Posts Tagged ‘opioid treatment program’

Naloxone in Action


At the recent American Society of Addiction Medicine (ASAM) conference, I read a poster describing a study entitled “Lives Saved with Take-home Naloxone for Patients in Medication Assisted Treatment.” The article, by Katzman et al., from the University of New Mexico School of Medicine, described the outcomes from providing naloxone overdose reversal kits to patients enrolling in medication-assisted treatment of opioid use disorders

The study subjects were admitted to medication-assisted treatment over three months in 2016. The poster didn’t say whether they started buprenorphine, naltrexone, or methadone, but I’m guessing the patients were admitted to methadone maintenance.

In the end, 244 subjects enrolled and had education about opioid overdose and how to use a naloxone auto injector kit.

Twenty-nine subjects were lost to follow up, leaving 215 subjects available for inclusion in the study. Of these 215 subjects, 184 didn’t witness or experience overdose.

That means 31 subjects either experienced or witnessed at least one opioid overdose episode.

The scientists conducting the study interviewed these 31 subjects, and discovered that 39 opioid overdoses had been reversed and all of those lives were saved. Thirty-eight people were saved with the naloxone kits distributed by the opioid treatment program, and one study subject was revived by EMS personnel.

When study authors looked at who was saved by these study subjects, they discovered 11% of people saved were acquaintances of the study subjects, 16% were family members, 58% were friends, 6% were the significant others of study subjects, and 13% were strangers.

The study authors concluded that “a significant number of lives can be saved by using take-home naloxone for patients treated in MAT [medication assisted treatment] programs.” The authors also felt the study showed that naloxone isn’t usually on the patient who entered treatment, but more frequently on friends, relatives, and acquaintances that the MAT patient encounters.

I was intrigued by this study because it mirrors what I’ve heard in the opioid treatment program where I work. We are fortunate to get naloxone kits from Project Lazarus to give to our patients. It’s rare that one of our patients enrolled in treatment needs naloxone for an overdose, but much more frequently, I hear our patients say they used their kit to save another person’s life.

If anyone doubted the abilities of people with opioid use disorders, and felt they couldn’t learn to give naloxone effectively, this study should put that idea to rest. If anyone mistaken thought people with opioid use disorders wouldn’t care enough about other people to put forth an effort to save another person, this study should put that idea to rest, too.

In fact, I’ve seen a real enthusiasm among our patients to make sure they have a kit, in case they get the opportunity to save a life. They are eager to help other people, and I find that to be an admirable attitude that’s nearly universal among the people we treat.

Sometimes I get into discussions with patients about what they think about the naloxone kits, and where they think the kits can do the most good. I’ve heard some good ideas. One patient said every fast food restaurant should have a naloxone kit, since she knew many people with opioid use disorder inject in the bathrooms of these facilities. Actually, I just an online article discussing something similar: http://www.wbur.org/commonhealth/2017/04/03/public-bathrooms-opioids  

This article expresses the problems that injection drug use has become for public restrooms, and makes a case for safe injection centers. This is presently illegal in the U.S.

Even Massachusetts General Hospital armed its security guards with naloxone kits, so they could give this life-saving medication to people they found who had overdosed in the hospital’s public bathrooms.

Another patient suggested giving naloxone kits to people living in trailer parks.

I know that feeds into a kind of stereotype of those who live in trailer parks, but apparently there is some basis for saying such residential areas have high density of people with opioid use disorders. It’s worth looking at.

Several patients said that all people receiving opioid prescriptions for chronic pain should also be prescribed naloxone kits, and I think that’s been recommended by many health organizations too.

Most communities have at least talked about arming law enforcement and first responders with naloxone kits, and hopefully that’s a trend that will continue to spread.

Naloxone isn’t a permanent solution for opioid use disorder, but it can keep the people alive until they can enter opioid use disorder treatment. Because dead addicts don’t recover.

