Posts Tagged ‘Project Lazarus’

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.

 

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Naloxone Controversy

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It’s a misleading title, because most people support naloxone use. At this point…there’s not much controversy. Unless you live in Maine.

Their governor, Paul LePage, vetoed a bill, passed by their State House in 2013, that allowed naloxone to become more widely available. He called the life-saving medication and “escape,” and “An excuse to stay addicted.”

Naloxone is an escape in a way – an escape from death.

However, before learning about naloxone, I had some concerns too. For example, would having naloxone available for an overdose encourage people to use more illicit opioids? Would addicts be more likely to push then envelop of safety in the quest for the ultimate opioid high?

The answer appears to be no, at least according to some small studies. One of them was a study of intravenous heroin addicts in San Francisco, who received an eight-hour training in how to prevent heroin overdose, how to give CPR, and how to administer naloxone. [1]

These twenty-four study subjects were followed prospectively for six months. These addicts witnessed a total of twenty opioid overdoses. All of the overdose victims were said to be cyanotic, unresponsive, and have no respirations. The addicts in the study, who had received the eight hour training, administered naloxone to 75% of the overdose victims they encountered. They performed CPR on 80% of the overdose victims, and 95% of the overdose victims had one or the other of the two interventions performed. All of these overdose victims survived.

The study did not show an increase in the incidence of opioid overdose. In fact, the addicts in the study used less heroin over the study period, even though no part of the study was dedicated to encouraging the reduction of illicit opioid use or to entering addiction treatment.

Granted, the study participants had to be motivated in order to spend eight hours doing the training, so maybe they were already motivated to cut down or stop using drugs. But on the other hand, about half of these study subjects were homeless, a demographic many in our society would assume is poorly equipped or motivated to help anyone else. Yet they demonstrated a remarkable willingness and capability to help peers dying from overdoses.

Emergency medical services were called in only two of the overdoses. When study subjects were asked why they did not call emergency medical services, half said it was due to fear of police involvement and arrest. Twenty-five percent said no phone was available, and 25% said they didn’t see a need for EMS.

This information underscores the importance of Good Samaritan laws. In the broadest sense, Good Samaritan laws protect a person who tries to help another person from civil or criminal penalties.

Initially these laws were passed to protect doctors from being sued if they attempt to save the life of someone who is not a patient. For example, if I witness a man choking to death in a restaurant and I rush over to do the Heimlich maneuver, I can’t be sued if I break his ribs in my effort to get him to hack up the meatball wedged in his trachea.

Good Samaritan laws, as they apply to drug overdoses, give some degree of immunity to people who try to intervene to save another person’s life from drug overdose.

For example, in my state, our Good Samaritan law says if a person seeks medical assistance for an individual suffering from a drug overdose, that person will not be prosecuted for possession of less than one gram of cocaine or one gram of heroin. The bill has provisions for doctors to be able to prescribe naloxone to any person at risk of having an opioid-related overdose. Doctors can prescribe naloxone to the friends or family members of a person at risk for an overdose, even if that person is not a patient of the doctor. This is called third-party prescribing; the law hacks through red tape of previous regulations that said doctors could only prescribe naloxone for their own patients. And our Good Samaritan law says a private citizen can administer naloxone to an overdose victim, and so long as they use reasonable care, will be immune to civil or criminal liability.

Not all states allow third-party prescribing of naloxone or even Good Samaritan laws. Look on the map at the top of this blog, and if you live in a state that hasn’t yet passed these laws, write your congressmen. This is such an important issue, and naloxone needs to be more widely prescribed. (I don’t know why Maine is colored on the map as if they have naloxone laws).

Who should get a naloxone prescription? Opioid addicts should obviously receive kits, and the friends and family members of these addicts. I believe it should be considered for any patient prescribed opioids, including patients on opioids for chronic pain, and patients prescribed methadone or buprenorphine to treat opioid addiction.

Kits should certainly be provided for high-risk patients – opioid addicts recently released from jail or detox units.

I wish I could prescribe kits for all of my patients on methadone or buprenorphine now, but aside from the program where I work in Wilkes County, it’s not yet easily available.

But it will be soon. In April 2014, the FDA approved a commercially available naloxone auto-injector marketed under the name Evzio. This kit, which delivers .4mg of naloxone intramuscularly or subcutaneously, has both written and voice instructions. Each kit contains two doses, and it can be administered through clothing. This kit should be available in pharmacies this summer.

