Opioids and Medications to Treat Opioid Dependence

Opioids and Medications to Treat Opioid Dependence


>>Hi, my name is
Colleen LaBelle. I work for Boston University
Medical Center and also for the Bureau of
Substance Abuse Services. I am the Program Director for their state office-based
opioid treatment program, which essentially is providing
training and technical support to 17 at-present community
health centers that are funded through the bureau and
additional health centers that are going to be coming on
board with funding that’s coming from HHS from the opioid
task force initiative that the governor put out. So I’m here today to
talk about medications to treat the opioid dependence
issue and that we’re struggling with in the state
of Massachusetts. So this is a billboard
actually that the bureau put out back some years, and I just
find that it’s very, you know, pretty much, it’s very poignant
in talking about, you know, what it is that happens. That people don’t
make the decision that they’re going
to become an addict. It’s not a career choice. It’s, you know, something that
happens unfortunately based on people’s behaviors
and people’s decisions to experiment with things. And from that we’re seeing
this horrific epidemic that’s impacting us. And this here is the map
that shows you back in 2005 when you look across the
country, it shows you people that are dying from overdoses
and those that are dying from traffic fatality. And in ten states in ’05,
they were more people dying from overdoses than
motor vehicle accidents. But we don’t talk about that. We still don’t talk about it. And as you can see when
you look at the map, Massachusetts unfortunately
had this statistic. And a few of the other northeast
states were also struggling. So then you take that and you
go ten years, five years further into 2010, and that statistic
has gotten even more horrific. And now there’s 31 states
that have been impacted by this opioid epidemic more so
than motor vehicle accidents. And now in 2015 I think we’re
somewhere around 37 or 38 states that hold this statistic. But again, when you look at the
news and you see what’s going on out there and
you talk to people, this is not what people
are talking about. This is not what’s on the
front page of the newspaper. No one’s talking about this
silence stigmatizing epidemic that’s hitting our communities
and our families across America. So in 2014 the CDC put
this statistic out, which again just really
speaks volumes because we talk about the Ebola epidemic. And we talk about other things
that are impacting people. And you’re talking about one
or two people potentially that have these fatal viruses. When we look at the opioid
epidemic, we’re losing over 120 people a day
in the United States of America from this epidemic. These are unintentional
overdoses. And so this is the biggest
public health problem that we are faced with
right now and the one that we’re probably talking the
least about is getting better. And in Massachusetts we’re
doing a much better job. Actually we’re a leader, and a
lot of what we are doing here across the country, people
seeing what’s happening and seeing even from the
era of Michael Botticelli and what he’s now doing across
the country at the White House. And his impact is
really changing the road and changing how we’re looking
at this disease, and hopefully that is going to
continue to spread. This here shows you in
Massachusetts it’s always hard to get the complete data as far as how many people have
died from an overdose. And the secretary’s office
is very committed to trying to get data in real time. They actually just came out
with data from 2014 that showed that we’re about a little over
1,000 people in 2014 looks like have died from
unintentional overdoses. And again, those
numbers are climbing. And it’s much higher than
motor vehicle accidents. And we had a period of time where the overdoses
have stabilized. And that’s actually
when we did a lot of [inaudible] administration. Massachusetts, again, much
ahead of the curve as much as [inaudible] administration,
reverse more than 2,000 overdoses
that have been reported. People don’t have to
report the overdoses now, so we don’t essentially know how
many people have been reversed. But we know that there’s a lot. But with that we’re still losing
greater than 1,000 people. And unfortunately the
numbers are not solid because when you look at
western Springfield and Boston, they don’t get reported
in that same database, comes from the M.E.’s
office, and as we all know, the M.E.’s office
unfortunately is very, very much behind
with the amount of medical exams they are doing. So we don’t have
hardcore members there. This here shows you where
this all happening from. So everybody knows we’re talking
very loudly about the fact that we have a prescription
drug epidemic and we’re over-prescribing
prescription drugs. And as much as that’s a
problem or has been a problem, that problem is really
resolving. Providers are becoming
more educated. Providers are being required
to take training programs, especially in Massachusetts. Some states are not there yet. Again, some of them are a little
bit further behind than we are. But in Massachusetts
all providers that have prescriptive
authority have to do three hours of [inaudible] or some type
of risk management credits now to actually renew
their licensure. And so with that, and
with, you know, the media and the prevention
and the education and what have you that’s been
going on across Massachusetts, we’re seeing less and less of
people prescribing opiates. And we’re also seeing
it in other places. Unfortunately, it feels like that pendulum is
swinging a little bit too far, and now we’re under-medicating
folks that do have chronic
and acute pain. And you know, people are being
stigmatized and treated unfairly that have those issues. And so that’s, you
know, a balance we have to figure out how to fix. But the other piece of this
that’s really disturbing is as the opiate prescribing
is going down, the heroin use is going up. So an unintended
consequence of us, you know, clamping down on prescribing
and providers thinking about it and not using opiates as
the first line all the time, and not using them in large,
large volumes, except for, you know, when they’re
actually necessarily. When you walk out
from a surgery, you shouldn’t be walking
out with 120 Oxycodones. You when you have
your teeth extracted, you shouldn’t be
getting OxyContin. You know, so trying
to think differently about all that is happening. But then those that were,
each either had an abuse issue and got shot off or
haven’t been able to get it because the resources
aren’t there, and less prescription drugs on the street are
turning to heroin. So that is very,
very, very disturbing. So in Massachusetts on
the governor’s task force, the governor is very committed. This is one of his
number one priorities. And with that, there’s four
areas that are being addressed, and that is prevention,
intervention, treatment and recovery. And in order for this to work,
this is a complex disease much like a lot of the other
complex diseases we all treat, especially in public
health sector. You can’t just treat one piece. You’ve got to treat
the whole person. And you got to put all
the resources in place in order for it to work. So when we sat down to
try to figure this out, and everybody was coming
from different silos and everybody had
their own agenda, it was really clear on it. You couldn’t just like do this
or do that and be done with it. We all had to come together,
and we all had to figure out how to do this collectively and
how to treat each person as an individual with that
individualized treatment plan. So drugs are affecting
all of us. I mean none of us can say that
we haven’t been touched by this. They, you know, addiction
affects the brain. It changes the brain chemistry. It creates medical
comorbidities. People are hospitalized
with the infections, with the cellulitises,
with this heart disease. You get endocarditis. People end up needing their
heart valves replaced. People are getting HIV. Hepatitis C is rampant
in substance abuse. As most of us know, mental illness is
obviously a factor here. And folks that are
struggling with mental illness that are not getting treatment
are at a really great risk here. The economy is a factor. Productivity, I mean
we know that one out of every ten full-time
employees has a substance use disorder. So if you think about that
in your work environment, you have somebody
struggling with substance use, they are not able to do
what it is they need to do. So that’s affecting
the entire team. The healthcare, and you know, cost factors is a
huge factor with this. People are being hospitalized. They’re then ending up in
six weeks of, you know, needing to be in a program where
they need to get IV antibiotics. They need after care. They need skilled
nursing facilities. There’s just so many
pieces to that. And the homelessness, the crime
