Posts Tagged ‘opioid addiction treatment’

Mandated Training?


 

 

 

 

It looks like 2017 is going to be the year of governmental solutions to the opioid use disorder problem.

I blogged last week about the regulation passed by the Virginia Board of Medicine. Now there’s a proposed bill making its way through the NC legislature, advocating new laws to help solve the addiction problem. Legislators certainly have their hearts in the right place. I agree with many parts of the proposed bill.

But now, I’d like to suggest a new regulation: ask all doctors to take an eight-hour course on opioid use disorder and its treatment with medication-assisted treatments, as a prerequisite to renewing their licenses.

I can hear my colleagues already howling with indignation. I’d feel the same way if I were them. It’s hard to admit you don’t have the education you need in an area of medicine. But this specialized area of medicine powerfully influences nearly all other subspecialties of medicine, so the consequences of neglecting the disease of addiction can be enormous.

Before I listen to my fellow physicians’ protests, I’d like to give examples, from my own community, of some things medical providers have done with patients prescribed opioids, and with patients who have opioid use disorder. I believe they all could have been handled better. Patient details have been changed to protect identities.

Example number one:

One of my patients needed to have surgery on his lumbar spine. He went to see the orthopedic specialist and was told he had to taper off methadone before the procedure could be done. I asked my patient why the doctor told him this, and the patient said he didn’t know. The patient said he was also told he couldn’t be “allowed” to have any pain medicine after he left the hospital after this surgery.

I’ve had other doctors in my area tell patients the same thing. One local weight loss surgeon tells patients they have to come off their evidence-based treatments (methadone or buprenorphine) for their potentially fatal medical illness (opioid use disorder) before he will agree to do any sort of gastric bypass weight loss surgery.

I was eager to have a discussion with my patient’s orthopedic surgeon, but my patient told me not to bother. He said he wasn’t going back to that surgeon anyway, and planned to get a second opinion at a nearby teaching hospital. I told him I thought this was a very good idea, though I was disappointed I couldn’t talk to the orthopedic surgeon. I was actually looking forward to that conversation. Probably the maniacal gleam in my eye made my patient tell me not to call.

Example number two:

Several weeks ago, I saw a new patient who was seeking admission to our opioid treatment program after being kicked out of a pain clinic. “Tim” (not his real name) had been going to several different pain clinics for years, and had been misusing his medication for at least two years. He was snorting oxycodone, around 150mg per day, and failed a pill count done by his pain medicine physician. His pain management doctor dismissed him from the practice, citing a “zero tolerance,” with no referral or further help. His friends told him about our treatment program, so he came for admission.

Tim was offered a choice between methadone and buprenorphine as treatment medications. He was so vehemently opposed to buprenorphine that it made me curious. He said that buprenorphine made him so sick, he nearly died.

I had already looked at his information on the prescription monitoring program, and saw that a few months ago, the physician assistant at his pain clinic prescribed Belbuca, along with relatively high doses of the usual immediate and extended release hydromorphone. This had piqued my interest.

Belbuca is a form of buprenorphine that’s approved for the treatment of pain. We don’t use it to treat addiction because it doesn’t have FDA approval for that purpose, and therefore isn’t covered by the DATA 2000 law.

Obviously this physician’s assistant who prescribed Belbucca failed to realize it would precipitate withdrawal in this patient who had been on full opioids for months.

I asked him to describe what happened after he took the first Belbucca. He said he felt like he had immediate onset of intense nausea and repeated vomiting so bad that he called EMS to take him to the hospital. He said he thought he was dying.

It doesn’t sound like anyone who saw the patient at the hospital told my patient his reaction was completely predictable.

I tried to explain to my patient that he may not get sick with buprenorphine if it were prescribed properly, but he was having none of it. That was OK, because methadone is still a great treatment for his opioid use disorder.

Example number three:

Some patients at our opioid treatment program stabilize on buprenorphine and then transfer to an office-based setting for care in a less restrictive setting. These patients have done well for months, so we wish them well, send their requested records, and encourage them to continue getting counseling in some form.

However, for some reason, some pain clinics take these patients off buprenorphine and start short-acting opioids. I’ve blogged about this problem before, dismayed at the predictable return of their opioid use disorder. They fail pill counts, and then get kicked out of treatment, having been set up to fail by their provider.

Now, things are getting weirder.

One patient, who did well for seven months at our opioid treatment program, transferred to a local office-based buprenorphine program. She did well for a few months, until she was switched to immediate and extended-release hydromorphone, which had been her drug of choice when she was in active addiction.