Until then, there are other options. Doctors can call a local pharmacy to see if they would be interested in making a kit for sale to patients. At a minimum, it would include one or two vials of naloxone, a needle and syringe, rubber gloves and alcohol wipes to cleanse skin prior to injecting. This would be a relatively cheap kit to make, but questions persist about who would pay for it: the patient, their health insurance company…
The Harm Reduction Coalition has been instrumental in providing intramuscular naloxone kits to anyone who wants one. They have contacted OTPs in my state to ask if they can hand out kits and other information, so that’s another possible source for a kit. If you are reading this article and want a naloxone kit for either yourself or a loved one, please contact either the Harm Reduction Coalition at: http://harmreduction.org
This wonderful organization does other good works besides distributing naloxone kits, and it’s worth checking out their website.

At the opioid treatment program where I work in Wilkes County, NC, Project Lazarus has paid all or part of the cost of intranasal naloxone kits for our patients who enter treatment. Thus far I know of three lives saved by these kits. None of them were our patients; our patients used their kits to save other people.

I’ve written about Project Lazarus before in my blog. This organization, founded by Reverend Fred Brason, has implemented ongoing measures that reduced the opioid overdose death rates not only in Wilkes County, but probably statewide as well. Other states have started programs modeled on Project Lazarus. You can go to this website for more information: http://projectlazarus.org I know that in the past, Project Lazarus has been willing to send a naloxone kit to anyone who has a need for it, so that’s another possible source for a kit.

I predict it will become easier to get relatively cheap naloxone kits from pharmacies everywhere as the momentum behind naloxone availability grows.

1. Seal et al, “Naloxone distribution and cardiopulmonary resuscitation training for injection drug users to prevent heroin overdose death: A pilot intervention study,” Journal of Urban Health, June 2005; 82(2): 303-311.

Naloxone

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Medical journals, news outlets, and the internet have been exploding with new articles about naloxone. As awareness of this opioid overdose antidote grows, more people are pushing for this drug’s wider availability.

I’ve posted blogs about how the Project Lazarus kits have saved lives in my Appalachian corner of the world, but now let’s review some of the science behind naloxone.

Naloxone is an opioid antagonist, which means the drug binds to the mu opioid receptors in the brain, but instead of stimulating these receptors to produce euphoria and pain relief, naloxone does the opposite. It occupies the receptor and prevents opioids from attaching to these receptors to cause euphoria and pain relief. Naloxone has a high affinity to the mu opioid receptors, meaning it sticks like glue to them, but it does not activate these receptors.

If you give naloxone to an average person with no prior opioid use, not much will happen. Because naloxone can block our body’s own opioids, endorphins, that person might feel a little achy, tired, and irritable. But for the most part, when naloxone is given to a non-user of opioids, nothing happens.

If the patient has used opioids just once, recently, the patient won’t have withdrawal when given a dose of naloxone, since the body isn’t used to having opioids anyway. Naloxone in this case restores the body to its usual state. This’s why naloxone can be useful in a patient given opioids for surgical anesthesia. After the surgery is over, doctors can use naloxone to reverse the opioid anesthesia if they want the patient to wake up more quickly.

But in a patient with opioid addiction (or in a chronic pain patient) who uses opioids daily, naloxone causes opioid withdrawal. With long-standing opioid use, the body makes adjustments to counteract the chronic presence of opioids. When these opioids are whisked away with naloxone, this balance is abruptly upset, and the patient goes into precipitate withdrawal, if enough naloxone is given.

Naloxone is the opioid buzz-kill drug… and it’s also the opioid overdose life saver.

People die from opioid overdoses because the brain gets saturated with opioids. The part of the brain that tells us to breathe during sleep, the medulla, also gets saturated, and eventually shuts off. This usually occurs gradually. The respiratory rate slows over one to three hours, until all respirations stop. Then tissues of essential organs like the brain and heart die from lack of oxygen.

If naloxone can be given during this process, the opioids are tossed off brain receptors, and the medulla fires urgent orders for the body to resume breathing. The patient wakes up, so long as irreversible damage hasn’t yet been done to the brain and heart. In some cases, the patient goes into full precipitated opioid withdrawal, but usually the naloxone doesn’t reverse all of the opioids on board, just enough to save the patient’s life.

It’s a dramatic event. I’ve seen this in the emergency department during my Internal Medicine training. A patient can be lying on a stretcher, dead… then one dose of naloxone…. and they are sitting up, asking what happened to them. And sometimes they vomit. That’s another thing I learned in training. After giving a dose of naloxone, take one step back. Even better, place the patient in the “recovery position,” illustrated at the top of this blog, so that if they do vomit, they won’t aspirate the stuff into their lungs.