and the violence, you know, are factors regulated to
someone’s substance abuse. And it’s not just the person on the street corner that’s
drinking out of the bottle or that’s homeless as in
substance abuse problems. This is affecting, you know, affluent communities
across America. And in Massachusetts
we’re seeing this. We’re seeing this hitting areas which never even knew the
words heroin or ever thought that that could be, you
know, a problem for them. So just, I just wanted
to just like, people hear the words opiate
and opioid all the time. And I just wanted to explain
to people what it meant so that you just had a little
bit of a handle on that. Opiates is something that
comes right from that plant. So that’s the poppy. And that is a pure
form of an opiate. But every drug that
somebody uses that has an opiate
in it is the same. It works the same way. The others are just
manufactured. So it’s either fully
manufactured or partially manufactured. So some part of it may
come from the plant, and the rest of it’s
manufactured. But they all work the same way. So what we’re trying
to do is to talk about everything as an opioid. That will, it kind
of covers everything. The other thing that’s important
about this just for people when you’re taking care of folks that may have a substance
use disorder is if you’re testing
somebody’s urine, and they’re on the, and
they’re abusing Sentinel, or they’re abusing Methadone, and you just do a standard urine
test that doesn’t have Fentanyl or Methadone in it,
it’s not going to show up on the urine screen. So those are the things
that are important when you’re looking
at, you know, opiates and opioids is testing for
the appropriate substance. So historically opiates have
been around a really long time. There were morphine
clinics back in the 1900s. And then what happened
is the AMA declared that you couldn’t treat
someone’s substance use disorder, which they obviously
didn’t call it that back then, in your office practice. And so that Harrison
Narcotic Act made it illegal to treat addiction. And so these clinics
closed down, and now people just
imagine what happened when you take someone’s
medication away from them that’s now dependent
is folks had nowhere to go. People didn’t understand
addiction that well. There were only two hospitals
in the entire country. There was a greater
than 90% relapse rate. So there was this
large period of time where people weren’t
being treated. People were being undertreated. We were undertreating
cancer and everything else, and it kind of feels like
we’re swinging that way now, which is a little concerning. Until like the 1960s. And in the 1960s, Dr. Dole and
his colleagues did research around Methadone
and learned that Methadone was actually
a really effective tool to treat opioid dependence. And so Methadone was actually
legalized back in the 70s. President Nixon allowed
it to come out and be regulated federally, you know, guided clinics, which most of us are very
familiar with, that have lots of rules and restrictions. And those rules and restrictions
still remain here today. They really haven’t
changed a whole lot. But it is an effective tool. I know a lot of people
have opinions and thoughts about Methadone. But I would caution you to
remember that it is a tool, and that those that you are
seeing that are not doing well on it, are those the
only people you know? Those that are doing well on
it are invisible to everybody. And that’s the unfortunate
thing. Methadone gets the back slack because they see the people
hanging out at the street corner that just came out of a clinic
or just came into our place and went to Dunkin Doughnuts and bought some Klonopin [phonetic], and now they’re nodding
out in their coffee. Those are the folks
that are not doing well. Not everyone does well
that’s in treatment that has a substance
use disorder. But there’s a lot of functional
people that get up and go to work every day and are
invisible to all of us. So this was a postcard. This is Mrs. Winslow’s soothing
syrup which has morphine in it. And if you can imagine,
they were using this for teething for children. Like, does anyone’s house
look like that at night? You know, really cozy. Everyone’s totally
cool, paying attention to what mommy’s reading. But you know, we
learn from this. You know, this is, unfortunately
people didn’t realize that this was really
not a cool thing to do. And some of us grew up
remembering Paregoric, you know, Paregoric is this
liquid formula that, it’s also a narcotic
factious schedule one. And they were using that
to put on kid’s gums when they were teething. So you did any of this today
they’d take you out in shackles. Your kids would be gone. Your life would be over. But just to let you know, I
mean, we’ve learned over time. Everyone remembers
Coca Cola for cocaine. And here is Bayer aspirin. Bayer was manufacturing
heroin and selling it over the counter to
treat your cough. So those of us in the
medical field know that that probably
worked real effectively, not just because it made
the person sedated and high but because heroin is an opiate. And when you have that really
horrible, horrible nagging cough that doesn’t go away, and that bronchitis, and they
give you Robitussin AC, it’s not the Robitussin
that’s doing anything, it’s the codeine
in the Robitussin. Because the opiate
suppresses the cough reflex. So I don’t think we’ll
be seeing, you know, Bayer manufacturing heroin
over the counter, although Portugal has legalized drugs
and has found it actually to be a very effective tool in that it’s decreased their
crime and their drug use. And people are in treatment. But I don’t foresee
that happening in the United States any
time in our lifetimes. This is a pretty, you
know, primitive picture. You know, this is
your brain on drugs. Those are, again, those
of us who have been around remember this
from the 80s. And you know it’s primitive,
but it’s kind of real when you really stop
and think about it. Opiates change your
brain chemistry. You know, I mean that is real. And when you stop and you think about this disease,
it is a disease. It has all the same
characteristics as the other chronic
relapsing diseases that we treat every day. You know, and when you don’t
treat it, it progresses. And it can be terminal. People die when we don’t
treat their terminal diseases. And so it’s not that
easy for that person who has now become dependent
on that drug to just stop. So we all have a control
center in our brain. It’s our midbrain. And it remembers things. And our frontal lobe
processes things. And what happens in
the addict’s brain is that midbrain becomes
changed, and it needs that drug to feel normal. So it’s no longer
a conscious choice for that person not
to use that drug. And what it is again
select go and gets released and makes people feel
good is the dopamine. So we all get dopamine surges. We need dopamine. Dopamine is a normal
part of life. And it sustains life. We need to have pleasure in
our lives from people, places, things, children,
you know, activities. But unfortunately with
opiates, and with an addiction, is your brain actually
gets a more of a dopamine surge than it would with normal pleasurable
activity. And so that’s where the
drug becomes the problem. Sorry I’ll just go
back here for a second. So you think about the person, so say you walk into
Disney World. Walking into Disney we
all get excited, right. I mean it’s just very euphoric. It’s a wonderful place. Children are having fun. There’s all this
like excitement. The person with addiction walks into Disney World
and they feel flat. They’re like I don’t get it. What’s everybody
all worked up about. Why is this such a great thing? And it’s because their
receptor, that their receptor, their normal is up here now. So normal is here for us. We’re feeling good. The person who use the drug, that receptor got set
to a higher level. So in order to feel good,
they need to be up here. So without that drug,
they feel blah. If you just imagine
not getting pleasure. So you had a substance
abuse issue. You stopped using. And now you feel flat. You have no pleasure. I mean that’s a pretty horrible
place for someone to be. And unfortunately that’s
what happens when addiction. Because of the brain change. So just in comparison, just to
try to think about this more. Because a lot of people
struggle with this. I think we, you know,
everybody does until you get a, you work with this so you
get more of a sense of it. This is a disease. And the problem with it is that is has a behavior
associated with it, okay. So people say they made that conscious choice
to use that drug. They made that decision. They made that bed, let
them sleep in it, okay. So you think of the diabetic. You know most diabetics,
you know, they may have diet issues
associated with the disease. It may be genetic. But it may be diet associated. They may not be taking
their medication. They may not be eating the
way they’re supposed to. They may not be following