This patient predictably lost control of how she was taking this hydromorphone, started injecting it, and failed a pill count. Her doctor then told her she must go for an assessment at a substance abuse treatment facility in order to continue being prescribed hydromorphone.

Ummm…here’s the thing…she was started on buprenorphine in the first place because she had an opioid use disorder.

I’m not saying every patient with opioid use disorder immediately loses control of their medication if they’re prescribed opioids. But after less than a year of recovery from severe, intravenous opioid use disorder, you don’t have to be psychic to predict this would happen. Handing this patient a bottle of her drug of choice with a thirty-day supply triggered a relapse back to intravenous drug use.

Example number four:

I’ve saved the craziest for last. This example is tragic, both because of the bad patient outcome, and because so many doctors dropped the ball on this patient.

The patient, who developed opioid use disorder during treatment of chronic pain syndrome, developed severe mid-back pain. He told the emergency room doctor that he had been injecting the pain pills prescribed to him by a local pain medicine practice, and the emergency department physician noted track marks on his arms.

The patient had a limited work up and was sent home with a diagnosis of non-specific back pain and referred back to his pain clinic. The patient, miserable with intense and severe pain very unlike his chronic pain, returned to that hospital’s emergency department three more times. On the next to the last time, he says he was told that the doctor would not see him because he was a pain medication seeker.

Several days later, on his last visit to the emergency department, the patient was nearly comatose, with a high fever and labs indicating sepsis, and overwhelming blood infection. The patient was immediately admitted to the hospital and started on a range on antibiotics, but failed to improve. His relative demanded transfer to the local teaching hospital, an hour away.

Upon arrival at the teaching hospital, this 44 year -old man was diagnosed with a spinal abscess that extended from the neck all the way to the end of the spinal cord. This infection had obviously started at the area of his intense back pain. His spinal cord was being bathed in pus rather than spinal fluid.

He was not expected to live.

He was taken to the operating room, where the infection was drained and washed away, and dead tissue removed. Against all odds, the patient survived, though he was a quadriplegic when he woke up after surgery.

After being treated with antibiotics for many weeks, he was sent to a physical rehabilitation hospital for months. Eventually, he regained some strength in his arms and legs, and against all odds, improved to the point he could feed himself, and could walk with great difficulty, with two canes. He was eventually released from the physical rehabilitation hospital.

Eight months since his last appointment, he went back to his pain clinic. The doctor resumed prescribing the same medications that the patient had been misusing.

Wait a minute, you will say. Surely that doctor wasn’t told about the whole IV use, spinal abscess, quadriplegia thing, right? Wrong. Records show he did know.

The patient, after trying very hard not to inject these medications, finally came to our opioid treatment program, and asked for help. He was referred to us not by our local hospital’s physicians, not by anyone at the teaching hospital, not by social workers at that hospital, not by the physical rehabilitation hospital, and not by his pain management doctor.

His friends, in treatment at our OTP for their opioid use disorder, and told him to come to us for help.

He was started on sublingual buprenorphine and has done beautifully.

One day, after he’d been on a stable dose of buprenorphine for a few weeks, I asked him what he thought when his pain management doctor offered to put her back on hydromorphone. He said, “I was surprised. I didn’t think it was a good idea, but I was in pain and in withdrawal, so I just took the prescription.”

I understood. After all his time in the hospital, this patient hadn’t had any treatment for the disease of opioid use disorder. He’d only had treatment of the sequellae of opioid use disorder.

At that time, saving his life was the most important thing. But later, why not address the original disease that caused this million-dollar hospital treatment admission? Why not direct the patient to treatment of his opioid use disorder when released from the hospital and/or physical rehab facility? Why not pause for more than a moment before writing a prescription for the same drug that caused the whole mess?

 

All physicians make mistakes, usually out of ignorance, and I’m no different. But now, the opioid addiction problem is so bad that each state is passing laws to fix the problem. Isn’t it worth passing a law that makes sure all physicians are part of the solution?

At a minimum, let’s teach all doctors that substance use disorders are diseases, and that we do have treatments available. Some treatments work better than others, and medication-assisted treatment of opioid use disorder works very well. In fact, there’s more evidence to support MAT than anything they are doing in their practices. Why not refer patients with problems rather than shaming and ignoring them?

Let’s teach physicians that failure to diagnose and refer patients with substance use disorder for appropriate treatment is malpractice, just as it is for all other medical problems.