Naloxone is a relatively cheap drug, and it can be administered in several ways: intravenously, as doctors and EMS workers have always done, intramuscularly, subcutaneously, and intranasally.

Project Lazarus uses this last method. Their overdose kits contain two vials of naloxone 2mg each, and are in a syringe with a nozzle that is attached to the end of the syringe. This causes the medication to spray when the plunger of the syringe is pushed. It’s sprayed up in the nose of an unconscious person, and gets absorbed quickly. In fact, the response rates of all methods of naloxone administration are about the same – two to three minutes. If the patient doesn’t respond after a few minutes, the second dose can be given. Or if the patient initially responds but then gets sedated again, the second dose can be given.

The Harm Reduction Coalition gives out kits with a vial of naloxone and a 3cc syringe and needle. It takes some skill to administer naloxone intravenously, but this kit can be used intramuscularly or subcutaneously. All the rescuer has to do is draw the medication from the vial into the syringe, then stick the needle into the thigh muscle and push the plunger. Usually that delivers the medication into the muscle, unless the person has a great deal of fat between the skin and muscle. But that doesn’t matter, since this medication also works when injected into the subcutaneous tissue.

Each version of a naloxone kit has its advantages. The intranasal kit doesn’t require a needle, so there’s no risk of an accidental needle stick by the rescuer. But it’s a little more expensive. The intramuscular kits are really cheap, but some people in the community worry about handing out a needle and syringe that could be used to inject drugs. I don’t worry about that, since needle exchange should be done in every community, but that’s a bit of a tangent. More practically, addicts don’t use 3cc syringes; they’re too large. Addicts would miss their shot, and too much of their drug of abuse would get left behind in that big syringe.

I don’t think it matters what kind of kit is made available to addicts, their families, and first responders. We just need to get some kind of naloxone kit to these people.

Of course, all these kits contain the recommendation to call 911 immediately. But those precious minutes before EMS arrives may mean the difference between life and death. If naloxone can be given, the patient may be saved. Their brain function may be saved.

To be continued…

Project Lazarus in the Huffington Post

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In a nice article in the Huffington Post, Project Lazarus, located in Wilkes County, NC, was highlighted as an example of how a community can take action to prevent drug overdose deaths. Please check it out at: http://www.huffingtonpost.com/2014/03/05/project-lazarus_n_4889620.html?1394071210

Many people think Project Lazarus provides naloxone kits to reverse overdoses, and this is true, but they do much more than that. Project Lazarus has sponsored educational programs for doctors to learn to be more cautious when prescribing opioids, has sponsored medication take back days where old prescription meds can safely be disposed, and has worked with agencies and organizations across North Carolina and the nation to better inform doctors, law enforcement, and elected officials about what works to prevent drug overdose deaths.

Project Lazarus helped pass a Good Samaritan law North Carolina (see my post of April 20, 2013). Under this new law, a person who calls 911 to save another person’s life – or their own – won’t be prosecuted for minor drug possession, since they were trying to do the right thing and save a life by calling 911.

The Huffington Post article describes how the opioid overdose death rate has been falling in Wilkes County, while the overdose death rate in other parts of the country has been steadily rising. They credit Project Lazarus for this reduction in overdose deaths.

While I’m sure Project Lazarus has played a huge role in reducing overdose deaths not only in Wilkes County and the state of North Carolina, other factors have helped. Being an opioid addiction treatment provider, of course I believe availability of addiction treatment reduced deaths too.

Project Lazarus also supported the opening of an opioid treatment program in 2011, Mountain Health Solutions. Started by Dr. Elizabeth Stanton, this program initially offered only buprenorphine. As it grew, it became obvious some patients needed methadone treatment, so option became available by late 2011. Mountain Health Solutions was eventually purchased by CRC Health in 2012, and has continued to grow. Located in a small town, we have nearly four hundred patients.

I am honored to be the medical director at this program. It’s one on the best programs I’ve seen, and we work hard to keep improving our quality of care. Our program has done outreach -particularly in the medical community- to try to reduce the stigma of medication-assisted treatment. If you read my blog, you know this can be both a joy and a challenge.

Initially, Project Lazarus paid for an intranasal naloxone kit for every patient entering our opioid treatment program. Now since our patient census has risen, Project Lazarus still pays half of the $50 cost of the kits. The opioid treatment program pays the other half, out of a $33 admission charge for new patients. I feel lucky to be able to partner with Project Lazarus, as I’ve seen these kits save lives.

I know of four occasions when a naloxone kit saved a person’s life. Three of these four times, that person saved wasn’t even in treatment for opioid addiction.

