Answer Addiction

Tag: buprenorphine

  • Why Aren't More Doctors Embracing Medication-Assisted Treatment?

    Why Aren't More Doctors Embracing Medication-Assisted Treatment?

    A new op-ed suggests that concerns about “branding” may deter many doctors from offering medication-assisted treatment (MAT) for opioid use disorder.

    A new op-ed on STAT News highlights a troubling concern in regard to medication-assisted treatment (MAT).

    Author David A. Patterson Silver Wolf, PhD, opined that the reason why methadone, buprenorphine and naltrexone aren’t more widely used to treat opioid use disorders (OUDs) may be due to “branding”—specifically, concern on the part of primary care physicians about the stigma associated with OUDs and its effect on their practice.

    But as Silver Wolf noted, the toll taken by the opioid epidemic on individuals and families all but required physicians to undertake the necessary steps to prescribe MAT, despite any qualms they may have.

    In the article, Silver Wolf, an associate professor at Washington University in St. Louis, Missouri and faculty member for training programs funded by the National Institute on Drug Abuse (NIDA), wrote that he came to his opinion after participating in a national panel of addiction experts that produced “Medications for Opioid Use Disorder Save Lives,” a report from the National Academies of Sciences, Engineering and Medicine.

    In the report, he and his fellow experts noted that while the need for medication-assisted treatment is sizable, and drugs like methadone and Suboxone have been approved as safe and effective treatments for OUD by the Food and Drug Administration (FDA), only a small number of physicians have signed up for the necessary training by the Drug Enforcement Administration (DEA) to be able to prescribe it.

    Silver Wolf also cited another STAT opinion piece, which speculated on some of the reasons why more physicians haven’t been lining up to prescribe MAT. One deterrent may be the process for receiving a federal waiver and the specialized training required to administer this treatment.

    But he also suggested that concern over the perception of those with substance use disorders by other patients may also color certain medical professionals’ opinions, who fear that the inclusion of such individuals to a patient base may negatively impact business.

    “Physicians whose practices focus on patients with opioid use disorder don’t have to worry about their ‘brand’ being harmed because it is tied to this treatment and this patient population,” Silver Wolf wrote. “But a typical primary care physician in Manhattan or suburban Atlanta or rural Nevada might worry about the potential trouble that patients with addictions might cause in their waiting rooms.” 

    The answer, according to Silver Wolf, is for more physicians to look past financial concerns and stigma, and take the steps to make medication-assisted treatment a part of their practice—even though, he adds, that many will not.

    But if individuals and families impacted by the addiction crisis—what the National Academies committee has come to view as an “all-hands-on-deck” situation—then Silver Wolf believes that physicians need to do the same.

    View the original article at thefix.com

  • Deregulating Buprenorphine Could Save Thousands Of Lives, Physicians Say

    Deregulating Buprenorphine Could Save Thousands Of Lives, Physicians Say

    Fewer than 7% of US physicians currently have the DEA waivers necessary to prescribe buprenorphine.

    An opinion piece by two physicians published in STAT Tuesday argues that deregulation of the opioid addiction treatment drug, buprenorphine, could save tens of thousands of lives every year.

    The authors, University of Rochester Professor Kevin Fiscella and Sarah E. Wakeman, director of the Massachusetts General Hospital Substance Use Disorders Initiative, strongly believe that making it as easy to prescribe buprenorphine as OxyContin or fentanyl is essential to the fight to end the opioid epidemic in the U.S.

    According to Fiscella and Wakeman, less than 7% of physicians in the country currently have the DEA waivers necessary to prescribe buprenorphine.

    Buprenorphine and methadone are currently the only approved drug therapies for opioid addiction disorders and is considered much safer than prescription opioids used to treat pain.

    However, doctors and nurse practitioners must jump through extra hoops in order to obtain permission to prescribe buprenorphine, while all DEA-licensed physicians are allowed to prescribe OxyContin and fentanyl.

    According to the Florida Academy of Physician Assistants (FAPA), all physician assistants need only to take a three-hour course in order to obtain a DEA license allowing them to prescribe controlled substances, including opioids. In contrast, physician assistants must go through 24 hours of training in order to prescribe buprenorphine on top of the training for the standard DEA license.

    An increasing number of studies have found that the over-prescription of OxyContin and, more recently, the misuse of the incredibly potent opioid fentanyl together have fueled an epidemic that killed close to 50,000 people in 2017 and likely more in 2018. So why, Fiscella and Wakeman ask, is a safer opioid that is approved to treat opioid addiction more difficult to prescribe?

    In order to prescribe buprenorphine, medical professionals must complete extra training, apply for a specially marked license, and agree to allow the DEA to inspect their patient records. All of these extra steps both increase stigma against addiction disorders and place unnecessary barriers in front of what is widely considered to be effective treatment for this massive problem.

