Posts Tagged ‘opioid treatment programs’

What I Do With My Day

Dr. Cat

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Some of my friends and family still don’t understand what I do for a living. When I was working in primary care, they understood. Now that I work with patients with substance use disorders, they are unsure. I tell them I do the same thing I’ve always done: I take care of sick people.

“Yeah, but they’re not sick sick, right? Not like people who usually go to the doctor.”

“Um, sometimes they are.”

For them and anyone else who wonders what an addiction medicine doctor does all day, this blog entry is a summary of a recent workday at the opioid treatment program where I work.

This was a Wednesday, which I dedicate to established patients. On Wednesdays, I talk to patients who are established in treatment about numerous issues, including adequacy of their dose, other medical problems, new medications, and other things. I also do yearly history and physical exams on patients who have been with us for a while.

In the following, I have changed the patients’ characteristics to protect their identity, while still conveying the essence of our interaction.

My first patient has been with us for several years and has done very well. She was seeing me for her yearly exam. First, I asked about her if her dose was still working well for her, and she said yes. She has been on methadone 105mg for more than a year, and her drug screens have been positive only for only methadone and its metabolites, since shortly after her admission.

This is a nice quality of methadone. Most patients don’t develop a tolerance to the anti-withdrawal effects of their dose, allowing them to remain comfortable on the same dose for months or even years. Other patients have fluctuations in their dose requirements, for assorted reasons: changes in other medical problems, changes of other medications, or changes in activity level, to list a few.

My patient looked at her picture on our electronic record, taken at her intake nearly two years ago. “I hate that picture! It looks awful. Can I get a new picture?”

“Sure, just ask the receptionist or your counselor. You do look different now. You look like that person’s younger, happier sister. But maybe it’s good to keep that old picture, at least in your mind, to remind you what opioid use disorder took from you – your joy.”

We proceeded with her history and physical, and at the end, I told her I thought her biggest health issue was smoking cigarettes. She was now abstinent from illicit drugs for nearly two years, but was still smoking nearly a pack and a half per day. I asked her if she had considered trying to quit. She said she would like to quit but wasn’t yet ready to try. I told her I thought she could quit, because she was doing so well in her recovery already. I asked her if it would be OK for me to ask her about smoking cessation in the future, and she said yes.

It’s important to hit the right tone with patients on this issue. I don’t want to pressure her and demand she try to stop smoking right now, because – of course – that approach doesn’t usually lead to behavioral change. Instead, I wanted her to think about why quitting smoking would be best for her, and to support her efforts in any way I can.

I can’t ignore the smoking issue. Tobacco-related illnesses are one of the most frequent killers of people in recovery, and I would not be doing my job if I ignored such an essential health issue. I like my patients, and I don’t want them to suffer illness and disability from a preventable condition, especially since their lives have changed so dramatically already.

My next three patients all wanted dose increases. Two were on methadone, and both were on sub-therapeutic doses, as evidenced by late-day withdrawal symptoms. I examined both before they dosed, so I could see them when their symptoms were at their worst. Both had large pupils and sweaty hands, and I ordered dose increases for both.

The third patient was a little trickier. He was dosing on buprenorphine at 16mg, and said he felt withdrawal symptoms of sweating with muscle aches and runny nose, which started at around 1pm each day. Since he doses at around six-thirty in the morning, his withdrawal symptoms started around six hours after dosing.

I didn’t think increasing above 16mg would cover the patient for a full twenty-four hours. I talked to the patient about switching to methadone, since unlike buprenorphine, there’s no ceiling on its opioid effect. As a full opioid, the more you take, the more withdrawal blocking effect.

He was reluctant to switch. He said he heard bad things about methadone, about how it gets in your bones and rots your teeth, and he didn’t want that to happen.

Inwardly, I sighed. Such ideas are still all too common in this region of the country. There’s still more stigma against methadone than against buprenorphine. While I’d love it if all my patients felt normal while dosing with buprenorphine, that’s not the case. There will never be one medication that’s right for everyone, and methadone is a life-saving medication too.

I corrected his mistaken impressions about methadone, without downplaying the real risks of methadone. I told him it was easy to overdose on methadone if he used benzodiazepine or alcohol while on it. I acknowledged that methadone does appear to be more difficult for most people to taper off of, but since he was early in treatment, we weren’t anywhere near close to considering any kind of taper.

He agreed to the switch, and I wrote an order to stop buprenorphine and start methadone. When patients switch from buprenorphine to methadone, I usually start methadone at a lower dose, at around 20-25mg on the first day. If they are older, on many medications, or have serious medical conditions, I may need to start lower than 20mg on the first day. I planned to see him again in a few weeks to see how he was doing.