up with their appointments, checking their blood sugars. So their diabetes goes
in and out of remission. They’re relapsing. But we never say that, right. So now their kidneys shut down. Their blood pressure is high. They’re not maintaining well. They need toes amputated. They have these acute problems
related to their disease. And a lot of it is
based on their behavior. Not all of it all the time,
but a lot of it can be. And we don’t judge that person. We don’t treat that
person differently. How about the hypertensive
patient who now knows they have
hypertension who’s supposed to follow a diet, who’s supposed
to take their medication. Who’s supposed to
walk every day. Who’s not supposed
to take salts in. Shouldn’t be drinking. You know, and now they
just drank two twelve packs to watch the Pats win, you know,
the World Series or whatever. Sorry, just lost that. But anyway, they watch the
Pats win the Super Bowl. And in doing so, they
drank two twelve packs. They got chest pain. They ended up in
the emergency room. They have already
had a stint put in. Now they just had
bypass surgery. Now they need another stint. Do we judge that person? Do we not treat that person? Do we tell them they
had a relapse? Or do we treat that person who’s
in an acute crisis who could die if we didn’t treat them. We treat them and we
don’t even think about it. And what about the asthmatic
who continues to smoke? Or who has smoked
all their life, and now they have
fairly bad COPD. And now they have asthma. They come in, they
can’t breathe. They need an inhaler. It doesn’t work. You do a net treatment. It doesn’t work. They need to go on a vent. We treat them because we don’t
they’re going to die, right. So all those folks have
behaviors associated with their disease. It’s not always their complete
reason for their disease. But they have behaviors and genetic components
in some of them. The same is the person
with addiction. The problem with the person with addiction is their
behaviors are really horrible. We can’t stand their behaviors. There’s no doubt about it. It’s horrible, horrible
behavior. They steal. They’ll take from
their grandmother. They’ll hold up a drugstore. You know, they will do whatever
it takes to get that drug to manage their disease. And that’s their brain that’s
telling them they need it. And they can’t go to their
local CVS and buy heroin. It just doesn’t work that way. So they have to manage
their disease. And in doing so, they engage in
some pretty horrible behavior. So I don’t want to, you know, say that’s okay because
it’s not. But I think you got to
stop and separate it. It’s not the person
you don’t like. It’s the behavior. You know, so when you take
that drug away from that person and that person’s in treatment, that person’s usually
a wonderful person. Think about the alcoholic. A lot of us know
alcoholics, right. And alcoholics are
typically have a great time. And when you take the drug away
and you get them into recovery, they are great people. But when they’re drinking,
you can’t stand them. They are like your
worst nightmare. You don’t want them
at the party. You don’t want them to
come to the family reunion because they’re going
to ruin everything. It’s the behavior. It’s not the person. And so just try to, you know, separate that when we’re
struggling with this disease which will tear on your
heartstrings and really, you know, push everybody’s
buttons. So what happens here? So I started talking about this. So when the person
uses, they get euphoric. So a person’s at a party. A teenager is at a party. They’re [inaudible], they’ve
got the pill thing going. You know, people
are sampling pills and trying different things. They take that pill
and what happens? They get high. You know, what happens
when you drink that alcohol for the first time? You get high, or you
use that other drug or whatever it is
you’re going to try. You get a euphoria. You get pleasure. So they go back the
next weekend. They try it again. They’re looking for that high
they felt the first time. People are always trying to
get back to that euphoria because it’s usually the
best feeling they’ve ever had in their life. People will tell you that. They’ll say oh my God, then
they’re chasing that high. I just want to feel
what I felt last time. But over time, they’ll
use again and again. Their body now needs the drug. So the more they do it, the
brain starts remember it. That midbrain is like
hmmm, I like this. I want more. But as they do it, their
body develops a tolerance. So they need it. And when you take it away,
they enter that red zone. So when that medication,
that drug. It’s not a medication
that’s being abused. When you take that drug away,
they go into withdrawal. When that person
goes into withdrawal, they are physically sick. It’s like the worst
flu of your life, and no one wants to be there. So what they’re going
to do is try to use. But the person who uses opiates,
opiates are short acting. The opiates people
like to abuse, not the, you know MS Contin, you know, people, or the Fentanyl the way
it’s supposed to go. That’s not what people
want to abuse. They want something that’s going to give them a big
bang for their buck. That’s why they used to take the
OxyContin and they would melt it down and get the entire 80
milligram that’s supposed to be over 12 hours in one shoot. That’s what they’re feeling. They don’t want that pill
that’s keeping them at a level. So when they go in and out
of that withdrawal every six to eight hours they
have to use again. So somebody who has an
addiction has a full time job. They have to figure out
how they’re going to use, when they’re going to use,
when they’re going to get it and how they’re going to
pay for it and how not to enter the red zone. And then we’ll see some of our patients they’ll
come in to see us. They’re sitting in the waiting
room, and now they’re gone. Where’d they go? They started going
into withdrawal. They couldn’t wait
for you any longer. They had to leave. And so, but they’re only using
now to keep from getting sick. Now just imagine that. Now you’re spending your whole
day trying to get drugged to keep yourself
from being sick. And a lot of our patients
that have been using 30 and 40 years will tell you that. We like love our
long-term heroin addicts, and they’re not using
anything else, because they just don’t
want to do this anymore. And they don’t want to be sick. And so to give them
something that manages that and is like a God sent. So this is what happens. Here’s your brain. Somebody uses, you get
high, you have a good time. We, you know, everybody does
things that are not good for us. But it doesn’t always
change your brain. But unfortunately with addiction
it actually literally changes your brain. So that’s what happens. That’s your midbrain. So this is the control center. It’s telling us, and you know, the midbrain is saying
that was good. I want more. Send more. I want more. I need that drug. And that brain is literally
screaming at that person when it no longer
becomes voluntary. So that’s when that person
needs that drug to feel normal and engages in horrific behavior
to manage their disease. So here again, it
just shows you that. So here you are the
normal, euphoric. And over time, it decreases,
and they’re just in a phase where they’re maintaining. Does that mean everyone
who’s using substances out there isn’t getting high? No. Unfortunately they may be
maintaining on their heroin, but then they’re putting
added things on top of it, which is what I think
we’re all struggling with. You know, and so you have that
person who is on Methadone, or you had a person
who is on Suboxone. And they may be taking those
meds, but then they’re, you know, taking Gabapentin,
and they’re taking Klonopin, and they’re adding other things
because unfortunately people who have substance use
disorders are smarter than we will ever be. And they are little chemists. And they have figured out what
to take and what enhances what and what’s going to
cause what euphoria. And that’s unfortunately
what a lot of us are seeing that we need to respond to. Because that’s the stuff that’s
really harmful for folks. So when someone does use, so I talked about they
go into that red zone. They have that physical
withdrawal. So you say okay, fine,
send them to detox. So they go to detox. Detox isn’t a treatment. And I just wanted everyone
to always understand that. Detox is detox. It takes the substance
out of your body. But now you need treatment. So when that person
comes out of that detox, that brain is still
screaming at them. Remember that receptor
has changed. That brain is screaming
for that drug. And they have the
long-term effects. So they have the muscle ache. They have pain. They can’t sleep. They can’t sit in
their own skin. They’re uncomfortable. They’re anxious. They have no pleasure. So that person is
absolutely miserable. And that’s called
protracted withdrawal. And that can go on
for months or years. You know, and so that
person needs treatment. Does that person