 

 

Access to Buprenorphine Will Expand; News About CARA

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Last week, the Department of Health and Human Services (HHS) announced it was raising the limit on the number of patients each doctor can treat for opioid use disorder with buprenorphine, from the present cap of 100 patients to 275 patients. However, each doctor must first meet criteria and complete an application procedure to be approved for this higher limit.

Initially, HHS wanted to increase the limit to 200 but for some reason ended up with 275. It’s still an arbitrary number, and opioid use disorder remains the only disease to have patient enrollment limits legislated for physicians.

HHS still wants physicians to meet extra requirements before they are approved to accept 275 patients, as I blogged about in my May 8, 2016 post:

  • Have professional coverage for after-hours emergencies.
  • Provide case management services
  • Use electronic medical records
  • Must use that practitioner’s state prescription monitoring program
  • Accept third-party insurance
  • Have a plan to address possible diversion of prescribed buprenorphine medication
  • Re-apply for permission to treat up to 275 patients every three years
  • Supply yearly reports about their practice and their buprenorphine patients

For some of the reasons I names in my May 8th blog, at this time I’m not planning to request permission to treat more than 100 patients.

This measure by HHS is a good and positive thing, and will help more desperate people get treatment. Just because I have a few objections to several HSS’s requirements doesn’t mean other doctors will feel the same way. I expect many physicians treating opioid use disorder will undergo the procedure to expand their patient limit.

 

Meanwhile, both the House of Representatives and the Senate passed the Comprehensive Addiction and Recovery Act (CARA) as of last week, and the bill is going before the President for his signature.

This bill, considered weak by some members of the House, contained only a fraction of the requested money to treat addiction. However, other advocates for addiction treatment say even a weak bill is better than none.

CARA’s content addresses the following:

Expand availability of naloxone to law enforcement and first responders, in order to quickly reverse opioid overdoses and prevent deaths. I think our own Project Lazarus helped get this ball rolling many years ago, and I’m so grateful my OTP has had support from them to give our patients naloxone kits!

Expand education and prevention efforts toward teens, parents, and aging people to prevent drug abuse and promote treatment and recovery.

Encourage states to improve their prescription monitoring systems. I hope some of that money will be directed to interoperability, meaning it will be easier to access a neighboring state’s prescription monitoring program. I also hope the Veteran’s administration will start reporting their data about prescribed controlled substances, too.

Prohibit the Department of Education from rejecting financial aid for people who have had past drug offences. I didn’t know people with drug offences on their record were denied governmental financial aid. If we want people to improve themselves and their life situations, why would we deny help for them? So this measure in CARA is great.

Expand resources to identify and treat incarcerated people with substance use disorders using evidence-based treatments.

Great idea, about forty years late.

Expand drug disposal sites to keep leftover meds out of the hands of children.

Just a question I’ve always had…Of all the tons of medication which have been collected at these disposal sites, has anyone ever studied how much controlled substances are collected?

Launch a “medication assisted treatment and intervention demonstration program.”

Not sure exactly what this will look like, but good luck with all of that.

I feel like I’ve beaten my head against the brick wall of prejudice and stigma against MAT in my community for four years. All I have is a headache…and resentment towards the medical community. I’d be very happy if someone else wants to take over for a while.

Launch a program to promote evidence-based treatment of opioid use disorder.

Well, yeah. it needs to happen. Actually it needed to happen about fifteen years ago, but whatever.

Director money towards law enforcement, to get people with substance use disorders help, rather than incarceration. CARA wants law enforcement to be able to work with addiction treatment services.

I indulged a private snicker at that last one. What a change from only a few years ago.

About six years ago, I was trying to educate people about medication-assisted treatment of opioid addiction. I thought I could help educate law enforcement personnel about addiction treatment, since they encounter it so much. I used the internet to find a journal for law enforcement.

I wrote to the editor, offering to write an educational article for their publication about opioid addiction treatment. My hopes weren’t especially high, but I wanted to give it a shot.

I was surprised when the journal’s editor took the time to call me in person. I was so excited!

Then the editor started talking to me like I was a naughty child. He asked what made me think it was appropriate to waste his time with such a query letter. He said I should have known better than to think any of his readers would be interested in the kind of thing I was offering to write, and he was calling to see what kind of person would be so unwise as to think otherwise.

I was stunned. I regret my reaction to him. I was so taken aback that I started apologizing to him, and said I was so sorry for bothering him and wasting his time.