 

You Can Find My Office Next to the Restroom

bathroom break

Warning: this is one of those fluffy entries, not much substances, lots of musings…

A few weeks ago, I ushered a new patient to my office for her initial history and physical. Once in my office, she looked around and said, “Wow, they don’t think much of you, do they?” At first I was puzzled, but then figured out she meant that my office is small and undesirably positioned right next to the patients’ restroom. It’s not furnished lavishly, only with the essentials: desk, exam table, and two chairs. I also have a file cabinet containing some species of records.

Perhaps in the business world, one’s value to a company is reflected in the lavishness of one’s office. It is not like that in the doctor world, or at least not in the doctor world I inhabit. I don’t think about the size of my office, the location, or the furnishings. As long as I have everything I need to do my job, I don’t care or even notice other amenities. But some of the patients notice.

I’ve had some patients ask how I can stand the smell. On intake days, with eight or so new patients in varying stages of opioid withdrawal, my office can sometimes take on a certain redolence from the restroom next door.

It doesn’t bother me. I became immune to bad odors in 1985, roughly when I started my clinical rotations in medical school. By the time I got to my residency program, any sense of smell I still had was burnt out during my two-month rotation through the emergency department. I’ve been exposed to massive burdens of every type of stench emitted from the human body. As a result, I reflexively start mouth-breathing in the presence of unpleasant smells. It’s automatic.

I’ve worked for five opioid treatment program companies, in fifteen separate facilities. In many of them, the doctor’s office was next to the restroom, but I’m sure that’s just coincidence.

The worst was in an old building shaped like a “U”, with the pharmacy in the center. My office was at one end of the “u” and directly across from…you guessed it…the patient bathroom. That wasn’t the worst thing, though. Unfortunately my office had an inch and a half gap between the floor and the wall, and it appeared to be a major thoroughfare for bug travel. It was not uncommon for a roach to emerge from the gap, waving antennae like he was a pageant queen.

I usually had my back to this area, so the patients would be the first to see the invader. Almost without exception, the male patients would jump to their feet and stomp the intruder into bug heaven. I would smile and say, “Thank you, my dragon slayer.” We would share a laugh and get back to business.

Why are the physicians’ offices less luxurious in the opioid treatment programs than the rest of the doctor world? I think for the same reason some OTPs are in run-down buildings in the worst part of town. The stigma against medication-assisted treatment makes it more difficult to get regular medical office space. For all I know, maybe only the buggiest places were rentable. It’s also possible that some opioid treatment programs don’t think it’s worth spending money for a nice facility.

Doctors’ offices at OTPs may tend to be shabby because doctors aren’t in the opioid treatment program every day. Obviously, the counselors who are there every day should get the nicest offices because they will be using them more hours per week. Often when the facilities are cramped for space, the program doctor has to share an office with one or more other people. I know where I work now, two or three other people work in my office when they need space. As a result, a variety of detritus comes and goes.

One day a patient asked, “Are those your shoes under the exam table?” I didn’t have to look up. I knew he meant the pair of espadrilles that appeared one day without any explanation. I said “No, I don’t know whose those are.” He looked at me oddly, as if that were a strange answer, so I told him, “That’s nothing; there are other random things. I just don’t ask anymore.” One day my office was filled with balloons, and on another day, with hot dog buns.

The shoes were gone a month or so later, as quietly as they had appeared.

At my other program, my office is so small that literally we have to ask the patient to leave the room so that we can wheel in the EKG machine, then come back in. It is very cramped, but what I really mind is the heat. This OTP is in the mountains, but as cold as it may be outside, it’s always summer in my office.

This office has no vents and no overhead lights. When I complained about the lack of proper lighting, the program manager brought in floor lamps. One gives a puny little light, and the other throws enough heat to keep French fries warm. I have to remember to dress for summer even in the middle of winter.

It would be easy to take shabby offices personally, but I don’t think that’s generally what is behind it. OTPs take a more utilitarian approach towards facilities than other branches of medicine. I think OTPs get so used to being the red-headed stepchild that they forget to take pride in their surroundings.

Having nice facilities may not feel like a high priority, but it should be. We need to provide space as nice as other medical offices. We provide an intensely important service, with literally decades of data to support what we do for patients. Maybe our surroundings should reflect the importance of what we do, and the significance of what we do.