    “Patients often experience barriers trying to fill prescriptions for buprenorphine—told they cannot fill it if the “X” is missing from the prescriber’s license number—or feel shamed when filling buprenorphine prescriptions,” the authors wrote. “Some feel embarrassed telling other doctors they are taking buprenorphine.”

    Fiscella and Wakeman conclude that deregulating buprenorphine—essentially making it as easy to prescribe as OxyContin and fentanyl—would increase treatment rates for opioid addiction and cause deaths from overdose to plummet. They cite policy in France which implemented this kind of deregulation in 1995 and resulted in a whopping 80% decrease in opioid overdoses.

    “[E]ven if deregulation of buprenorphine prescribing led to ‘just’ a 50% decrease, that would mean 20,000 fewer deaths.”

    View the original article at thefix.com

  • Florida Versus Evidence: How I Lost My Children Because of Past Drug Use

    Florida Versus Evidence: How I Lost My Children Because of Past Drug Use

    When my first slew of drug tests returned negative, the opposition began slinging whatever they could think of in my direction, hoping something would stick.

    I am living in two worlds. One is a world populated by doctors and advocates, run on the tenets of research and science and reason. It is a world in which addiction is treated with medicine, and where there’s no question that people who use drugs deserve to be safe and free of avoidable infections and diseases. In this world, nobody hesitates to administer naloxone if the occasion calls for it. In this world, people are not afraid to touch the bodies of drug users, and we all understand that if you can self-administer naloxone, you don’t need naloxone. I experience this world through phone lines, e-mails, and social media. I write about this world; this world is my template for how all worlds should be.

    Addiction as Moral Failure

    Then there is the world where my life takes place. In this world, having an addiction is a moral failure. Drug use is met with punishment. Judges replace doctors and toxicologists, making medical decisions and determining the results of drug tests with reckless abandon. In this world, abstinence is the only route to health. In this world, a hit of pot is just as chaotic as compulsive, daily injections of heroin. In this world, there is no sterile equipment; in this world, everyone is sick. Here, you can be sentenced to death just for being the friend of someone who overdoses. This is the world I touch with my fingers and teeth—the world where I walk, and eat, and breathe. This is the world where I live.

    I became involved with the Florida Department of Children and Families in April 2018. I was never charged with a crime or afforded the presumption of innocence, evidentiary standards, or jury decision that would have accompanied a criminal charge. Instead, one judge—virtually accountable to no one and equipped with full immunity—deemed my husband and me guilty of some nebulous pre-crime like the woeful characters in Philip K. Dick’s short-story-turned-film “Minority Report.” Apparently, I am guilty of the possibility of neglecting or otherwise harming my children in the future because I have a diagnosed substance use disorder.

    Since that decision, I have been forced to obey the mandates set forth by my county’s child welfare authorities in an attempt to win back custody of my girls. So far, not a single mandate has been evidence-based.

    I love writing about harm reduction, evidence-based addiction care, and trauma-informed mental health practices. I enjoy staying informed about best practices in addiction medicine. I am proud that I get to help demystify and destigmatize addiction and mental illness, and I am honored to have the opportunity to speak with the researchers who have dedicated themselves to driving us out of the dark ages of addiction medicine. But now that I am living in those dark ages myself, I can’t shake a sense of bitterness: I write about a better world, but it’s one that I only get to view from afar.

    Substance Use Disorder Treatment and Geography

    In 2017, I wrote an article for OZY about the general disparities between addiction care in red states and blue states. I was living in Seattle, Washington, at the time but I’d had some experience trying to get help for addiction in Florida—so I knew how backward providers could be. For example, when I gave birth to my daughter in Palm Beach while on prescribed methadone, hospital staff refused to let me breastfeed her. She was treated for Neonatal Abstinence Syndrome (NAS) and pediatric staff claimed that enough methadone would be passed through my breast milk to potentially harm her. In reality, numerous studies have found the exact opposite to be true and breastfeeding is now recognized as one of the most effective balms for NAS, due to the maternal contact and general health benefits of breast milk. The amount of methadone passed through breast milk is too negligible to help or harm.

    As I wrote in the OZY article, Democratic-ruled states are more likely to offer Medicaid coverage for methadone and buprenorphine, while Republican states are less likely to even offer the medications themselves, much less cover them. People in red states also face harsher penalties for drug crimes and are less likely to be allowed to continue a methadone or buprenorphine prescription while incarcerated. (Though this is a nationwide issue, blue states are leading the reform.) But writing the story from Seattle meant writing from a place of comfort: I was living among the reformers—walking within the pages of history that will be attributed to the good guys. I was able to take my buprenorphine every day because my state insurance covered it. I was surrounded by intelligent, informed people with whom I could speak honestly about my decision to engage in non-abstinence-based recovery. When I wrote about the issues in the system, I wrote from a place of distance. Of privilege.

    I did not appreciate how lucky I was until I dove headlong into the true trenches of the Drug War. 