Most recently, a parent used a kit to reverse an opioid overdose in a child who accidently ingested the parent’s medication. The parent called 911 and while waiting for EMS to arrive, used one of the two vials in the kit. The child partially woke, and started breathing better. Then EMS arrived and took the child to the hospital. This child survived a potentially fatal overdose and is back to normal with no lasting damage, thanks in part to that naloxone kit and a parent who knew how to use it.

Naloxone kits can be obtained much more cheaply, but contain Narcan vials, a more dilute form of naloxone that is meant to be injected. Those kits, which cost a few dollars, contain a syringe and needle instead of the Project Lazarus kit for nasal administration. Trying to inject naloxone into a vein is technically much more difficult than spraying the more concentrated form of naloxone up into the nose.

And unfortunately, a kit containing a needle and syringe would meet resistance from the public. I can imagine all sorts of angry phone calls to our opioid treatment program: “My son came to you people to get off the needle and you GAVE him a needle and syringe??” Politically, the public would more likely oppose distribution of a naloxone kit with a needle than a kit for intranasal use.

Fifty dollars for an intranasal naloxone kit to save a life is a pittance in the overall picture. Some insurance companies will cover these kits, as will Medicaid, but most of our patients have no insurance. They pay for their buprenorphine/methadone treatment out of their own pocket. Fifty dollars is a big sum for these patients.

I am blessed to work for an opioid treatment program that gets financial help from Project Lazarus for these kits. And I am very blessed to work for a for-profit company, CRC Health, which is willing to bear half the cost of the kits, since this comes out of their profits. Most opioid treatment programs do charge patients an admission fee, but unlike Mountain Health Solutions, don’t put that money towards buying a naloxone kits for their patients.

This is an example of the success that can happen when agencies work together toward a common goal.

Each State Gets a Report Card

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You have got the check this out…an organization called Trust For America’s Health, or TFAH, supported by the Robert Wood Johnson foundation, has released a report called, “Prescription Drug Abuse 2013: Strategies to Stop the Epidemic.” You can find the report at their website at: http://www.healthyamericans.org

This report grades each state on its policies for managing the prescription pain pill epidemic.

The report begins with a description of the scope of the problem: current estimates say around 6.1 million U.S. citizens are either addicted to or misusing prescription medications. Sales of prescription opioids quadrupled in the U.S. since 1999, and so have drug overdose deaths. In many states, more people die from drug overdoses than from motor vehicle accidents. The costs of addiction and drug misuse are enormous; in 2011, a study estimated that the nonmedical use of prescription opioids costs the U.S. around 53.4 billion dollars each year, in lost productivity, increased criminal justice expenditures, drug abuse treatment, and medical complications.

The report identifies specific groups at high risk for addiction. Men aged 24 to 54 are at highest risk for drug overdose deaths, at about twice the rate of women, although the rate of increase in overdose deaths in women is worrisome. Teens and young adults are at higher risk, as are soldiers and veterans. (Please see my blog of October 19th for more information about veterans.) Rural residents are twice as likely to die of an overdose as urban residents.

TFAH’s report declares there are ten indicators of how well a state is doing to fix the opioid addiction epidemic. This report grades each of the fifty states by how many of these indicators each state is using. TFAH says these ten indicators were selected based on “consultation with leading public health, medical, and law enforcement experts about the most promising approaches.”

Here are their ten indicator criteria:
 Does the state have a prescription drug monitoring program?
 Is use of the prescription drug monitoring program mandatory?
 Does the state have a law against doctor shopping?
 Has the state expanded Medicaid under the ACA, so that there will be expanded coverage of substance abuse treatment?
 Does the state require/recommend prescriber education about pain medication?
 Does the state have a Good Samaritan law? These laws provide some degree of immunity from criminal charges for people seeking help for themselves or others suffering from an overdose.
 Is there support for naloxone use?
 Does the state require a physical examination of a patient before a prescriber can issue an opioid prescription, to assure that patient has no signs of addiction or drug abuse?
 Does the state have a law requiring identification to pick up a controlled substance prescription?

 Does the state’s Medicaid program have a way to lock-in patients with suspected drug abuse or addiction so that they can get prescriptions from only one prescriber and pharmacy?

I thought several of these were bizarre. Several are great ideas, but others…not so much. For example, I think a law against doctor shopping leads to criminalization of drug addiction rather than treatment of the underlying problem. The addicts I treat knew that doctor shopping was illegal, but still took risks because that’s what their addiction demanded of them. Such laws may be a way of leveraging people into treatment through the court system, however.