My next patient had been admitted to the hospital for exacerbation of COPD, and the day I saw her was her first day back at our OTP. She usually doses on methadone at 80mg per day. The hospital didn’t call to confirm her dose with us, so I was very worried that she had gone without methadone for the five days she was in the hospital, on top of the COPD exacerbation.

When I (finally) got her records, I saw she was dosed at 80mg per day, because that’s what she told them she was taking.

I’m glad they dosed her. But it seems to me they should confirm that with her treatment facility before dosing her at that amount. Nearly all our patients will tell their other physicians the truth, but what if the patient, in a misguided attempt to feel better, exaggerated her dose and said she was on 110mg per day?

What if this patient wasn’t even currently in our treatment program? Dosing a patient at 80mg per day who wasn’t already on methadone at that dose would be deadly. When the stakes are that high, why take that risk? I know our phone system has byzantine voicemail, but the 24-hour number is given at the beginning of the voicemail, so they should be able to reach an administrator at any time, who can get all needed information for them.

Anyway, my patient was feeling better, and had no gap in treatment since she’d been dosed while in the hospital. I made note of some new medications and applauded that she had five days without cigarettes and encouraged her to continue the nicotine patches she’d been started on.

I had asked to see my next patient for an odd reason: we got a call that this lady was injecting her methadone dose each day. The caller remained anonymous, which always makes me suspicious of the caller’s motives, but I felt I needed to check it out anyway.

It’s rare for anyone to inject methadone. For one thing, methadone has a high oral bioavailability, due to excellent oral absorption. With methadone, you can get around 90% of an intravenous dose just by swallowing that dose. But injection drug use is about more than just the physiology. Often there’s a psychological component. Patients accustomed to injecting drugs can get a rush of dopamine just with the ritual of injecting.

I didn’t think this patient I was seeing would be doing that, since she’d been in treatment for over a year. All of her urine drug screens were positive only for the expected methadone and its metabolites.

When I saw her, I told her we received reports that she was injecting her methadone, and that I was sorry to inconvenience her, but I needed to check for myself, for safety reasons. To my great surprise, I found track marks. I asked her about what caused the marks, and she denied any IV drug use of her methadone or anything else, but there was no mistaking what I was looking at.

I told her I was afraid to give her further take-home doses, and that she needed to dose with us on site from now on.

She was furious, and while I understood her anger, I was in a pickle. There was no way I was could give her take home doses, given what I saw. It wasn’t safe. Her explanations of how the tracks came to be there didn’t sound realistic at all (cat scratched her in the same place multiple times, repeated injury from a fishing hook in the same area multiple times). I tried to be frank with her, and told her I knew tracks when I saw them.

Some physicians might not be so confident. Early on in my career as a physician treating opioid use disorders, I might have been a little unsure. After seventeen years of doing this job, I know track marks when I see them.

She asked when she could get her take home levels back, and again I was stumped. How could I ever be confident this patient wouldn’t inject take home medication? I could keep a check on her arms, but of course she could use other sites, and do I really want to have to ask a patient to strip so I can be sure there’s no injection drug use? No, I’m not going to do that.

If I knew what happened, it would give us something to work with, but my patient was unwilling or unable to tell me, so she will have to dose with us daily.

The rest of the day continued like this, with patients asking for dose increases, some asking for recommendations about how to go about decreasing their dose, and others checking in because they were medically fragile. I like to see patients with significant medical issues every three to four months, so I can stay current about any new medications, and remain updated on the status of their other medical issues.

This is what I do during my work day. I love my job and feel like I can help people and make a difference in their lives. I’m better able to do that where I work now than I ever could during the years I worked in primary care.

I’ve got the best job in the world.

 

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

Liquid methadone

 

 

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

I enthusiastically support medication-assisted treatment (MAT) for opioid use disorder, but no treatment works for everyone. Some patients may be too ill for this form of treatment and some may not be ill enough, and find other treatments that work for them. Here are some reasons a patient may not be suitable for MAT:

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

A few weeks ago, a woman came to our opioid treatment program who hadn’t used opioids for nine months, and – by her history – never had an obsession or compulsion to use them in destructive ways. When I explained to her why our treatment wasn’t appropriate for her, she became angry, and said it was her right to get treatment because of the CURES grant.

This made no sense to me, and I tried to explain myself several times, but she left, angry she was being denied a treatment that the government was paying for, because she felt that meant she was entitled to the medication if she wanted it.

