed an office visit, without calling to re-schedule. When she came the next week, she was positive for opioids on her urine drug screen.

We talked about her relapse extensively. She said she was upset one day, and had taken a few pain pills her mom had around the house.

We talked about what this meant. She already talked to her sponsor and had picked up a white chip at her 12-step meeting. We talked about how relapse is often a part of a person’s recovery. Since she was fortunate enough to survive it, we needed to examine her relapse process in detail, to learn from it.

I was unsettled, since I thought she had been doing great. I could tell she was unsettled too, and I made her next visit in one week instead of our usual one month.

She missed that visit, and I was really worried.

When she did make it in to my office a few weeks later, she falsified her urine drug screen. I told her I was really worried, because that was so unlike her. She admitted to relapsing back to heavy pain pill use.

We discussed treatment options. I wanted her to go to an inpatient program, to become re-stabilized, and then come back into treatment with me. We also discussed transferring her temporarily to an opioid treatment program, where she can go each day to be dosed, and where there’s more accountability.

She refused both of these options, saying she couldn’t miss work, and both would interfere with her work schedule. She was sure she could pull herself out of this relapse, if only I would give her another chance.

She kept her appointment a week later, but she was still illicit opioids. She said she was filling my Suboxone prescription, but only used it if she couldn’t find anything else. She had stopped going to 12-step meetings. Her mom came with her to this visit, and I asked if we could include her mom in her session. My patient not only refused to allow her mom to be a part of the conversation about treatment options, she also revoked the release for me to disclose anything to her mom.

I told my patient it was no longer safe to treat her in an office-based setting. I gave her one more week’s prescription and told her she had one week to decide what option she preferred: inpatient medical detoxification followed by inpatient residential treatment, or transfer to an opioid treatment program. I gave her the number and address of the OTP, where I knew she could continue on buprenorphine while she regained her stability.

I never spoke to her again.

She didn’t keep her next appointment. Three weeks after this missed appointment, she went to an opioid treatment center (not the one I’d recommended), which only used methadone. After she took her first day’s dose, she took a handful of Xanax and died in her sleep that night.

I thought about those last sessions multiple times, and wished I’d handled them differently. I think I believed her when she said she could stop using heroin on her own, since she had done so well while in recovery. Surely, I thought, she doesn’t want to stay stuck in active addiction any longer. Surely she has the tools to get back on the right path.

But this is a deadly disease. Even two years of joyful recovery didn’t save this patient in the long run.

I’m sorry to end on such a somber thought. However, I need to remember the stakes are so very high for our patients, and all relapses are serious.

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The Difference a Day Can Make

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News about the cause of Prince’s death was released last week. According to numerous news reports, he died from an overdose of a synthetic opioid called fentanyl, an opioid so potent that it’s measured in micrograms instead of milligrams.

This is the same drug that anesthesiologists and anesthetists get addicted to. It’s such a powerful drug that often the deceased is found with the needle still in his arm.

News stories don’t say how Prince took the medication, only that it was self-administered and that it killed him. Reports didn’t say whether it was prescribed for him or obtained illicitly.

I came of age in the 1980’s and like so many of my friends, loved Prince’s music. He was such a great musician that he managed to remain creative long after the 80’s were done, however.

I remember seeing the clip of Monica Lewinsky hugging President Clinton, and wondering if she chose her hat after listening to his “Raspberry Beret.” I was in recovery from addiction myself by the time New Year’s Eve, 1999 rolled around, so it was one of best New Year’s I’ve ever had. I remembered it, for one thing, and remember listening to the song that night, of course, while we were bracing for the Y2K apocalypse that never came.

Prince had been treated from chronic hip and leg pain, and probably developed addiction as a complication of that treatment. In that regard, he is just like so many of my patients. They never intended to become addicted. Prince, as a Jehovah’s Witness, would theoretically be at lower risk for addiction than many people, since he didn’t drink alcohol or use illicit drugs. But like so many other people, he appears to have developed addiction during the treatment of pain.