And where are the indicators about addiction treatment? Toward the very end of this report, its authors present data regarding the number of buprenorphine prescribers per capita per state, but make no mention of opioid treatment program capacity per capita for methadone maintenance. Buprenorphine is great, and I use it to treat opioid addiction, but it doesn’t work for everyone. And there’s no data about treatment slots for prolonged inpatient, abstinence-based treatment of opioid addiction.

Expanded Medicaid access for addiction treatment is a nice idea… but not if doctors opt out of Medicaid because it doesn’t pay enough to cover overhead. If expanded access is not accompanied by adequate – and timely! – payment to treatment providers for services rendered, having Medicaid won’t help patients. Doctors won’t participate in the Medicaid system. I don’t. I have a few Medicaid patients whom I treat for free. It’s cheaper for me to treat for free than pay for an employee’s time to file for payment and cut through red tape.

In one of the more interesting sections in this report, each state is ranked in overdose deaths per capita, and the amount of opioids prescribed per capita.

The ten states with the higher opioid overdose death rates are: West Virginia, with 28.9 deaths per 100,000 people; New Mexico, with 23.8 deaths per 100,000; Kentucky with 23.6, then Nevada, Oklahoma, Arizona, Missouri; then in eighth place is Tennessee, with 16.9 deaths per 100,000. In ninth and tenth places are Utah and Delaware. Florida came in at number 11, with 16.4 deaths per 100,000.

North Carolina placed 30th in overdose death rates. We’ve had a big problem with prescription drug overdose deaths. From 1999 until 2005, the death rate rose from4.6 per 100,000 to 11.4 per 100,000. But at least our rate has not increased since 2005. The rate in 2010 was still 11.4. It’s still way too high, but many agencies have been working together over the past six years to turn things around. In a future blog, I intend to list the factors I think helped our state.

Use of the ten indicators does appear to correlate with reduced rate of increase of overdose deaths. In other words, states with more laws and regulations have had a slower rise in overdose deaths than states with fewer laws and regulations, though there are some exceptions.

This report also compares states by the amount of opioids prescribed per year, in kilograms of morphine equivalents per state per 10,000 people. Florida, not surprisingly, came in at number one, with 12.6 kilograms per 10,000 people. Tennessee and Nevada tied for second and third place, with 11.8 kilos per 10,000 people. The next seven, in order, are: Oregon, Delaware, Maine, Alabama, West Virginia, Oklahoma, and Washington. Kentucky was 11th, with 9.0 kilos per 10,000. North Carolina doctors prescribe 6.9 kilos of opioids per 10,000 people per year, in 27th place and less than the national average of 7.1 kilos.

It appears to me that amount of opioid prescribed per capita does correlate, somewhat, with overdose death rates.

Let’s look closer at Tennessee, the state who, just a few months ago, rejected a certificate of need application for an opioid treatment program to be established in Eastern Tennessee. In 1999, Tennessee had an overdose death rate that was relatively low, at 6.1 per 100,000 people. By 2005, it zoomed to 10.4 per 100,000 people, and by 2010, rocketed to 16.9 per 100,000 people, to be in the top ten states with highest overdose death rates. Furthermore, Tennessee is now second out of fifty states for the highest amount of opioids prescribed per 10,000 people. Only Florida beat out Tennessee. And lately Florida has made the news for its aggressive actions taken against pill mills, which may leave the top spot for Tennessee.

West Virginia is no better. It was the worst state, out of all fifty, for overdose deaths, at 28.9 per 100,000 people in 2010. Wow. If you think lawmakers are asking for help from addiction medicine experts…think again.

West Virginia legislators recently passed onerous state regulations on opioid treatment programs. That’s right, lawmakers with no medical experience at all decided what passed for adequate treatment of a medical disease. For example, they passed a law that said an opioid addict had to be discharged from methadone treatment after the fourth positive urine drug screen. In other words, if you have the disease of addiction and demonstrate a symptom of that disease, you will be turned out of one of the most evidence-based and life-saving treatments know to the world of medicine. West Virginia passed several other inane laws regulating the medical treatment of addiction.

Getting back to the TFAH study, the report calculates that there are 21.6 million people in the U.S. who need substance treatment, while only 2.3 million are receiving it. This report identifies lack of trained personnel qualified to treat addiction as a major obstacle to effective treatment.

This report makes the usual recommendations for improving the treatment of addiction in the U.S… They recommend:

 Improve prescription monitoring programs. Nearly all states have them, except for Missouri and Washington D.C.

States should be able to share information, so that I can see what medication my North Carolina patients are filling in Tennessee. Right now, I have to log on to a separate website to check patients in Tennessee, so it takes twice as much time. Tennessee is already sharing data with several other states, but not with North Carolina, or at least not yet.