In reality, he behaved like an asshole. If he didn’t want to waste time, he could have passed on the urge to call me to tell me how stupid he thought I was.

I wish I would have stuck up for myself in that conversation. I like to think I would handle it differently today.

Anyway, now, six years later, the government earmarked money to help law enforcement learn about opioid use disorder treatment.

While writing this article, I’ve come to realize I have bitterness towards people in law enforcement, medical fields, judicial, etc…when they denigrated my efforts to educate them about medication-assisted treatment for opioid use disorder.

I don’t want this bitterness. It’s too hard on me. It’s a weight that interferes with my enjoyment of life, and I’m going to release it.

The tide has begun to turn. We have legislation addressing the terrible opioid addiction problem we have, and money earmarked to help the problem. I want to be able to work with people who may have said bad things about medication-assisted treatment of opioid use disorders in the past. I want to work with those people without feeling resentment and without indulging in sarcasm.

Conference

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I just got back from the yearly American Society of Addiction Medicine conference. As always, it was a treat. It’s so refreshing to be surrounding by other physicians who know addiction is a treatable illness and not a moral shortcoming. I feel revitalized from being around people who also love treating people with substance use disorders, and who also love seeing people get well and get back to being themselves.

This conference was huge. Over 1800 people attended. When I went to my first ASAM meeting in 2004, I think there were around 300 attendees. What a difference!

This year, I sensed even more hopefulness and enthusiasm than in past years. Last month, Addiction Medicine was finally recognized as a legitimate specialty of medicine. Finally, we got recognition that we have a substantial body of science with data that supports the work we do.

Recently, there’s more conversation about treating people with opioid addiction. We see television shows, online articles, and blog posts about the opioid addiction epidemic and the death toll it’s exacting on our nation. Even President Obama recently emphasized the importance of treating people with opioid addiction, and the obligation of incorporating medication-assisted treatment. More federal and state grants are available to start programs to help people with substance use disorders.

All of these recent changes encouraged me, but the speakers at the ASAM conference pushed my enthusiasm further.

On the first session of the first day, Dr. Nora Volkow, director of NIDA (National Institute on Drug Abuse), spoke. She was her usual brilliant self, giving a concise summary of this nation’s present opioid addiction situation. She discussed many of the same studies I’ve highlighted in my blog over this past year, so I felt good about that.

Next to speak was Dr. William Miller, the “father” of Motivational Interviewing. His lecture, titled “The Power of Empathy in Addiction Treatment,” was a gift. It reminded me of why I love what I do, and how I can continue to improve as a clinician.

I also went to his ninety-minute session about the basics of Motivational Interviewing. I’ve read all three editions of his book, “Motivational Interviewing,” and I’ve seen videos of therapists using MI as a counseling technique. Motivational Interviewing is an evidence-based method of counseling people in order to help them change.

MI sounds much easier than it is. It also looks easy when I watch other people do it, but it’s much more difficult than it looks. Fortunately, my fiancé is a “MINTee,” meaning he’s one of the Motivational Interviewing Network of Trainers for Motivational Interviewing. I figure that can’t help but rub off on me. Plus, he helps train the counselors at our local opioid treatment program. In my obviously biased opinion, he’s helped our counselors become much better at their jobs, which ultimately benefits our patients.

I went to many other ASAM sessions – from a lecture on contingency management techniques to a discussion about buprenorphine doses above 16mg. All were excellent. Even though it’s impossible to attend all the sessions, since many times there were four of five going on at the same time in different rooms, I plan to listen to the recordings of them all on ASAM’s website when they become available.

And I will return to work a better, more enthusiastic doctor.

 

Update

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Last week, I told my readers about a letter I sent to my local newspaper, trying to explain the usefulness of methadone (and buprenorphine) treatment for opioid addiction. Happily, my entire letter was published in our local paper under the heading of “Guest Columnist.”

I was elated, especially since this piece of writing was on a topic about which I’m passionate.

I checked Friday’s paper to see if anyone had responded to my column. There were no replies, but there was another article in that issue, titled, “Task Force Targets Schools.”