need medication? Not everybody. But a lot of folks do. But on top of that
they need counseling. They need to figure out how
to live without the drug. And that’s the really hard
part is how do I live my life without using a substance? And patients, you know, don’t
know how to do that or can’t, or don’t have the skillset. And that’s where they need
our guidance and our support. The detox is the easy part. Getting them through that
first part of it is the after piece of the struggle. Something I know we’re
not, we’re not talking about adolescence, but I
think adolescence is important to all of us. Excuse me. So adolescence, whether
you have adolescence, whether you know adolescence,
whether your family, wherever, it’s important. This is prevention. We’re all public health workers. We all take care of the public. And we need to do our
job as best we can, is trying to get messages out. Adolescence is the
most challenging time. And anyone who’s ever had a
kid or has children will tell that I don’t know what happened
to my kid, who took their head, swapped it and sent
somebody else up. Because they engage in
behaviors like this. But when we all stop and think
about our adolescence, you know, you think about crazy
stuff you did, right. And you think oh my
God, how did I make it? I don’t understand. Or you think about other
people that did it. But adolescence is a time when your brain is literally
going through changes. And you don’t think
rationally like an adult thinks. You don’t think of
the consequences. How many of us would
jump off that bridge? You know, I’d be there. Okay, how deep’s the water? Is the tide out? Are there rocks down below? I’d have to check all that out. Where are the boats? These kids aren’t
thinking about that. They’re thinking about
oh my God, big energy. Lots of bang for my buck
without a lot of exertion. And my friends are
doing it, okay. That’s all. Not, my mom’s not doing it,
but my friends are doing it. So it’s not about consequences
when you’re an adolescent. Everything is impulse driven. I mean you’re not, this kid’s
like no gear, no nothing, out on the street
on a skateboard. Like can you imagine? He’s not thinking about whether
the car stops, whether he rolls under it, whether
it hits the brakes, whether something comes behind. That’s not where his brain is. And that’s because his brain
is an adolescent brain. The adolescent brain, if you
look at the brain on the right, is using the amygdala
component of the brain. That’s the impulse part. Biggest bang for your buck. What does an adolescent
want to do? They want fun, and they
don’t want to do anything. They don’t want to
do the laundry. They don’t want to
do their homework. They don’t want to mow the lawn. They want to play games on
their computer, on their iPhone, and they want to, you know, do
fun things with their friends. But it’s normal. It’s frustrating,
but it’s normal. An adult who’s grown and has
the mature brain is using their frontal cortex. And they’re processing
and judging and thinking through things before
they do things. Or at least we hope they are. So this just shows you, and this
is why this riff is happening. We have learned through science
that the adolescent brain goes through this change and
all the neurons slop off, and they rebuild. And they get stronger
and more effective. And when that brain is
finished developing, that brain will be
faster and more efficient than any of our brains. However, that time period
doesn’t actually happen until early 20s are complete. And the last part of the brain to develop is the
frontal cortex. This is why when we try
to reason and rationalize with adolescents,
we struggle so much. Because that’s not where
their brain is that. They’re using, they’re
functioning off of impulse. So you know we say
kids can more out. They’re 18. They can go to war. They can vote. You know, they can, you know, they can do all these
other things. But in reality, their
brain is still developing. And so that’s really
important to think about, because when you
talk about addiction, and that adolescent picks
up a drug or an alcohol, in that time period, when their
brain is still developing, their risk of developing
addiction is so much greater. So we know that the adolescent
who uses substances is between 12 and 17 is 67% more
likely to become addicted. And even between 18 and 25, they’re 26% more likely
to become addicted. So it’s not just about
telling kids what to do, it’s about trying to guide them
for the rest of their life. They’re trying to help
them make good choices so that their life
doesn’t become impacted by substance use. And that’s a really hard
thing to do because again, adolescents don’t listen to us. They don’t think
we know anything. They’re thinking their parents,
somebody swapped their head. And they want you to
drop them at their corner and their friends
know everything now. So. Unfortunately this is a
hard thing to do, and again, the HHS secretary
is really committed. And as people have started to see the PSA announcements
that are out, really talking about prevention
and education, and there’s going to be a lot more coming. And a lot more education. Education is actually going into
the schools where it’s going to be mandated that addiction
education has to happen, some type of an evidence-based
curriculum in every school district. So how do we treat this? What do we do? So when someone, if
someone gets to the point where you haven’t treated them
and started using substances, you have to treat them. Can they go without medication? Some people can. But some people, most
people cannot unfortunately. So that new receptor,
that’s your pleasure center. That’s the thing that gives you
the biggest bang for your buck. So we have a full agonist. We have partial agonist. And we have antagonist. And so we’ll talk
about those three. So your antagonist is
something that’s going to block your receptor. So remember your neuro receptor
is your pleasure center. Somebody who has a
substance use disorder, you don’t want them to use. That’s the goal. You don’t want them
to use that substance. So if you can block that
receptor and keep them from using, that sounds like
a good thing to do, right. So there is a medication
that you can give somebody that does that, and
that’s called Naltrexone, or otherwise known as Vivitrol. So what that drug does is
when you give that medication to the person either orally with
the tablets on the top right, or by injection, with the
injectable on the bottom right, you’re going to block
that opioid receptor. So if that person
goes ahead and uses, they’re not going
to get any effect. It’s somewhat like
Antabuse for alcohol, but Antabuse actually
makes somebody sick if they were to drink. In this case it will
just block it. So the person takes their
medication in the morning, then they go and inject heroin. And they’re not going
to get any benefit. They’re not going
to feel any effect. So the Naltrexone
formula is the oral. That’s a tablet. So somebody can take
that in a tablet formula. And anyone who has prescriptive
authority can prescribe it. It’s pretty safe. Some people get some
stomach distress with it, but it’s a really
pretty safe medication. The hard part about this is
keeping somebody taking it. And so people will just
get up in the morning, make a conscious
decision, I’m not going to take my Naltrexone today. I’m going to get
high this weekend. You know if you have a
spouse or a family member, or you’re in a program
or somewhere where someone’s administering
medication, then that helps your chances
of continuing the medication. But when you’re on your own
and you have a disease that, you know, affected your brain, you might make the
wrong decision and stop taking the medication. So what the company
then did is they changed and made a new formula
called Vivitrol. And that’s the injectable
formula. And the injectable formula
can actually be used for opiates or alcohol. It’s kind of a nice thing. It has to be given
once every 30 days. It’s a pretty big injection, so people in the
medical field is 3.4 MLs, which is substantial. Usually we don’t go over
3 MLs in an injection. And it gets given in the butt. It’s a deep intramuscular
injection. It’s pretty safe. It is expensive. And if somebody were
to use on top of it, they’re not going to feel it. The problem is you can’t give
it to somebody if they’re using. They have to come off
the opiates first. And there has to be no opiates
on the receptor, or you’re going to make them really,
really sick. So that’s the challenging
part about it. It is once a month. It gets refrigerated. It has to be given by a
physician, a medical provider. And you need to get
approvals for it. But all the insurers
in Massachusetts, I should say all the insurance
except self-insurance is some that may be a little bit
quirky, will cover it. But a lot of times it comes
from a specialty pharmacy, which is a challenge because
it has to be delivered. And it has to be refrigerated. But the straight Medicaid, standard Medicaid