TFAH also recommends linking prescription monitoring information with electronic health records.

 Easy access to addiction treatment.

Duh. The report accurate describes how underfunded addiction treatment has been, and says that only one percent of total healthcare expenditures were spent on addiction treatment. We know how crazy that is, given the expense of treating the side effects of addiction: endocarditis, alcoholic cirrhosis, hepatitis C, gastritis, cellulitis, alcoholic encephalopathy, emphysema, heart attack, stroke, pancreatitis, HIV infection, gastrointestinal cancers, lung cancer…I could go on for a page but I’ll stop there.

Access to treatment is limited by lack of trained addiction professionals. Doctors abandoned the field back in 1914, when it became illegal to treat opioid addiction with another opioid. Even with the dramatic success seen with methadone and buprenorphine treatment of opioid addiction, there are relatively few doctors with expertise in this treatment.

This reports shows that two-thirds of the states have fewer than six physicians licensed to treat opioid addiction with buprenorphine (Suboxone) per 100,000 people. Iowa has the fewest, at .9 buprenorphine physicians per 100,000 people, and Washington D.C. had the most, at 8.5 physicians per 100,000 people.

North Carolina has 3.2 buprenorphine physicians per 100,000 people, while Tennessee has 5.3 physicians per 100,000. This makes Tennessee look pretty good, until you discover than many of Tennessee’s physicians only prescribe buprenorphine as a taper, refusing to prescribe it as maintenance medication. If these doctors reviewed the evidence, they would see even three month maintenance with a month-long taper gives relapse rates of around 91% (1)

I’m really bothered by the lack of attention to the number of methadone treatment slots per capita. That’s information I’d really like to have. But the authors of this report did not deign to even mention methadone. Even with forty-five years’ worth of data.

**Sigh**

 Increased regulation of pill mills.

 Expand programs to dispose of medications properly. In other words, make sure citizens have a way to get rid of unused medication before it’s filched by youngsters trying to experiment with drugs.

I know many tons of medications have been turned in on “drug take-back” days. But I’ve never seen any data about how much medication is addictive and subject to abuse, versus something like outdated cholesterol lowering pills.

 Track prescriber patterns. Another benefit of prescription monitoring programs is that officials can identify physicians who prescribe more than their peers. Sometimes there’s a very good reason for this. For example, a doctor who works in palliative care and end-of-life care may appropriately prescribe more than a pediatrician.

I get uneasy about non-physicians evaluating physicians’ prescribing habits, though. I think this is best left up to other doctors, enlisted by the state’s medical board to evaluate practices. Other doctors are better able to recognize nuances of medical care that non-physicians may not understand.

 Make rescue medication more widely available. In this section, the report’s authors make mention of Project Lazarus of Wilkes County, NC, a public health non-profit organization dedicated to reducing opioid overdose deaths, not only in that county, but state-wide. Project Lazarus is well-known to me, since I work at an opioid treatment program in Wilkes County.

 Ensure access to safe and effective medication, and make sure patients receive the pain medication they need. Obviously, we want opioids available to treat pain, especially for acute pain. Hey, you don’t have to convince me – read my blog from this summer about how grateful I was for opioids after I broke my leg. Opioids were a godsend to me in the short-term, and knowing what I do about opioids, I didn’t use them after the pain subsided.

It was an interesting report, though I saw some unfortunate gaps in their information, particularly regarding opioid addiction treatment availability.

But at least this is another agency looking at solutions and making some helpful recommendations.

1. Weiss et al, “Adjunctive Counseling During Brief and Extended Buprenorphine-Naloxone Treatment for Prescription Opioid Dependence,” Archives of General Psychiatry, 2011;68 (12):1238-1246.

Another Life Saved by Project Lazarus Naloxone Kit

Back to Life

Last week I talked to a young person, a patient at an opioid treatment program, who saved someone with her Project Lazarus naloxone kit. As you know if you read this blog regularly, Project Lazarus is a non-profit organization that started in Wilkes County, North Carolina, dedicated to reducing drug overdose deaths. As part of the project, Project Lazarus pays for naloxone kits for patients entering medication-assisted opioid addiction treatment. The patients are given a prescription for a kit that will be filled for free at a local pharmacy.

These kits are ingenious, because the naloxone is already packaged in a syringe with a spray attachment. There’s no needle. The person administering the drug pushes the plunger of the syringe to spray the medication into a nostril. Naloxone is absorbed through the skin of the nostril and into the bloodstream, reversing the effect of all opioids. In this way, naloxone immediately brings the person out of opioid-induced sedation or coma.