This article was about the meeting of a drug abuse task force formed earlier this year by local people. Before you ask, yes, this is in the same county where Project Lazarus, founded in 2008 in response to high drug overdose death rates, has its headquarters. And no, I do not know why people in this new task force feel the need to re-invent the wheel, particularly in an area where the prior inventors of the wheel have had such success and nationwide praise. Indeed, many other areas of the country have copied the Project Lazarus model of addressing the multifactorial causes and contributors of addiction

Anyway, I don’t know the motivations of this new task force. Interestingly, this quote was found early in the article: “Education and dissemination of information appears to be the greatest way the task force can make a difference.” This was said one of the co-chairmen of the organization. This quote was in the context of providing information to youths to prevent drug use and drug addiction.

I sure as hell wish that statement also applied to facts around treatment of addiction.

At some point, methadone apparently became the topic of discussion, which was a shame, because task force members sound like they don’t know anything about methadone. I wish they would have read my guest column two days prior!

Here’s a quote from the paper from one of the task force members: “From the way I understand it, the methadone clinics are not weaning these people off methadone. They’re going for treatments and they’re just going and going and going,” According to the article, he also said that state government should be involved in requiring plans that give people certain amounts of time to be off methadone and then with helping them.

Then the co-chair of the task force, a law enforcement trainer at the local community college, said methadone clinics are supposed to have personalized plans for people who come in for treatment. “It doesn’t appear that those plans are followed exactly the way they should be,” he added. “It’s a business model.”

I’m not sure what qualifies this man to know how long methadone should be prescribed for the purposes of treating opioid addiction. He’s not a doctor.

Then another person in the task force said the goal is for a person going to one of the clinics to be off methadone in a year, “but that doesn’t happen…. It’s a business.” She said only a small percentage kick their addictions.

Who is this second person? She is – wait for it – a Licensed Clinical Addiction Specialist. She works for a program where we have referred patients in the past.

As all my readers know, I am a calm and patient person who never takes things personally (yeah that’s sarcasm). Even more fortunately, I’m not the litigious type, because when someone says at a public forum that the local methadone clinic keeps patients on methadone because it’s a business model, that’s a defamatory statement. That implies I prescribe methadone to make money and not to help patients. This statement attacks my character as the medical director of that program, and cast dispersions on my professional integrity.

Drug addiction treatment should be about science, not opinion.

I know the right thing to do, the grown-up thing to do… call task force members and politely offer to educate them about MAT.

I’ll get there. But right now, I’m not ready to be a grown up.

Celebrity Overdose Deaths

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Recently, the overdose death of a beloved celebrity restarted discussion of addiction treatment in the mainstream media. I have mixed feelings about such discussions.

On the one hand, I don’t think it’s appropriate for outsiders to comment on whether the celebrity got the best available treatment. It feels reckless for someone to say he should have had this treatment or that, without being privy to the personal medical history of the celebrity. Those details can make a big difference in deciding the most appropriate treatment. Of course in hindsight we can say the treatment chosen didn’t work… but as I’m painfully aware, even the best evidence-based treatments can have disastrous outcomes in individual patients.

On the other hand, celebrity deaths can focus the public on pertinent addiction issues facing society. For example, the death of 1980’s basketball star Len Bias helped change public perception about the risks of cocaine use. Mr. Bias, the second overall draft pick of the NBA in 1986, was the picture of physical health. When this young man died of a cardiac arrhythmia from cocaine use, people stopped looking at cocaine as a harmless party drug. There was a shift to a more realistic view of cocaine as a potentially addictive drug that can cause serious medical problems, including death, even in young healthy people. It’s possible Len Bias’s death, untimely and tragic, saved some number of young people from experimenting and becoming addicted to cocaine.

I am thankful that some light is being shed on the treatment of opioid addiction, even though the cause of this examination is due to a celebrity death. Perhaps something good can come of tragedy.

Realistically, are opioid addicts, including celebrities, being told of all evidence-based treatments for the disease? I don’t have facts or figures, but I’m confident the answer is a resounding “No.”. Most Minnesota model, 12-step based inpatient drug rehabs still discourage patients with opioid addiction from considering methadone or buprenorphine, even though medical evidence proves such treatments to be the most successful. Is this ethical? I don’t think so.

In a recent article from Alcoholism & Drug Abuse Weekly (Feb 10, 2014) on this same topic, even the deputy director of the White House Office of National Drug Control Policy Michael Botticelli says, “For people with opioid dependence, MAT should be the standard of care.”

So how are Minnesota Model facilities, opposed to MAT, able to maintain accreditation if they don’t inform patients of all evidence-based treatments? It’s unethical. Our first obligation is to do the right thing by our patients, based on scientific data.

This wouldn’t be allowed in any other field of medicine.