plans all cover it. And you can purchase it, like
you can go get it at CVS. And so that is so much
easier to deal with. At BMC we actually do it
through our internal pharmacy so patients don’t have to deal
with that piece of it just to take that loop out. But it’s definitely a challenge
in the ordering process. So then there’s a full agonist. A full agonist is something that
totally occupies that receptor. So remember that receptor is the
pleasure center in the brain. And if you give somebody
a full agonist, the more they take the
more effect they get. And those are typically
the drugs our patients who have opiate dependence
like to abuse. Now Methadone I put there only because Methadone
is a full agonist. And it can be abused
in different formulas. But it’s not typically a
medication that patients would like to abuse because it’s
long-acting versus short-acting. So it’s not going to give
them that same euphoria. So again, the more somebody
uses of a full agonist, the more effect they will get
on that receptor in the brain. And that can be risky, because
they can have an overdose with that medication
or with that drug if they’re [inaudible] it. So with Methadone we
know it’s evidence-based. And we know that it
works effectively. It’s given in a controlled
setting, or it’s given, some people do take homes
or maybe in a program where they get their
medication brought to them. It has counseling and
therapy associated with it. And people have individualized
treatment plans. It is a hard system. You know people have to get
up every day, show up and have to live near a clinic or
be able to get to a clinic, and that can be challenging. When someone takes it, so the
patient shows up in the clinic and sees the nurse
in the morning. She lays eyes on them. A lot of people need that. For a lot of people
it’s a great therapy because somebody’s
laying eyes on them. They’re not just left
to their own devices. They see and they
look okay, they hand, they give them their medication. They swallow it. They have to speak after
they take it so you’re sure that they took the medication. And usually within 30 to 60 minutes it
starts having an effect. People say they just went
to the Methadone clinic and now they’re wasted. Well if they’re wasted after
they left the Methadone clinic, A, their dose is too high. Or B, they did something
between the Methadone clinic and when you saw them. And when I say the providers
to anybody who’s seeing this with patients, is we need
to do something about that. We can’t just keeping
a back seat if they don’t know
they’re wasted because they’re on Methadone. They shouldn’t be
wasted on Methadone. And if they are, like I
said, their dose is too high or they took something
else along with it. So when this happens and
someone calls and says hey, one of your patients is in the
waiting room because somebody’s out there nodding out,
and I go talk to them. And I figure out if the patient
belongs to the Methadone clinic and it’s a patient of
ours, then we get a release and we call the Methadone
clinic. And we’re not calling
them to rat them out. Something’s wrong. We need to figure
out what’s wrong. And the unfortunate thing with
Methadone is it’s separate from the medical system. And it needs to be integrated. We all need to be
working together to try to help our patients. So we know that that
person is not safe. That something’s wrong. That person should not be
nodded out, you know, sedated. Can’t stand up. Can’t have a conversation. And so either their does is too
high, they took something else, and either the Methadone
clinic doesn’t know about it. Because they’re not seeing that. Remember they saw them
first thing in the morning. They looked good. Now their medication has
peaked a few hours later. Maybe their does is too high. Or maybe they took
something on top of it that bumped its effect,
and now they’re wasted. And so if that’s the case,
we need to get at that so we can keep that person safe. But talking to the medical
staff, and working as a team, is the only way we’re
going to help our patients. And so I always say
that to patients. And people are always
yelling and screaming about the Methadone clinic. Have you talked to them? You know, we need to
connect those systems. Lots of stigma, you
know, around Methadone. This is a picture
from the lovely Herald which annoys me on
a regular basis. But back in ’05 they went
in front of Topeka Street, which is family of
Boston Medical Center, and they took a picture of people standing outside
the Methadone clinic. Now remember those clinics
are typically on side streets. There’s not enough
room for people inside. They’re standing in line. So you know, there’s a lot of
things like that with Methadone that can be a struggle. But these guys had
their, you know, 18 wheelers parked out in front. Herald came along, took a picture said this is
why the [inaudible] leaking because the junkies built it. I mean really? And this is what horrifies
people about these systems and why people don’t want
to go to Methadone clinics. Because of this type of stigma. These are functional people that
are getting out of bed every day and going to work and were
invisible to all of us, other than the fact that
someone saw their truck. You know so it’s just, you
know, people need treatment. Treatment works. And we have to stop judging the
treatment and what, you know, what is needed for
someone’s recovery. So what medication does
do is it’s not, you know, replacing one illegal
drug for a legal drug. It’s replacing a change that’s
happened in somebody’s brain. It’s like giving the
insulin to the diabetic who has pancreatic issues
related to their disease. It’s fixing a brain change. It’s taking the withdrawal away, and it’s making the
brain work better. And it’s taking the
cravings away. So that person is not running
around chasing a drug all day because their brain is
screaming that it needs it. Or they’re physically or mentally ill related
to their disease. So when we look at
Methadone clinics, this just shows you
nationally, this was in ’09. I don’t have an update. I apologize. But there’s not access
to Methadone everywhere. Massachusetts is very fortunate. We are very innovative
in our treatment. And we have lots of
Methadone clinics. And we have satellite clinics. We do have a few
holes in this state, maybe like in Martha’s
Vineyard in Nantucket and then in rural areas in Western Mass,
we’re, it’s a bit of a distance for someone to get to a
clinic, which can be a barrier if you don’t have a car and there’s no public
transportation. But for the majority of it, we
actually have really good care. But in other states it doesn’t
mean they don’t have a need, and they don’t have a problem. But they don’t have to allow
treatment with Methadone. And some states have
made that decision not to allow Methadone maintenance. So Buprenorphine is the
medication that’s come about more recently
than Methadone and is being used differently. So what happened in 2000,
so remember me talking about the Harrison Narcotic Act
made it illegal for you to get, to treat someone’s
addiction in your practice. What happened in 2000 is the
Drug Addiction Treatment Act came about and stated that
patients could now be treated for the opiate dependence
in your practice if they had a medication
that was a schedule three, four or five and the medication
was regulated for the purposes for opioid maintenance or detox. So it doesn’t mean any drug
that’s a schedule three, four or five you can use. It has to be approved
for that purpose. Now this does not
change Methadone. Methadone is a schedule two. So the regulations around
Methadone have not changed. So the rules of Methadone
have not changed. The thing with this that
is also different is that it can only be
prescribed by a physician. The physician has to be
licensed and approved to prescribe the medication. Has to have what we
call an X number. So they have to go through
an additional training that will then give them
an additional DEA number. They can treat 30 patients
for the first year, and then they can apply for an
extended waiver for up to 100. So unfortunately it’s
the only treatment that physicians are limited by how many patients
they can treat. But the concern was we wanted
to do this safely and correctly, and we didn’t want
to create pill mills. And wanted patients to
get evidence-based care. So I think that was the
reason that this happened. Why NPs and PAs weren’t allowed? I don’t know, but we’re
actually, there’s a lot of issues going on right now. And Senator Markey hatches the
[inaudible] Act that’s being looked at trying to add in
MAs, I mean NPs and PAs, and also to increase the
numbers for physicians so we can get some more
treatment out there. So Buprenorphine is
a partial agonist. So we talked about
a full agonist. And we talked about
an antagonist. Buprenorphine is
a partial agonist. You got [inaudible] receptor,
your pleasure center. If you take Buprenorphine