I talked to this person who used her kit, to get the full description of events. I’ve changed some details to prevent anyone from recognizing her.

Cindy said she was driving across town when she had the sudden urge to visit a relative, whom we will call Bob. Bob was on parole, and Cindy wanted to stop by and say hello. Bob isn’t an addict, but has occasionally experimented with illicit drugs, including opioids. When Bob opened the door for Cindy, his first words were, “I think I’ve just taken an overdose.” An acquaintance sold Bob some prescription opioid pills, and moments before Cindy stopped by he took all of them. Right away, he began to fear he’d taken too much.

Cindy wanted to take Bob to the hospital but he refused, fearing his parole officer would find out he’d used illegal drugs. Cindy agreed to stay with Bob, and warned him that if he passed out, she would call EMS, but Bob begged her not to do this.

At first they talked and watched TV, but within an hour Bob got sleepy and his head nodded. Initially Cindy could still wake him by shouting, but she was alarmed to see his breathing slow. She said his lips began to turn blue, and he was taking huge noisy breaths only a few times per minutes. She lived nearby, so she sent her boyfriend to get her naloxone kit. She pushed the plunger and sprayed the naloxone into Bob’s nostril. She said it took less than a minute for him to wake with a start. He even jumped out of his chair. He was standing up and breathing heavily. It was a few minutes before he felt like himself again. Cindy started to call 911 but Bob again pleaded with her not to do so because of his fears about what would happen with his parole situation.

Cindy was (correctly) worried the naloxone wasn’t going to last, so she sat with Bob through the whole night. Several hours after the first naloxone dose, she gave him a second dose, since he was again breathing slowly and heavily. It worked as well as the first. Thankfully, he was OK after that.

The next morning, Bob was grateful to Cindy for saving his life. He knew he had nearly died, and told Cindy he was never going to use drugs again. The event happened a week or so ago, and Cindy says as far as she know, Bob hasn’t used any drugs since.

Cindy saved Bob’s life because she had the Project Lazarus kit. I asked her what she would have done without it, and she said she would have called 911 even over Bob’s objections – she wasn’t going to watch him die.

This whole episode illustrates some of the problems that can contribute to overdoses. First, it isn’t only addicts who die from overdoses. Bob is a young adult who by Cindy’s report has only experimented with drugs. The trouble is that with opioids, your first experimentation can be the last thing you ever do. If Bob isn’t an addict, he may be able to stop using after this near disaster.

Second, it shows the new Good Samaritan law doesn’t go far enough. Bob was fearful about legal consequences of getting much-needed medical help. If Cindy hadn’t dropped by, this young man probably would have died. He had a brief period of time between realizing he may have taken an overdose and becoming so sedated he was unable to call for help, but he didn’t call, because he feared legal consequences. I think the Good Samaritan law should be broadened to include seeking help for oneself as well as for other people.

Third, would it have been better for Cindy to forget her kit and call the ambulance for Bob? Maybe, though not from Bob’s point of view. Stories like these travel fast along the drug addiction grapevine, so I’m hoping more people will get interested in having a kit that can reverse an overdose, if for no other reason than getting help without involving authorities.

I advocate making these kits available for anyone who wants one, if that’s financially possible. Over the period of a little more than a year, I’ve heard of two lives saved from opioid overdoses because other people used their naloxone kits. In both situations, the person saved was not the addict for whom the kit was prescribed, but a relative of that addict. This underlines the importance of getting these kits in the hands of friends and family members of all opioid users, even if the users are not addicts. Since the recent passage of the Good Samaritan law, it’s legal for physicians to prescribe naloxone for family member and friends of opioid addicts.

In the news last week we learned Project Lazarus of Wilkes County will get an infusion of $2.6 million over the next two years from both a private charity and government funds. The naloxone kits are only one part of the total program, and I hope to see funds for the kits expand so that any doctor can write a naloxone prescription for any opioid addict, friend or family of an addict that can be filled for free.

The Drug Czar Praises Project Lazarus

On Wednesday, August 22, the Drug Czar came to town.

Mr. Gil Kerlikowske, the director of the ONDCP (Office of National Drug Control Policy) gave the keynote speech at the Project Lazarus Symposium held in Wilkesboro, NC.

Being a drug czar isn’t as much fun as it sounds like it might be. It means Mr. Kerlikowske works hard helping to create the drug control strategy for the nation. His agency advises the president regarding drug-control issues, and sets the tone for the nation’s approach to drug addiction and treatment. For more information see my blog of April 20th, 2011. At the Project Lazarus Symposium in Wilkesboro, Mr. Kerlikowske gave the keynote speech and elaborated on these topics.