    In Recovery and Losing Custody

    In Broward County, Florida, my children were removed from me because of unsubstantiated accusations of drug use. When my first slew of drug tests returned negative, the opposition began slinging whatever they could think of in my direction, hoping something would stick. Most of it revolved around the fact that I was poor—but ignorance about mental illness and addiction reared its ugly face yet again. The opposition cited my prior child welfare investigation in Florida—the one that was triggered by my daughter’s NAS. It was a routine investigation that had been deemed unsubstantiated. These types of investigations are typically labeled “harmless.” I had been in compliance with my methadone program, and my daughter’s doctors had no concerns—but five years later, the opposition used that prior methadone prescription as a basis for deeming me an unreliable witness: the dirty, lying junkie. 

    When I was asked under oath whether I had spoken with one of my husband’s siblings about possibly purchasing marijuana, I admitted that I had. Clinicians in addiction treatment recognize that drug cravings are normal and applaud us when we admit that we think about buying drugs but then decide against it. But the guardian ad litem attorney—the counsel whose job it is to protect my daughters’ interests—argued that by considering using marijuana, I placed my sobriety and therefore my children at risk. It didn’t matter that I canceled the purchase and honestly acknowledged that I’d thought about it. The judge called my process of considering marijuana but then deciding against it “drug-seeking behavior.” She gave custody of my daughters to my husband’s parents.

    The terribly irony underscoring the entire proceeding is that if I were still living in a state that embraced the most current research on addiction, I would never even have been in a courtroom. The accusation against me stated that I left my daughters in the care of their grandparents for three days while I used drugs outside of the home. According to the U.S. Department of Health and Human Services, “drug tests do not provide sufficient information for substantiating allegations of child abuse or neglect or for making decisions about the disposition of a case.” Drug use on its own, away from any children, is not child abuse. A parent who leaves their child with a family member to go to a bar for an evening is generally considered to be engaging in responsible substance use.

    The federal government recognizes that child abuse cannot reasonably be defined as placing a child with a trusted caregiver, leaving the home for a couple days, and returning sober. It doesn’t much matter what went on during those two days. True or false—the accusation against me never described child abuse. A more enlightened jurisdiction would have recognized that. The separation trauma that my children and I have endured over the past nine months is completely attributable to our location.

    I used to write about addiction and drug policy from a place of privilege. Now I am writing from the deep trenches. I feel as though I am performing a kind of literary necromancy whenever I publish—except that instead of communing with the dead or demonic, I am writing from within that unillumined place, hoping that, by disseminating research, facts, and the words of distant experts, I can summon reason back into my life.

    View the original article at thefix.com

  • How to Taper Off Suboxone: A Survival Guide

    How to Taper Off Suboxone: A Survival Guide

    “Fear is common and normal for a number of reasons, but the fear usually gives way to a sense of confidence and optimism when a taper is done correctly…Be patient.”

    Note: This article is not intended as a replacement for medical advice. This is merely the experience of 21 people interviewed by the author who have successfully tapered off buprenorphine-based medications (Suboxone, Zubsolv, Bunavail, Subutex, etc.) or significantly reduced their dose. Please consult your doctor before beginning a taper. 

    After two and a half years of taking Suboxone, I’ve decided that it’s time to start the tapering process. I don’t like having to rely on this little orange film strip each morning to get out of bed, the tidal wave of nausea, being constantly hot, the restless legs, and the constipation. This is an incredibly difficult decision because Suboxone has saved my life. Additionally, studies have demonstrated the effectiveness of Suboxone and found it’s reduced overdose death rates by 40 percent. 

    Some people decide that it is best for them to take Suboxone for life. Shannon has been taking 16 milligrams of Suboxone for 17 years and has no intention of tapering. She said: “I’m never getting off, why fix something that isn’t broken? I love life now. I’m a great mother, wife, daughter, sister, aunt, and trustworthy friend to all those that know and love me. I have absolutely no shame being a lifer. I’ve been to the depths of hell and now I’m in heaven. I believe without subs, I would be dead.”

    Like Shannon, fear of relapse and withdrawals makes me terrified of coming off Suboxone. I imagine waking up panicked and glazed in sweat, running to the bathroom to puke and worst of all, the black hole of depression and existential dread that is common with opioid withdrawal. These are common fears for people coming off opioid addiction treatment medications. In order to help others like me who are interested in tapering, I researched this topic and surveyed 21 people: 13 have successfully tapered off Suboxone and eight have significantly lowered their doses and are currently at or under six milligrams per day.

    Slow Taper

    Sixteen of 21 people I surveyed reported using a slow taper to come off or lower their dose. Dr. Jeffrey Junig of the Suboxone Talk Zone Blog suggests that the optimal dose to “jump” or quit taking Suboxone is .3 mg (about 1/3 of 1 mg).

    Junig writes: “I have had many patients taper successfully off buprenorphine. Fear is common and normal for a number of reasons, but the fear usually gives way to a sense of confidence and optimism when a taper is done correctly…Be patient. Tapering by too much, or too quickly, causes withdrawal symptoms that lead to ‘yo-yos’ in dose.”

