The new normal

The Cincinnati Enquirer has a new piece on one week in the heroin epidemic in Cincinnati. It’s worth your time.

Here’s the closing:

It’s almost midnight on the last day of another week, and the heroin epidemic has done its damage.

18: Deaths known or suspected to be the result of overdoses.

180: Overdoses reported to hospitals in the region. This figure underestimates the actual number of overdoses because it only includes those requiring hospital treatment.

210: Inmates in the Hamilton County Justice Center, the region’s largest jail, who admitted to using heroin or other opioids. Jail officials have estimated that as many as half of all inmates, about 870 this week, have an opioid problem.

$95,550: Cost to taxpayers to house those 210 inmates for one week. If the inmate total is closer to the estimated 870, the cost would be $395,850.

15: Babies born with health problems because their mothers used heroin or other opioids.

34: Investigations opened in southwest Ohio into the well-being of a child whose parent or guardian was known or suspected of using heroin or other opioids.

102 hours, 42 minutes: Time it took first responders to tend to overdose patients. This figure is considered low by dispatch supervisors because many overdose runs are not initially called in as such.

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A closer look at the evidence

Someone sent this document today and highlighted this statement, “The evidence of the effectiveness of MAT is overwhelmingly positive. 115, 116, 117

That statement provides 3 sources:

115 Addiction Treatment Forum. MAT with Methadone or Burprenorphine: Assessing the Evidence for Effectiveness. February 10, 2014. http://atforum.com/2014/02/mat-with-methadone-orbuprenorphine-assessing-the-evidence-for-effectiveness/. Accessed October 31, 2016.

116 Fullerton CA, Kim M, Thomas CP, et al. Medication-assisted treatment with methadone: assessing the evidence. Psychiatric Services. 2014 Feb 1;65(2):146-57. doi: 10.1176/appi.ps.201300235.

117 Thomas CP, Fullerton CA, Kim M, et al. Medication-assisted treatment with buprenorphine: Assessing the Evidence. Psychiatric Services. 2014 Feb 1;65(2):158-70. doi: 10. 1176/appi.ps.201300256

The first source, 115, really just introduces and refers to the other two sources, 116 and 117. It may be worth noting that the word “recovery” appears zero times in each of the two articles.

I have not reviewed the second source, 116, but will try to do so in an upcoming post. However, the authors summarize the post with this table:

The third source, 117, was reviewed in a previous series of posts. I’ll re-post the first in that series below.

A closer look at the evidence


Thomas CP, Fullerton CA, Kim M, et al. Medication-assisted treatment with buprenorphine: Assessing the Evidence. Psychiatric Services in Advance. November 18, 2013; doi: 10.1176/appi.ps.201300256.


This meta-analysis provides a review of the 19 studies and a summary of each.

Let’s look at the studies. Some of them consider the effects of various doses and other factors. I’m just going to report on the outcomes above.

Study 1

The summary reports “fewer positive urine drug screens”. I wanted a little more info, so I went to the original study. It doesn’t report exact percentages, but I found this graphic.

study1

So, it looks like approximately 70-75% of male subjects receiving buprenorphine tested positive for opioids and about 90% of female subjects tested positive.

Study 2

This study compared buprenorphine vs high-dose methadone vs low-dose methadone and it was a year long (that’s really good!). Here’s the summary: “At 26 and 52 weeks, the high-dose MMT group had better retention (31% versus 20% at 52 weeks, p=.009) and less opioid use (p=.002) than the low-dose MMT or fixed-dose BMT groups.”

So, high-dose methadone lost 69% of the patients, while buprenorphine and low-dose methadone lost 80% of the patients.

I was curious about “less opioid use” and went to the original study. The researchers did drug screens for opioids and other drugs. “Urine samples were considered to be opioid-free if the test reading was less than 300 mg/mL.” For patients that were retained for all 52 weeks there were 156 drug tests. This outcome was measured by giving 1 point for each opioid-free test. A single patient got 156 points. The median scores were 59 for high-dose methadone, 16 for buprenorphine, and 24 for low-dose methadone.

Study 3

This study compared different doses of buprenorphine. “For retention, 40% in 1-mg group completed treatment, 51% in 4-mg group, 52% in 8-mg group, and 61% in 16-mg group.” 61% retention sounds more encouraging, but over what period of time? Unfortunately, it’s only 16 weeks long.

The summary also reported that the “8-mg group had significantly fewer positive screens than the 1-mg group”. This got me curious about these drug use outcomes.

Here’s what I found:

  • “42% (306/736) failed to contribute a single urine negative for opioids”
  • “36% (68/188) of the 8 mg group” failed to contribute a single urine negative for opioids
  • “Not a single patient contributed the full complement of negative urines”
  • “only 18% (132/736) provided more than 24 negative urines” (i.e. 50% of the maximum possible)

The original study also had the following sentence, “Acceptance of the efficacy of buprenorphine as a maintenance treatment has to be tempered by the reality that the drug use status of many patients will not be altered by buprenorphine.”

Study 4

This study compared buprenorphine maintenance in a primary care setting vs buprenorphine delivered in a methadone clinic. The study is short (12 weeks) and small (23 subjects per treatment condition).

Here’s the summary: “A trend toward higher retention at 12 weeks was noted in the primary care setting (78% versus 52%, p=.06). Patients in that setting had significantly lower rates of illicit opioid use as measured by urine drug tests (63% versus 85%, p,.01) but no difference in rates of cocaine use.”