The patient takes opioids for pain, but has never developed opioid use disorder.

Such a patient may be physically dependent, but lacks behaviors that indicate loss of control over opioids. The patient denies any misuse of medication, or obsession and compulsion to continue using opioids despite adverse consequences.

Opioid treatment programs (OTPs) have stringent regulations put on them by both federal and state governments. OTPs are designed to treat patients with opioid use disorder; these are patients who 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 opioid use disorder, 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.

While opioid treatment programs aren’t set up to treat chronic pain, many of our patients with both opioid use disorder and chronic pain find methadone and buprenorphine helps with pain. That’s a nice benefit. Many of these patients feel less pain once they’re out of the miserable cycle of intoxication and withdrawal. So less pain is a happy side effect of our treatment.

Having said this, there are those unfortunate patients who have been dismissed from pain clinics for reasons other than misuse of opioids. They don’t meet criteria for opioid use disorder, but they are clearly physically dependent on opioids and can’t find timely treatment. I have – at times – admitted these patients, under an exception filed with SAMHSA, with the understanding that they would be better served by eventually transferring to another pain management program.

The patient with opioid use disorder asking for maintenance treatment has been physically dependent for less than one year.

Methadone is difficult to taper off of, and federal and state regulations say it cannot be prescribed for people with opioid use disorder with less than one year of physical dependence. This is a somewhat arbitrary cut off, and the OTP physician can ask for an exception to this regulation if she feels it’s in the best interest of the patient.

Even if the OTP wants to treat the patient with maintenance 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.

This doesn’t apply to office-based buprenorphine practices, who don’t have to follow federal and state regulations for opioid treatment programs. 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.

To further confuse this issue, patients who have been on MAT in the past may be re-admitted onto MAT even without a year of physical dependence, if that patient thinks that relapse back into active opioid use disorder is imminent. Also, pregnant patients with opioid use disorder don’t have to meet the one-year requirement because of the benefits to both mom and baby with MAT.

The person with opioid use disorder can go to a prolonged inpatient residential treatment program.

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 use disorder, they are often 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 people with opioid use disorder can’t access this kind of treatment, with extensive post-treatment counseling, monitoring, and accountability.

A person with opioid use disorder 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. However, it’s a complicated problem, and the admitting physician needs to make a judgment about the risks of starting treatment while the patient is physically dependent on sedating medications, compared to the risks of delaying treatment for the opioid use disorder.

The FDA issued a statement in 2017 saying that “the opioid addiction medications buprenorphine and methadone should not be withheld from patients taking benzodiazepines or other drugs that depress the central nervous system…” They issued this statement after releasing the black box warning in 2016, saying opioids combined with benzodiazepines or other sedatives was dangerous and could result in death.

I believe this more recent statement was their way of indicating the risks may be outweighed by the benefits for patients contemplating admission to treatment for opioid use disorders with MAT. After all, patients with active opioid use disorder can die.

The person with opioid use disorder 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 opioid use disorder. Sadly, it’s getting ever harder to find such facilities for patients who need them.

Some patients may have neurologic dysfunctions that impair their ability to understand and consent to treatment. Such patients usually have people authorized to make decisions for them, and we must bring that person into the discussion and get consent to treat from them.

If a patient has some sort of temporary condition that impairs their ability to understand and consent to treatment, we may ask them to return on another day. For example, we sometimes have a new patient present for intake who is impaired to the point where consent is impossible. We make sure a responsible party can drive them home, and make plans for them to return the next day.

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.

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 use disorder with methadone riskier to the patient than untreated opioid use disorder. We know for sure that untreated opioid use disorder produces high risks 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 patient’s 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.

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. Most opioid treatment programs are open seven days a week for dosing.

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 person with opioid use disorder time to regain physical and mental health. Once on a stable dose, the recovering person can make changes in his life, with the help of counselors and other OTP workers. He can get back to work, any criminal activity, form better relationships with his family and himself, and recover a better quality of life.

Will that person ever do well off methadone? There’s no way to know. Some patients can taper off methadone, if they bring the dose down slowly enough that they don’t feel intolerable withdrawal. Some, perhaps most, recovering people 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.

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. I try to explain these medications don’t work like that. If the patient wants to get off all medications quickly, I can give referrals to programs that can help them. This way, patients can’t later say they were misled, and feel like they have liquid handcuffs, chained forever to methadone, with its many regulations for treatment.

I hope this gives a little guidance as to which patients are most appropriate for medication-assisted treatment.