    Amanda* agrees with Junig’s advice not to try to jump from too high of a dose. She said that when she jumped from 2 mg cold turkey it was “40 days of hell.”

    To avoid a hellish experience like Amanda’s, Junig advises reducing your dose by 5% or less every two weeks or 10% every month. Sound confusing? Junig simplifies: Use scissors to cut half of an 8 mg film. Then cut half of that, then half again. Put the doses in a pill organizer so they don’t get lost or accidentally consumed by children or pets.

    Holistic Remedies

    There are a handful of holistic remedies that can help with the tapering process. Folks I surveyed said that yoga, meditation, and healthy eating are pillars of their recovery. Studies have confirmed the benefit of yoga for improving quality of life in those withdrawing from opioids as it alleviates anxiety, restless legs, insomnia, and even nausea.

    Sarah said: “I tapered with a clean diet with digestible nutrient-dense food and smoothies and stayed hydrated. I got plenty of sun, used yoga and exercise too.”

    Others recommended vitamins and other supplements including: L-Tyrosine, DLPA, Vitamin C, Omega 3 Fish Oil, and ashwagandha. They used melatonin for sleep and Kava tea for relaxation. (Consult your physician before taking any supplements. Even benign substances may interact with other medications or have unintended side effects.)

    Marijuana

    Four out of 21 people polled used marijuana to deal with the difficult side effects of tapering off Suboxone. Barry said: “I know that some people may not see marijuana as a way that should be used to taper, but for me I was desperate to try anything that worked. I consider marijuana a lesser of evils. It helped with restless legs, nausea, pain, and anxiety.”

    Marijuana may now be a viable option for those who wish to try it, because it’s now legal for medical use in 29 states and for recreational use in nine states plus Washington DC. Unlike opioids, marijuana provides pain relief with a lower risk of addiction and nearly no risk of overdose. Plus, comprehensive studies like this one from the American Pain Society found that medical cannabis use is associated with a 64 percent decrease in opiate medication use.

    While studies have supported the use of marijuana to reduce opioid use, further research needs to be done as reported in the The Daily Beast. Dr. Junig also advises that patients should not start new mood-altering, addictive substances in order to taper off Suboxone.

    CBD Oil

    Three of the Suboxone patients polled were able to taper with the help of cannabidiol, also known as CBD oil. Experts emphasize the distinction between marijuana and CBD oil: CBD oil is not psychoactive, meaning that it doesn’t make patients feel “high” like the THC in marijuana. CBD oil may be a more viable option for people in states where marijuana has not been legalized and also for those who do not want mood altering affects, but strictly relief from physical symptoms. “I used CBD oil during the taper because pot isn’t legal in my state and it helped with restless legs, sleep, and anxiety,” Pablo said.

    A 2015 study in Neurotherapeutics examined the therapeutic benefits of cannabidiol as a treatment for opioid addiction. They found that CBD oil is effective in reducing the addictive properties of opioids, mitigating withdrawals, and lessening heroin-related cravings. Specifically, it relieved physical symptoms such as: nausea, vomiting, diarrhea, runny nose, sweating, cramping, muscle spasm. Additionally, it treats mental symptoms like anxiety, agitation, insomnia, and restlessness. The study states CBD oil is effective with minimal side effects and toxicity.

    Kratom

    In our survey, the people who tried kratom claim that the herb is a controversial yet effective way for tapering from Suboxone. Some experts agree. According to the Mayo Clinic: “In Asia, people have used kratom in small amounts to reduce fatigue or treat opium addiction. In other parts of the world, people take kratom to ease withdrawal, feel more energetic, relieve pain, or reduce anxiety or depression.”

    Four of the individuals surveyed used kratom for tapering off Suboxone. Christine said, “I was very tired when coming off Suboxone, so kratom helped give me the energy to work, clean my house, and take care of my kids.”

    Cristopher R. McCurdy, PhD, a professor of medicinal chemistry at University of Florida’s College of Pharmacy in Gainesville, studies kratom. McCurdy told WebMD: “I definitely believe there is legitimacy to using kratom to self-treat an opiate addiction.”

    Despite these positive reviews, the Mayo Clinic and Web MD caution that kratom can also lead to addiction and withdrawal. According to an article on WebMD, “There’s little research on the herb’s effects on people, and some experts say it also can be addictive. The herb is illegal in six states and the District of Columbia, and the Drug Enforcement Administration is considering labeling it as a Schedule I drug…For now, the agency calls it a ‘drug of concern.’”

    Pharmaceutical Remedies

    Five of the people surveyed said that they tapered with the support of medications prescribed by their doctors to treat individual withdrawal symptoms. It is best that patients talk with their doctors and addiction professionals to see if a particular medication is right for their situation.

    Happy tapering! I plan on writing more in the future about my experience and progress tapering off Suboxone. If you’re embarking on this journey, I wish you luck!

    The names of some individuals have been changed to respect their privacy.