it only partially attaches to the receptor. So that makes it a safer option. So it’s going to be less abused. If someone wants to get
high, they’re not going to be using Buprenorphine. They want something that’s going to give them the biggest
bang for their buck. Buprenorphine is only
going to partially work. So the more you take,
it doesn’t go higher. So more is not better. Which is a hard concept for
all of us to wrap our heads around because we all
think more is better. But it’s kind of like
taking your vitamin C. If you take your vitamin C, you
take more of it than you need, your body just excretes it. You do the same thing
with Buprenorphine. Your body is just going
to excrete the drug. It’s not going to hold on to it. So patients don’t have a really
good reason to take more of it. Can they take things on top of
it and make themselves high? Absolutely. And that’s unfortunately
what people do with this and other medications. So even though physicians
are the only ones that are prescribing
the medication, this medication will not
work, this treatment, without a multidisciplinary
team approach. Much like Methadone. Substance abuse. Mental health. We need the whole team
to make this happen. And so the doctor prescribes,
but the nurses in a lot of these clinics
are the ones doing that day-to-day management. Counselors are seeing them
and doing the therapy. And we’re working with all the
other extended treatment arms with that patient. So the team effect is
what helps and what works. This is a complex chronic
disease that requires lots and lots of different venues to
get the person what they need. So the other tricky piece
about it is the person walks into detox, people
typically go to detox. They walk in the door. They get medicated. You just start medicating them. They’re chasing the
nurse down the hall. They want every medication
that’s in that order that they can have to
manage their withdrawal. If that detox is using
Suboxone, otherwise known as Buprenorphine, you
can’t just medicate them. So say the person
walks in there. They just use two grams of
heroin, and they’re going to use a Suboxone protocol, if
you were to give them Suboxone, you’re going to put
them into withdrawal. So you actually have
to wait for the heroin to start coming off
the receptor. So typically when somebody uses, they use something that’s
short-acting, so it only takes like six or eight hours or so. Starts coming off, and we start
titrating the Suboxone on. It sounds complicated. It freaked a lot of doctors
out in the beginning. People didn’t want to do this. Oh my God. People [inaudible]. And they’re going to be sick. They’re going to be vomiting. Patients can do this
better than we can. You know it just mean, you know, we’ll say to patients Sunday
night use your last time and come in on Monday morning. They come in. We assess them. They get started. I mean it’s, it’s
actually that simple. But you want to make sure,
we want to make sure they’re in withdrawal before we do that. When they take their medication, it gets given a little
differently. It goes under the tongue. It’s a sublingual
administration. A little different. It’s like giving
someone Nitroglycerin. So it’s a pill that goes under
your tongue and dissolves. It takes a period of time. It can chalky. It can be bitter. It can make some saliva. So it’s a little tricky. And people have to
get used to that. And usually it starts working
within a couple of hours. But the level of the
medication builds over hours and actually doesn’t
come to a full effect for like three to five days. So if you’re changing
somebody’s, if you dock or someone’s changing
someone’s dose, and they say well I
don’t feel any better. Well it may take them a few
days to get that full effect. And so they need to
kind of be patient. And working and supporting them through that is really
important. So when you’re giving
someone Subxone, again, it’s much like your [inaudible]. It’s going to take
away the withdrawal. It’s going to take
away the craving. It’s going to help return
the changes in [inaudible]. So here’s your patient
who using heroin. The receptor’s really happy. It’s like a lock and key. So you put the key in the
lock, and it opens the door. That person is getting the
biggest bang for their buck. They’re getting what it
is they wanted to get. So that person, you
know, is on the street, and someone says here
try one of these. And they take a Suboxone. This is what happens. The Suboxone literally kicks
the heroin off the receptor. And you say well why
does that happen? You know it’s like
a partial agonist. The other one’s a full agonist. Suboxone is actually stronger. It’s got more of a
super glue effect. So the Suboxone is going
to kick that heroin down. And what’s going to happen
is that receptor goes from being way up
here to further down. It’s more, it’s a less
of a euphoric effect. And it drops the receptor. So when it drops the receptor,
the person feels withdrawal. So somebody who’s using
doesn’t want to take Suboxone. That’s the bottom line. Somebody who’s in withdrawal, somebody who’s dope
sick so to speak. I hate that word. But somebody’s who having
withdrawal symptoms, stopped using, is not going
to get sick when they take it. It’s going to replace
the receptor, take away the cravings
and the withdrawal. But you don’t take it when
you’re actively using. So the other thing that’s kind
of nice about it is it sits on the receptor and it holds
on for a long period of time. It’s got like a 37 half-life. So Johnny’s been
on his medication. He’s doing really well. He’s feeling good. He’s not craving. He’s not having withdrawal. He’s going with meetings. But he bumps into Joey on
his way to his session. Joey says hey you
want to get high? Sure. People, places, things. It’s not craving. It’s not withdrawal. But it’s what he knows. So what does he do? He tries to get high. So he uses heroin. But what happens, remember
that heroin is strong, but Buprenorphine is
stronger than the heroin. So that people are
being hold on tight. The super glue is still working. And it’s not letting that
heroin attach to the receptor. So all Johnny gets is pissed
off that he just used, and he didn’t get high. Can he keep using to try
to break through that? Absolutely. But first of all he’s
wasting a lot of money. And he’s putting
himself in harm’s way. But most folks aren’t
going to do that. Unfortunately what they’ll
do instead is not take their Suboxone. And that’s what some
people will do. You know it’s Friday. I wake up. I’m not going to take
my Suboxone today. And then Friday night
I’m going to get high. And I’m going to get
high all weekend. And then I’m going to wake up
on Monday morning, and I’m going to feel a little withdrawal. I’m going to take my Suboxone,
and I’m going to go to work. For some people, that’s
a great thing to do. And they really are
enjoying that and having a good
time with that. That is really unsafe. And that’s why people
need to be monitored. I mean you need to
keep an eye on people. This is a disease that
affects the brain. People don’t always
make good choices. So we have to monitor them to
help if they’re making choices and changing their behavior. And as we all know, changing
behavior is the hardest thing we all do. You know, how often to
start the gym on January 1st and by the 10th you’re
no longer going. Behavior change is hard. And so when patients pick up
and they start and they stop, they’re putting themselves
at risk for an overdose. So if somebody not using
opiates for three to five days, and they pick back up, their risk of overdoes
is so much greater. And so that’s the
really scary part about that person who’s a
weekend warrior who starts and stops their medication. So this just shows you,
so when I was trying to explain this to you. When you take it, you
put it under your tongue. You see those two little white
lines, that’s where it gets, that’s how it goes
into your system. It bypasses your stomach. It gets absorbed through
those veins into your system without going through
the stomach. So it works faster than if
you were to take it and have to swallow it and wait for it
to get absorbed and all that. It’s not going to work as fast as sticking a needle
in your arm. But it’s definitely
working faster. And that’s with, it’s
just a tricky thing to do. And there’s both the tablet
and the film, which I’m going to show you on one
of the slides. Both of them are
the same medication. They’re just different formulas. So [inaudible] has been pretty
safe, pretty well tolerated. It’s much like other opiates. It doesn’t cause a whole
lot of side effects. You can get some headaches. Usually they start
in the beginning, and they usually go away. If someone has a
history of migraines, you’re more apt to
get headaches. Constipation, we
saw a ton of this when we first started
giving this medication. Because we were asking our
patients how do you feel? How do you feel? Do you need more? Well that was a dumb question. So everybody needed more, and
every ended up on 32 milligrams. And everybody was having a