Saddest of all the information I read in news reports is that Prince had an appointment with an addiction medicine doctor the day after his death, to get help with his opioid addiction. By now, it’s well-known that Dr. Kornfield, an addictionologist in California, sent his son with a Suboxone film intended for Prince, but by the time the son arrived, Prince was dead. Prince supposedly had an appointment with a Minnesota addiction medicine doctor the next morning.

One day later, he could have had the help he needed. This underlines the seriousness of the opioid use disorder.

If you have this disease, learn from Prince. Anyone can develop the disease of addiction, even a musical genius. So get help now. Tomorrow may be too late.

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.

Which is better, Suboxone or methadone?

 

Patients often ask which medication is better to treat opioid addiction: methadone or Suboxone? My answer is…it depends.

 First of all, the active drug in Suboxone is buprenorphine, and I’ll refer to the drug by its generic name, since a generic has entered the market. We’re no longer just talking about one name brand.

 The principle behind both methadone and buprenorphine is the same: both are long-acting opioids, meaning they can be dosed once per day. At the proper dose, both medications will keep an opioid addict out of withdrawal for 24 hours or more. This means instead of having to find pain pills or heroin to swallow, snort, or shoot three or four times per day, the addict only has to take one dose of medication. Addicts can get back to a normal lifestyle relatively quickly on either of these medications. Both methadone and buprenorphine are approved by the FDA for the treatment of opioid addiction, and are the only opioids approved for this purpose.

Buprenorphine is safer then methadone, since it’s only a partial opioid. A partial opioid attaches to the opioid receptors in the brain, but only partially activates them. In contrast, methadone attaches to opioid receptors and fully stimulates them, making it a stronger opioid. Because buprenorphine is a partial opioid, it has a ceiling on its opioid effects. Once the dose is raised to around 24mg, more of the medication won’t have any additional effect, due to this ceiling. But with methadone, the full opioid, the higher the dose, the more opioid effect.

 Because buprenorphine is a safer medication, the government allows it to be prescribed in doctors’ offices, but only if the doctor has taken a special training course in opioid addiction and how to prescribe buprenorphine, or can demonstrate experience with the drug. This office-based treatment of addiction has a huge advantage over treatment at a traditional methadone clinic. Treatment in a doctor’s office doesn’t have to follow the strict governmental regulations that a methadone clinic must follow. Methadone clinics have federal, state, and even local regulations they must follow, and patients have to come to the clinic every day for dosing, until a period of months, when take home doses can be started for weekends.

 The law allowing buprenorphine to be prescribed for opioid addicts from offices instead of clinics was passed in 2000. It was hoped that relatively stable opioid addicts would get treatment at doctors’ offices, and addicts with higher severity of addiction would still be treated at methadone clinics.

 But it hasn’t worked out quite like that. Because buprenorphine is relatively much more expensive than methadone, addicts with insurance or money go to buprenorphine doctors’ offices, and poor addicts without insurance go to methadone clinics. Rather than form of treatment being decided by severity of disease, it’s decided by economic circumstance. This means that some of the opioid addicts being treated through doctors’ offices really aren’t that stable, and have been selling their medication, making it a desirable black market drug. Most of the addicts buying illicit buprenorphine have been trying to avoid withdrawal or trying the drug before paying the expense of starting it.

 Treating opioid addicts for the last nine years, I’m continually surprised at how people’s physical reactions to replacement medications are dissimilar. Some patients don’t feel well on buprenorphine, but feel normal on methadone. For other patients, it’s just the opposite. For many, either medication works well.

 Addicts (and their doctors) tend to assume that all opioid addicts will be the same in their physical reactions to these replacement medications, but they aren’t. For example, last week I saw a lady who insisted she’s never had physical withdrawal symptoms from methadone. But most patients find methadone withdrawal to be the worst of all opioids.

 And sometimes I have a patient I expect will do very well on buprenorphine, but they don’t. they feel lousy.

 So the answer to question of which medication is best – buprenorphine is safer, and not as strong an opioid, so it’s the preferred medication. It’s also more convenient, but much more expensive at present. But a great deal depends on the patient, and how she reacts to medications.

 Neither medication is meant to be the only treatment for opioid addiction. Best results are seen when these medications are used along with counseling, to help the addict make necessary life changes.