    Have you successfully tapered off Suboxone or methadone? Or are you a “lifer” like Shannon? We’d love to hear your thoughts, experiences, and tips in the comment section.

    View the original article at thefix.com

  • Lawmakers, Healthcare Facility Clash Over Treating Inmates With Addiction

    Lawmakers, Healthcare Facility Clash Over Treating Inmates With Addiction

    Is the risk of overdose higher in prison or upon release?

    A fight is underway in the state of Vermont over the execution of legislation designed to provide treatment for prison inmates with addiction.

    S.166, which was signed into law in May 2018, provides treatment with buprenorphine to inmates with the approval of a doctor—but legislators were dismayed to find that the medication was only being provided to inmates who were within weeks of their release dates.

    At the heart of the argument is the determination of medical necessity for treatment. 

    State Senator Tim Ashe, who was the bill’s main sponsor, told the Burlington Press that holding back treatment until a release date is counterintuitive. “For people who are serving relatively brief sentences, those who suffer from addiction should be getting the treatment and not having arbitrary deadlines,” he said.

    Centurion Managed Care, the state-contracted company assigned to provide health care for Vermont inmates, said the deadlines are in place to avoid increased risk of overdose after release.

    Risk of overdose is low in prison, according to Annie Ramniceanu, director of mental health and addiction services for the state Department of Corrections (DOC)—and therefore buprenorphine is not medically necessary until the risk is higher upon the inmate’s release. “Just because you want it doesn’t necessarily mean you meet that medical necessity,” she said.

    Ramniceanu’s position has health care advocates and criminal justice reform groups up in arms.

    Tom Dalton, executive director of Vermonters for Criminal Justice Reform, filed a complaint with the Department of Health’s Board of Medical Practice against Centurion’s medical director, Dr. Steven Fisher, that claimed that inmates are suffering due to the company’s directives and have taken to using buprenorphine smuggled into prisons.

    “Many high-risk incarcerated patients who are self-identifying as struggling with addiction and asking for help are unable to access treatment,” wrote Dalton in the complaint. “Some are being released back into our communities untreated.”

    Dalton’s stance is echoed by other public figures, including Burlington Police Chief Brandon del Pozo, who in a Facebook post from October 17 wrote, “Treat every prisoner who needs it with buprenorphine, methadone or Vivitrol as best fits them (Vermont is at least trying)”—as part of a list of strategies to combat the regional opioid epidemic that has gained national attention.

    DOC Commissioner Lisa Menard told the Burlington Press that the department is working to fully implement S.166 in the prison system, including a recent expansion of treatment to inmates who have reached their minimum release date, and treating inmates with longer sentences with other forms of medication-assisted treatment (MAT). 

    For Dalton, however, it’s the core issue that needs changing. “Their ignorance is killing people,” he said.

    View the original article at thefix.com

  • Will Naloxone Be Co-Prescribed With Opioid Painkillers In The Future?

    Will Naloxone Be Co-Prescribed With Opioid Painkillers In The Future?

    While some states already require the co-prescription, the FDA is considering making it a requirement across the US.

    In an effort to decrease overdose deaths, doctors could soon be required to prescribe an opioid overdose antidote any time they prescribe prescription painkillers, according to Food and Drug Administration (FDA) Commissioner Scott Gottlieb.  

    The idea of co-prescription, according to the Washington Examiner, isn’t a new idea. In fact, some states such as Arizona, Virginia, and Vermont, already require the co-prescription of the overdose reversal drug known as naloxone.

    Naloxone comes in the form of a nasal spray as well as an auto-injection so it may be administered by those not in the medical field.  

    Other states considering such laws include California, Florida, New York, Ohio, Texas, and Utah. 

    Such laws are supported by the manufacturers of popular overdose antidotes, such as Adapt Pharma, the company that distributes Narcan. 

    “We are trying to do anything we can to build awareness and broaden support,” said company chairman and CEO Seamus Mulligan, according to the Examiner. 

    Kaleo, the manufacturer of the naloxone auto-injector, is also supportive, telling the Examiner in May that it “welcomes” the idea of co-prescribing.

    “We believe that doctors, pharmacists and other healthcare professionals play a critical role in developing and managing a comprehensive treatment plan for their patients, as well as helping a patient and their loved ones recognize the potential risk for opioid emergencies, even when pain medications are taken as directed,” the company said.

    Current laws vary from state to state. In Vermont, prescription rules are connected to other laws requiring doctors to check patient databases before prescribing an opioid.

    In Virginia, it’s recommended that high doses of pain prescriptions are given with an overdose antidote prescription as well.

    Additionally, doctors are encouraged to prescribe the antidote when prescribing opioids and benzodiazepines, as the two can lead to overdose.

    The Centers for Disease Control and Prevention (CDC) has made similar recommendations in its guidelines to doctors. 

    While naloxone can save lives, it’s not considered a treatment for substance use disorder. 

    “Naloxone allows someone another day to have an opportunity to overcome their addiction,” New York state Sen. George Amedore Jr. said, according to the Examiner. “It’s not the whole answer or the cure-all.”