little business on the side and selling some of it off. And everybody was constipated. So we learned that they
didn’t really need that. The nausea, so if you can
imagine putting a pill under your tongue and
it makes all the saliva and has a chalky taste. It’s first thing in the morning. You haven’t had your coffee. So it can make people feel
nauseous, and hopefully for most folks that gets better. The anxiety piece, you know,
so when some folks use drugs, people are self-medicating. We know those people
self-medicate all the time. When you feel horrible,
you’re going to self-medicate, which is why a lot of
our patients, you know, with mental illness and substance abuse,
are using drugs. So they may have
an anxiety disorder that wasn’t being treated. But the drugs they were
abusing were treating it. So now there’s, you’re
seeing this. You’ve got to treat it. You’ve got to figure it out because you’re going
to lose that person. Sweating, we saw a lot of this when we were dosing
at high doses. But we’re not seeing
so much of it anymore. And insomnia is not
a really big problem. People typically can
sleep okay on it. But it was, we have
seen it in a few cases. The pain, I would encourage
anyone whose patient is now telling you they’re having
pain, to get them seen. If they weren’t complaining
pain before and now they are, there may be something going on that they were
self-medicating and didn’t even know. We actually had one gentleman
who’s one of my HIV patients, I did HIV for like 20 years, who got on the medication, felt like he had finally
got his life together but was having horrible pain. He had lymphoma. But we didn’t know it because
he was using three grams of heroin a day, which
was masking the pain. So again, so if the pain is new, we need to make sure
you’re getting it worked up to make sure there’s not
something else going on. Side effects [inaudible],
this was something that really got worked
up in the beginning. People were worried about
this with this medication. It’s then pretty safe. There’s a little bit more. Or the liver [inaudible]. So you definitely want to be checking those
before your [inaudible]. Buprenorphine is some
enzyme elevation. And if there is, you
just want to monitor it as clinically indicated. Vomiting, again, can be
a horrible side effect, but it’s like less than 1%. And if it happens, you may not
be able to get that person, you know, through that. It can be very challenging. Most medications, there’s
not that drug, drug, interaction that we
see with Methadone. And we don’t really
need to adjust dosing. Some patients that are
on HIV medications, it may be a little bit
of an issue with some of that anti-retroviral,
so you can work with the ID docs on that. But it, again, not a
huge amount of need to a dose to adjusting doses. CNS depression, you
shouldn’t see it. People should not
be sedated on this. And if they are, maybe
their dose is too high. Or maybe it’s interacting with
something else they’re taking. And rashes and hives and
graphospasm, we don’t see this. I’ve seen a few people with like
minor rashes that have resolved. It’s a pretty well
tolerated medication. It gets absorbed orally. It gets excreted
through the urine, so you will pick it
up in a urine screen. It can be abused intra nasally. Most patients won’t use it this
way because it’s very toxic to the nasal cavity and burns. And it’s only a short-term
euphoria. But they will get high. I mean people are creative. People will use it
rectally as well. People will use medications
in any way that’s going to give them a euphoria. So just to be aware of
that, that can be a factor. The risk of overdose with this
medication, when used alone and taken correctly,
is really low. When you combine it
with other things, you’re going to get
into trouble. And this is what we see
with all of our patients. You know patients are combining
benzos and amphetamines and alcohol and cocaine. And when they do
that, that’s typically when we see an overdose. But if somebody’s
on a prescription for both medications,
it’s really important that they’re monitored even more
closely because of the factors that can suppress the
central nervous system. So there were deaths
associated with this in France. We haven’t seen a lot of it. Although when you
look at the ME reports and you see the combination
of medications, I would say we are seeing it. It just hasn’t been reported. So alcohol, you know, so
you have your patient. We start them on the medication. They used alcohol 30 years ago. But they’ve been using
opiates for the last 30 years. So now you’re managing
their opiate problem. They’re taking their medication. They’re doing well. Their alcohol may come back. You know, and so you
have to be aware of that. You know, so the
patient starts drinking. We need to address that. We need to see them more often. We need to do breathalyzers. Maybe they need to go to detox. Maybe we need to
change what we’re doing, and they need another
treatment option. So being sensitive and aware
of that is really important. So we want to monitor
our patients. So patients, you know, when
we’re treating patients for anything, you should
be monitoring them. It’s not good practice
not to keep an eye on what’s going on
with that patient. And even if you’re doing that
as a provider or if you’re doing that as a support person or somebody who’s
managing them in a program. Looking at a patient,
seeing how they’re doing. Are they taking their
medication? Has their behavior changed? Are they going to
their appointments? You know, do they look like
they’re potentially using? Is something not going on right. So keeping an eye on
changes in our patients and the public is
really important because those are the things
that help us grab them when something’s up
before we lose them. It’s not about catching people. It’s not about kicking
people out of care. It’s about how to
help folks before that train runs off the track. And so when, and when
we’re managing patients on these medications,
we see them often. So we can check it. So we can do a urine screen. So we can see them. Patients who struggle with addiction have a really
hard time telling the truth. Because they are so afraid
of what’s going to happen, and they’re so used to
telling a lie to get through what it is
they need to do. So when you get that urine,
you can have that conversation. It’s like okay, so
urine has cocaine. Do you want to talk about that? Not you used cocaine, we’re
going to kick you out. That’s not what we’re
doing here. We’re trying to figure out what
do we need to do different? You know, do we need to pick up
the phone and call a counselor? Do we need to come
in more often? Do they need to go to a
day treatment program? Is this not working? Do they need to go to Methadone? Do they need to go to
detox, residential? It’s about trying to figure out the right treatment
for that person. So this is the film
which I talked about. So both medications,
the pill and the film, are the same medication. And the only reason, and
actually there’s one, it’s a buccal mucosa one
that I haven’t even seen yet. But it’s just about
who’s manufacturing it. This one’s actually a
little easier to take because it dissolves faster, and
it doesn’t make that huge amount of saliva that we
see with the pill. And the only difference is what
the insurance is paying for. That’s all I care about. Who’s paying for it? That’s what we’re ordering. And so it’s about getting the
patient what their insurance will cover. And unfortunately,
they’re all over the map. We have Medicare plans. Most of the Medicare
plans I think are paying for the film right now. And a lot of the standard
Medicaid are paying for the pill. And then some of the
other is like Health Net and [Inaudible] Care
are paying for the film. So again, it’s just whatever
the payer is paying for. This one comes in an
individually packaged, like if you’ve seen
those, the dental strips, like the teeth whiteners that
come in those foil packages, that’s what this comes in. It’s like you got a folds here,
and then you’ve got to tear down here to take it out. Each one is individual. And the reason for
that was safety. At least that’s what
they’re saying. But the reason is safety, because now you’re
not exposing children. We were having issues, and
we’re still having issues with all opiates,
unfortunately and unbelievably, with children getting it in
their hands and in their mouth. And if you can imagine this
medication is absorbed orally. So kids, what do they do? They throw stuff in their mouth. Mom pulls it out, but they
may still have gotten some of the medication. And that’s where the issue is. So with this, it’s safer. It’s not out. The kids can’t see it because
the tablets were orange. You know, they’re
kind of attractive. Kids see an orange tablet. It looks like candy. It’s chalky. It’s bitter. They stick it in their mouth. They may actually like
it for a few seconds. Which can create
a lot of danger. So yes there’s misuse,