The Drug Czar came to Wilkesboro because of the impressive program Project Lazarus. Project Lazarus is a grass-root, non-profit organization established in 2008 in response to the very high rates of opioid overdose deaths in Wilkes County. That county had one of the highest drug overdose death rates in the entire nation, but over the last four years, those rates have dropped dramatically. For more data about these rates and about Project Lazarus, go to their website at:  http://projectlazarus.org

The ONDCP has placed more emphasis on prevention and treatment, acknowledging that law enforcement efforts alone won’t fix our nations’ problems. During his keynote address, Mr. Kerlikowske praised Project Lazarus and said it should be used as a model for communities in other states facing the same problem of overdose deaths.

Project Lazarus’ founder and CEO, Fred Brason, gave an overview of the components of the program and most recent data. Then Mr. Kerlikowske spoke for about twenty minutes, explaining the ONDCP’s vision for drug control policy. Then came a roundtable discussion where parties from various agencies and organizations explained their role with the project.

I was invited to the roundtable because I am the medical director at Mountain Health Solutions, an opioid treatment program in North Wilkesboro that prescribes both buprenorphine and methadone to treat patients with opioid addiction. This OTP is now owned by CRC Health, but was started by Dr. Elizabeth Stanton nearly three years ago, in response to the need for medication- assisted treatment in Wilkes County. At first, her program prescribed only buprenorphine, but later she saw the need for methadone for those patients for whom buprenorphine didn’t work.

I started working there relatively recently. I’ve been amazed at the number of patients presenting for treatment for pain pill addiction, nearly all of whom live in this relatively small community. At present we have more than three hundred and fifty patients enrolled in treatment.

As part of Project Lazarus, all of our patients receive a prescription for (free) naloxone kit to prevent opioid overdose deaths. I was invited to the Project Lazarus Symposium because in my blog on March 28th, 2012, I described how a patient of our OTP clinic saved a relative’s life by using one of the kits.

At the roundtable, I said a few words about the effectiveness of medication-assisted treatment using buprenorphine and methadone, and then made a few comments about the overdose death that was prevented with the naloxone kit.

Next, during the roundtable discussion, representatives from many different organizations and locations across North Carolina described the role Project Lazarus plays in their missions. Representatives from such disparate populations as the Cherokee Nation and the military at Ft. Bragg described how they used Project Lazarus’ programs to keep patients safer. Several epidemiologists gave information about the lowered overdose death rates in Wilkes County. A local doctor explained how doctors have revised their prescribing of opioids in the Emergency Department. We also heard from several people connected with the Harm Reduction Coalition, and from the county’s sheriff.

Representatives from state organizations such as the Governor’s Institute on Substance Abuse, the North Carolina Medical Board, the NC Department of Health and Human Services, and the NC Division of Public Health, Injury and Prevention all explained how they worked with Project Lazarus. For example, a portion of Project Lazarus’ activity has been to encourage physicians to sign up for – and use – our states’ prescription monitoring program.

We heard about the Chronic Pain Initiative, a program developed with the help of Project Lazarus, which helps educate physicians about the best practices of opioid prescribing. Initially meant for Medicaid patients, the Chronic Pain Initiative is now available to help all patients.

This initiative helps reduce overdose deaths by providing physicians with, among other things, a toolkit for healthcare providers. It gives them everything from evidence-based information about safe opioid prescribing to a form that can be filled out to gain access to the NC CSRS. It contains worksheets, flow sheets, and addiction screening tools. It contains everything a doctor could want to keep patients on opioids as safe as is possible, while still making opioids available for patients who need them.

I’ve blogged about this program in the past. I knew there was more to Project Lazarus than distribution of naloxone rescue kits, but I didn’t know the full extent of the Projects activities in the state. At Wednesday’s program, I was impressed as professionals from organizations across the state explained how Project Lazarus helps them prevent, intervene, and treat opioid addiction, and reduce overdose deaths.

I was inspired with the depth of knowledge and commitment of all of these people, and by their collaborative spirit. People in all strata of the community cared enough about overdose deaths that they were trying to fix the problem before more lives are lost. These groups were cooperating, which is essential. Both Gil Kerlikowske and Fred Brason took pains to emphasize the importance of working together and not against each other.

In other words, naloxone kits aren’t enough to fix the epidemic of opioid overdose drug deaths. Law enforcement can’t arrest our way out of this problem. Prescription monitoring programs aren’t enough to stop all drug diversion. It takes the sustained efforts of people different segments of the community, working together, to get results. No one intervention is enough. That was the bottom line message I got from the Project Lazarus Symposium and the Drug Czar.