    As such, some officials are also calling for wider access to buprenorphine, a medication that helps to lessen cravings and withdrawals. 

    The FDA will hold a meeting on Dec. 17-18 to determine more ways to make the overdose antidote more readily available. 

    View the original article at thefix.com

  • Lack Of Suboxone Access Leads Users In Need To The Black Market

    Lack Of Suboxone Access Leads Users In Need To The Black Market

    President Trump is expected to sign a bill to expand medication-assisted treatment but it remains unclear as to how soon that will take place.

    A new feature by NPR underscores a potentially dangerous conundrum for health care professionals and individuals seeking treatment for opioid use disorder: while buprenorphine (also known as Suboxone, Subutex and Zubsolv) has proven effective in blocking the effects of opioids, it’s also difficult to find and a challenge to obtain due to federal limits on prescribers.

    As a result, many prospective patients have turned to the illicit market, where Suboxone can be obtained via diversion, or from patients who sell or give away their own prescriptions.

    President Donald Trump is expected to sign a bill to expand medication-assisted treatment (MAT), but as NPR noted, it remains unclear as to how much access will be granted and how soon that will take place.

    Along with methadone and naltrexone (Vivitrol), buprenorphine is one of three federally-approved drugs to treat opioid dependency.

    As the NPR feature stated, while it is less potent than heroin or prescription opioids, including fentanyl, it is possible to overdose on buprenorphine if mixed with other substances.

    But such instances are rare, especially when the drug is formatted with the overdose reversal drug naloxone. As Dr. Zev Schuman-Olivier, an addiction specialist and instructor at Harvard Medical School, said, “The majority of people are using it in a way that reduces their risk of overdose.”

    Despite its effectiveness and relative lack of harmful side effects, obtaining buprenorphine is subject to federal regulations in regard to who can prescribe it—medical professionals need a special waiver to do so—and how much can be obtained. Currently, those doctors that meet the federal requirements to prescribe buprenorphine are limited to treating 275 patients.

    Nurse practitioners and physician assistants may apply for a waiver to administer the medication as well. Under the SUPPORT for Patients and Communities Act, the number of such health professionals and the length of prescription may be increased.

    Until that bill is signed, buprenorphine remains both difficult to obtain and expensive. According to 2016 estimates provided by the U.S. Department of Defense, medication and twice-weekly visits to a certified opioid treatment program are $115 per week or nearly $6,000 per year. That puts the medication out of range for many in need, forcing them to turn to diversion situations for assistance.

    But as NPR noted, that scenario can be dangerous: patients need assistance from a treatment professional for proper dosage and treatment for mental health issues that may come as a part of addiction.

    Diversion has become prevalent enough to warrant calls for more regulations regarding buprenorphine and stronger enforcement against those that break the law. But the NPR story quoted Basia Andraka-Christou, an assistant professor and addiction policy researcher at the University of Central Florida, who said that stricter rules are not what’s needed for patients.

    “I guarantee you, they’re either going to go and buy heroin and get high, which surely is not a great policy solution here,” she said. “Or they’re going to go buy Suboxone on the street.”

    View the original article at thefix.com

  • An Open Letter to Addiction Treatment Providers

    An Open Letter to Addiction Treatment Providers

    There’s something wrong with addiction patients feeling the need to ask for medical advice from their communities because they don’t trust their providers.

    Maybe you’re a psychiatrist. Maybe you’re a dosing nurse at a methadone clinic. Maybe you’re an inpatient counselor. Maybe you work in an emergency department, or you’re an OBGYN; maybe you don’t specialize in addiction at all, but you regularly come into contact with people who are struggling with the condition. If you’re a medical professional, and all or some of your clients have a substance use disorder (SUD) diagnosis, this letter is for you.

    I am a person in remission from a substance use disorder. I’m here to tell you that addiction patients need you to understand our condition. That sounds basic, I know. It is basic. But here’s the thing: too many of you don’t understand. I’m not trying to attack you. I’m not saying you’re all misinformed. There are unquestionably many caring and well-informed providers doing excellent work in this arena. But it’s also true that enough of you are misinformed to be causing major problems for SUD patients. And that needs to change. Like yesterday.

    Right now my husband is white-knuckling his way through methadone withdrawal while his clinic works on getting him safely back on his therapeutic dose after one of you, a behavioral health doctor, rapidly dropped him 100 milligrams without consent, for no medical reason, while he was in the hospital for mental health reasons. And in 2014, my newborn daughter went through over a month of neonatal withdrawal from my prescribed methadone, which could have been prevented or lessened if my pre- and postnatal providers had made a few small changes to their protocols; sadly, this kind of medical treatment is still provided to mothers and infants across the country.

    Every damn day SUD patients crowdsource medical information from social media communities and online forums, often due to mistrust in the medical community when it comes to addiction care.