abuse, diversion. Not just around this medication,
but around lots of things. But we want to provide treatment
that is safe and appropriate. And so if we’re getting
reports of this diversion, we need to respond to it. But you hear people say all
the time, it’s on the street. They’re selling it. Well less than 5% of the doctors
in this state are waivered to provide this treatment. We know that we can’t
meet the demands of the people needing treatment. So if there’s a need, there is
going to be a resource, right? So drug dealers will
sell anything. We had a patient the other
day who came to our clinic, we saw them, and we learned that he purchased two urines
downstairs, one after the other, when we were seeing him
we were trying to figure out what was going on,
for 20 bucks a piece. Drug dealers will sell urine. They’ll sell anything
if hit has market. So there is Buprenorphine on
the street, but you’re not going to go, when you hear a drug bust
you don’t hear them busting them with grams and grams
of Buprenorphine. It’s usually a couple
of tablets. And I’m not trying
to minimize that. We don’t want this medication
on the street clearly. We don’t want any
medications on the street. But they’re being sold. So we want to treat
people safely. We hear that something’s
going on. We’ll respond. We’ll bring somebody in. We’ll go pill count. We’ll get them small scripts. You know, we’ll try
and figure that out. But usually it’s because someone
can’t get the medication. They are trying not
to be withdrawn. They don’t have the money
to get the medication. The docs they know of in their
area are only charging cash. And that’s another problem. And that’s why the state’s
really trying to do, you know, this huge effort of trying to
get more and more treatment into the community
health centers so we can have community
providers that are treating patients,
taking their insurance, and we don’t have this
concern about diversion in our patients paying cash. So this is just an
educational brochure. And these are actually at the
[inaudible] clearinghouse. And I didn’t take
the other picture. I apologize. But anyone who’s on this
medication and lives in a house with any children should
have this brochure. Or has children. Because again, if kids
get their hands on this, they put it in their mouth,
it’s oral, it’s absorbed, and they’re going to put
themselves potentially in a respiratory distress. So if any one child gets this, they need to call
poison control. They need to call 911. The child needs to be
seen and evaluated. So we put this together by, from all the [inaudible]
community health centers back a few years ago. And we give this
out to our patients in English and in Spanish. So this just speaks to
what I was talking about. So there’s only 4 or 5% of the
doctors in the entire country that are waivered to
prescribe this medication. In Massachusetts we’re
a little bit over that. But there’s 38,000
doctors in Massachusetts. There’s only 1,500 that
are doing Buprenorphine. If you took that,
you cut it in half, half of them are not treating
very many or taking cash. And then you’ve got
like 700 providers. Not a lot of people
to go around. And some of them have, you
know, only small practices or don’t want to treat anyone
other than their patients. So the ability for folks to get
treatment is very challenging. And we’re trying to do a better
job at getting, at improving that and providing it, again, into the community
health centers so that that’s not a
problem for our patient. So addiction is challenging. Treatment is challenging. Getting somebody through
those five years is really challenging. But we know that if somebody
can get through five years of abstinence, that
they’ve got an 86% chance of remaining and recurring. And that’s great. But that five years
will take a lot of years off your life trying
to help them through it, but just supporting
patients and just knowing that this is a rocky, rocky
road that has lots of bumps and trying to get people, to keep them alive and to
get them there is what we’re aiming at. This, we know the death rates
are lowered by 70% in people who are on Methadone
maintenance. They’re in treatment. So we know people
do better and care. It was a health affair study
that showed patients into care on [inaudible] and working in Massachusetts had a 76% more
likelihood of staying alive. And also their comorbidities
and hospitalizations and their criminal
incarcerations went down. So when no medication works,
we know it’s cost-effective. And we know it’s
evidence-based scientific care that we should be providing
to patients that need it. We know this disease affects
people from all walks of life. People used to think differently about heroin epidemic,
the opiate epidemic. But I think that’s
clearly changing. We have, you know, teenagers. They’re attending
each other’s funerals. We have obituaries we’re seeing
where people are now coming out and talking about
their family members. I read one the other day from
a young girl from Wisconsin who wrote her own
obituary because she knew that she wasn’t going
to make it. And it was just heartbreaking. So she wrote this in intent that
she was going to die and wanted to impact other kids not
to go down that road. So this is a complicated
complex disease. It requires everybody
to come together. It will have bumps. There’s nothing smooth about it. And the psychosocial component
of it cannot be, you know, overstated in how
important that is. Treating the mental
illness is critical in managing this disease. You know we get somebody,
we’re treating them, and they’re doing well. And [inaudible] and now
we’re seeing depression, anxiety, PTSD. If we don’t treat that, we’re
not going to manage that person. We’re going to lose that person. And so having the ability
to treat everything in a coordinated
effort in working with all the providers
is of great importance. These are some websites, some Buprenorphine
[inaudible] websites. Great resources. In Massachusetts we have
an addiction nurse group, which actually is the largest
chapter in the country. You’re always welcome
to email me. I actually run, I actually
manage the addiction nurse group. But we also have chapter
members that are in the offices. And we provide educational
venues for nurses and other providers
who want to go. And we do CEU trainings,
and we do monthly meetings. We do coordinated efforts
around recovery day. And for those who
are interested, recovery month is in September. And so trying to get
involved in taking care of our patients holistically
is what we’re all aiming to do. Thank you.


2 thoughts on “Opioids and Medications to Treat Opioid Dependence

  1. From 1999 to 2016, more than 200,000 people died in the U.S. from overdoses related to prescription opioids. Overdose deaths involving prescription opioids were five times higher in 2016 than 1999.
    The figures are preliminary estimates from the National Safety Council, which says it currently estimates that last year, "38,300 people were killed on U.S. roads, and 4.4 million were seriously injured, meaning 2015 likely was the deadliest driving year since 2008."
    So should we start taking people's licenses away? Sure, there is a problem but LYING about the statistics isn't going to get you anywhere. If you take the data above and average the 17 years the 200,000 lives were lost to opiate overdoses, that would be 11,765 lives a year and in 2015, there were 38,300 people killed in motor vehicle accidents…3 times as many as opiate overdose deaths!
    Oh, here are some sites where I got my information:

    https://www.npr.org/sections/thetwo-way/2016/02/18/467230965/2015-traffic-fatalities-rose-by-largest-percent-in-50-years-safety-group-says

    https://www.cdc.gov/drugoverdose/data/overdose.html

  2. And as someone who RESPONSIBLY takes their opioid medication as prescribed (by the book, to the letter) I resent almost this entire presentation. There is not ONE word uttered about the patient's perspective. It's all "about" the patient. Some of the slides are almost condescending in tone and I find that highly offensive. It's almost as if you and the medical community cannot fathom that anyone taking high doses of opioids could ever be high-functioning, let alone responsible. It's insulting and I am tired of hearing how I am an "addict". I am not; my body is dependent on the medication that I take. It is not much different than a diabetic is dependent on insulin. Would I die if I quit taking my medications, no but I sure would want to. My medication keeps me functioning at a semi-normal level, where I am able to walk somewhat normally and go about daily activities. My disease and pain keeps me from working but my medications help me maintain a certain quality of life I would not have otherwise. So until you have walked a mile in my shoes and my pain…stop trying to take away my only form of relief; because believe me, I've tried just about everything else.

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