    Sara E. Gefvert, a certified recovery specialist who runs the Methadone Information Patient and Support Advocacy (MIPSA) Facebook group, says that she created MIPSA because she saw members of other communities receiving unreliable responses to medical questions. “Many MAT sites and groups I saw were not monitored frequently for correct and accurate content or were only adding to the misinformation and stigma that persons in recovery face, especially being on medication-assisted treatment.”

    In just one day, questions asked in five separate addiction treatment-focused Facebook groups included: 

    What kind of pain relief options are available during labor while I’m on buprenorphine?
    Should I raise my methadone dose if I have psychological but not physical cravings?
    Is it normal to lose my sex drive while on methadone?
    Am I still in recovery if I drink alcohol occasionally?
    Can cold-turkey opioid withdrawal kill you?
    Is it safe to detox while pregnant?
    Can you combine buprenorphine and methadone?
    Should my methadone be making me nod out?

    And others along those lines.

    These are all medical questions with real world consequences—some dire. The answers to these questions should be coming from trusted providers with medical expertise. Sure, people crowdsource medical information from the internet all the time, but it’s usually about pretty mild concerns, or trying to squirrel out whether they should go to a doctor. On the other hand, these addiction specific questions are often accompanied by complaints that the patient couldn’t get a straight answer from her treatment provider, or that the information she received was the opposite of what she read in a research study or an online article. There’s nothing wrong with people seeking community input on issues they’re facing, especially when the answers are reviewed by knowledgeable and professionally trained administrators like in the MIPSA group.

    There is, however, something wrong with addiction patients feeling the need to ask for medical advice from their communities because they don’t trust their providers.

    This seems to be an especially prevalent issue for medication-assisted treatment (MAT) patients. I was on methadone for about a year in 2013 and 2014, and on buprenorphine from 2014 to June of 2018 (with a short break of about five months in 2016). Before starting methadone, I was actively addicted to heroin for close to five years. In all of that time, I heard a lot of different things from a lot of different doctors, nurses, counselors and detox staff in virtually every region of the country. For example:

    Buprenorphine is only good as a detox aid.
    Buprenorphine works best as a long-term treatment.

    Methadone is more addictive than heroin.
    Methadone creates a dependency but effectively treats addiction.

    Breastfeeding while on methadone is unsafe.
    Breastfeeding while on methadone can help ease neonatal withdrawal.

    I can’t count myself sober if I take medication
    I’m at an increased risk of relapsing and overdosing if I detox.

    Addiction is a disease.
    Addiction is a spiritual malady.

    How was I supposed to tease out the truth from all that?

    With all the confusing and contradictory information that patients receive about addiction, it would be easy for someone to assume that the medical science is still out. In reality, there’s quite a lot of straightforward, peer-reviewed data about substance use disorders. Frankly, there is no excuse for a medical provider to ignore these facts. For example, decades of research have shown that methadone (a long-acting opioid agonist) and buprenorphine (a partial opioid agonist), help deter opioid misuse, decrease the risk of fatal overdose, and may help to correct neurochemical changes that took place during active addiction.

    To quickly address some of the other misinformation I’ve encountered:

    • Both methadone and buprenorphine treatment are appropriate, and in fact designed, for long-term use. Patients who choose to taper from these medicines can do so safely, but there is no generalized medical reason why someone with an opioid use disorder should be forced off either medication.
    • Breastfeeding while on methadone or buprenorphine is considered safe as long as the mother is not using other substances.
    • If a patient is using these medicines as prescribed and is not using other substances in a compulsive manner, they are in remission from their substance use disorder. In other words, they’re sober (though defining oneself with the term “sober” is a personal choice).
    • Addiction is medically defined as a disease. Which means that the onus is on our medical providers to stay informed about the science of this disease.

    Ultimately, you can’t be held responsible for everything your patient does. But you do have a responsibility as a treatment provider to give your patients accurate and informed medical advice.

    According to the Substance Abuse and Mental Health Administration (SAMHSA), about 20 million adults in the United States have a substance use disorder. So we’re not talking about some rare condition that only a handful of specialists can be reasonably expected to understand. This is a common, treatable disorder with a robust body of solid research behind it. You need to read that research. You need to stay informed. If you don’t have an answer to a patient’s question, you need to refer them to an accessible colleague who will. You took an oath to do no harm. Staying informed about addiction medicine is part of keeping that oath.

    Sincerely,

    Elizabeth Brico

    View the original article at thefix.com

  • Why Hospitals Offer Treatment Referrals In Lieu Of Addiction Services?

    Why Hospitals Offer Treatment Referrals In Lieu Of Addiction Services?

    Only 5% of ER doctors work in hospitals that offer buprenorphine or methadone.

    A recent Huffington Post feature highlights a conundrum within the medical community’s response to the opioid crisis: emergency room patients with opioid use disorder who receive a dose of buprenorphine are twice as likely to continue treatment within the next 30 days than those who were referred to outside treatment facilities.

    Despite those statistics, a survey by the American College of Emergency Physicians (ACEP) found that only 5% of ER doctors work in hospitals that offer buprenorphine or methadone, of which there are less than 100 in the United States.

    The ACEP study, which polled 1,261 emergency physicians in 2017, found that 9 in 10 respondents felt that the number of patients seeking opioids had increased or remained the same during that year. But at many hospitals, patients seeking medical assistance for addiction-related issues are given the phone number for local clinics.

    Dr. Andrew Kolodny, co-director of the Opioid Policy Research Collaborative at Brandeis University, cites a number of reasons why this approach might be favored over administering buprenorphine or other opioid treatment drugs.

    Emergency doctors and nurses may have antipathy towards drug users, who are often in their worst possible states when arriving at emergency services, said Kolodny. Hospital administrators, too, may perceive such patients as poor insurance risks, especially those in states that have not expanded Medicaid; offering services beyond treatment referral could take up staff and available beds.

    Prescribing buprenorphine also requires a license from the Drug Enforcement Administration (DEA), and many physicians are not willing to complete the eight hours of clinical training required to receive it.

    But as the Huffington Post feature notes, a number of hospitals across the U.S., including 10 in Maryland and multiple locations in California and South Carolina, do offer addiction services, which typically entail screening by caregivers and an interview with a peer recovery coach to determine if the patient is willing to accept treatment.

    ER doctors and nurses will treat the patient’s most urgent medical needs, and then administer a dose of buprenorphine. 

    A 2017 study by the Yale School of Medicine found that patients with opioid use disorder who receive such a dose in an ER were twice as likely to be involved in some form of treatment a month later, compared to those who were not. Dr. Eric Weintraub, an associate professor of psychiatry at the University of Maryland School of Medicine, is a proponent of addiction services in emergency rooms, and now works to help other hospitals adopt that approach.

    “We’ve learned that certain places are conducive to engaging patients in treatment,” Weintraub told HuffPost. “One of them is the ER. The other is the criminal justice system. We need to grab those opportunities and offer patients effective treatment when they’re ready.”

    Currently, addiction treatment specialists are watching addiction services programs in Maryland and other locations to see if the approach proved effective over long-term periods. “If this movement… is successful and starts to become normalized nationwide, it could change everything,” said Kolodny.

    “If you really want to see overdose deaths come down in the United States, getting treatment with buprenorphine has to be easier and cheaper for people with substance use disorders than getting heroin or other opioids off the street,” he said. “And what could be easier than walking into an ER and getting started on buprenorphine?”

    View the original article at thefix.com

  • New Dosage Strength Of Opioid Addiction Drug Approved By FDA

    New Dosage Strength Of Opioid Addiction Drug Approved By FDA

    The FDA commissioner noted that the approval will expand access for patients and reduce drug development costs.

    The U.S. Food and Drug Administration (FDA) approved a new dosage strength for a maintenance drug for the treatment of opioid addiction.

    Cassipa, which is a sublingual (applied under the tongue) film that combines the opioid treatment drug buprenorphine and the opioid overdose reversal drug naloxone, will now be available in a 16 milligrams/4 milligrams dosage, and according to FDA Commissioner Scott Gottlieb, should be used in conjunction with counseling and therapy.

    The new dosage strength is approved by the FDA in both brand name and generic versions, and in various strengths.

    The approval underscores the agency’s emphasis on greater development of and access to medication-assisted treatment (MAT) for substance use disorder. The full range of MAT is a key element of the U.S. Department of Health and Human Services’ Five-Point Strategy to Combat the Opioid Crisis, and was the focus of guidelines issued to drug manufacturers for evaluating the effectiveness of new or existing MAT products. 

    In a statement issued in April 2018, Gottlieb described the FDA-approved MAT drugs—methadone, buprenorphine and naltrexone—as “safe and effective in combination with counseling and psychosocial support to stabilize brain chemistry [and] reduce or block the euphoric effects of opioids.”

    The FDA has also cited statistics from the Substance Abuse and Mental Health Services Administration (SAMHSA), which found that patients using MAT for opioid dependency have reduced their chance of overdose death by half.

    In addition to its suggested efficacy for opioid use disorder, Gottlieb noted that newer treatment options like the increased dosage strength for Cassipa will not only “broaden access for patients,” but may also “reduce drug development costs, so products may be offered at a lower price to patients” via the agency’s “streamlined approach to drug development for certain medication-assisted treatments that are based on buprenorphine.”

    This approach is the abbreviated 505(b)(2) pathway under the Federal Food, Drug and Cosmetic Act, which allows manufacturers to use the FDA’s findings regarding the safety of their product to grant approval.

    The FDA is advising that Cassipa should be used in conjunction with a complete treatment plan that includes counseling and other support, and should only be used after the patient is introduced to the drug and stabilized up to a dose of 16 mg of buprenorphine using another marketed product. Additionally, Cassipa can only be prescribed by Drug Addiction Treatment Act-certified prescribers.

    View the original article at thefix.com