78% retention is great, but it’s only for 12 weeks.

And, the better outcome for drug use was 63% of drug screens being positive for opioids. (I went to the original paper and found that 30.5-38.5% of tests were positive for cocaine.)

The closest they came to measuring abstinence was this, “The proportion of patients who achieved 3 or more consecutive weeks of abstinence from opioids, as determined by thrice weekly urine toxicology testing, was also higher in the primary care setting (44%, 10 of 23) than in the drug treatment setting (13%).”

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Note: This is not an argument against access to any kind of care. It’s just a push for good informed consent that empowers patients to advocate and choose for themselves.

Other posts in this series

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How do we know if we do not ask?

 

listenRecovery Science shared a couple of qualitative studies on the experiences of MAT patients.

The first identified 7 themes:

  1. Patients may not be aware of treatment alternatives
  2. Treatment expectations and goals may differ between clinicians and patients
  3. Prior experiences with buprenorphine or methadone influence treatment decisions and expectations
  4. Accountability and structure facilitate treatment engagement for some, create barriers for others
  5. Desire, among some, to avoid methadone clinics or associated stigma
  6. Fear of continued addiction and perceived difficulty of withdrawal among people who have a goal to be drug-free
  7. Among patients with chronic pain, pain control is an important consideration

The second identified 4 themes:

  1. the loss of hope,
  2. trapped in OMT,
  3. substitution treatment is not enough, and
  4. stigmatization of identity.

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1 in 12 US physicians received a payment involving an opioid

From the American Journal of Public Health:

Approximately 1 in 12 US physicians received a payment involving an opioid during the 29-month study. These findings should prompt an examination of industry influences on opioid prescribing.

That’s not 1 in 12 pain specialists, or 1 in 12 addiction medicine specialists, that’s 1 in 12 US physicians.

Here are more details:

Over the study period, 375,266 nonresearch payments involving a marketed opioid were made to 68,177 physicians, totaling $46,158,388. Total payments increased from $18,958,125 in 2014 to $20,996,858 in 2015, an increase of 10.7%. The number of payments increased from 145,715 in 2014 to 184,237 in 2015, an increase of 26.4%.

The 5 opioid products constituting the greatest proportion of payments were fentanyl ($21,240,794; 46.0% of total dollars), hydrocodone ($7,123,421; 15.4%), buprenorphine transdermal patch ($5,141,808; 11.1%), oxycodone ($4,487,978; 9.7%), and tapentadol ($4,296,130; 9.3%). Overall, payments for FDA-approved abuse-deterrent formulations totaled $9,352,959 (20.3%), and payments for buprenorphine or buprenorphine/naloxone marketed for addiction treatment totaled $4,561,729 (9.9%).

The median payment was low, around $50.

However, a JAMA published study reached the following conclusions about compensation as small as a meal:

Receipt of industry-sponsored meals was associated with an increased rate of prescribing the brand-name medication that was being promoted. The findings represent an association, not a cause-and-effect relationship.

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Meanwhile . . .

While opioids get all the attention (justifiably, due to the death rates), Marc Schuckit discusses findings from a recently published study of alcohol use and alcohol use disorders (AUD):

The results documented substantial increases in the prevalence of past 12-month drinking, high-risk drinking, and AUDs. The largest increase related to the rate of the most serious problems, AUDs overall, which shot up by 49.4%, from 8.5% in 2001/2002 to 12.7% about a decade later. These figures are limited to the past 12-month, or current, diagnoses and do not include individuals who are in potentially temporary remissions. Respondents with lifetime but not current AUDs are also likely to carry future health care costs through enhanced vulnerabilities for cancers, cardiac disease, and other serious disorders associated with histories of heavy drinking.

The overall changes in prevalence over the decade were even greater for several population subgroups including women (an 83.7% increase in AUDs over the 11 years), African American individuals (a 92.8% increase in AUDs), individuals aged 45 years to 64 years and 65 years and older (with 81.5% and 106.7% increases in AUDs, respectively), those with only high school educations (a 57.8% increase in AUDs), and individuals with incomes less than $20 000 (a 65.9% increase in AUDs). During that same period, high-risk drinking, described using the previously mentioned criteria, increased from 9.7% to 12.6% (a change of 29.9%), with similar subgroups as reported for AUDs demonstrating the greatest increases. The proportion of drinkers increased from 65.4% to 72.7% (an enhancement of 11.2%). Similar results have been reported in other national surveys, indicating that the National Epidemiologic Survey on Alcohol and Related Conditions findings are not anomalies.

What the hell is going on?

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Sentences to Ponder

stop.think. by sarcasmo

photo credit: sarcasmo

. . . the clinicians of the future, really need to be oriented in a counselor mode, where they are not just telling you what the options are, but also eliciting from you very clearly what your goals are, and then making a recommendation about what most matches your goals. What are your priorities for your quality of life as well as quantity of life? People have priorities besides mere survival.

When we don’t ask and don’t know how to ask what those priorities are, the treatment is often mismatched with those priorities, and that’s where you get suffering, and that’s where you get lots of hot air from doctors, and you have total misalignment. When you are able to elicit those goals and then align the care with it, you have massively better outcomes, both for quantity and quality of life.

Atul Gawande

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Sentences to ponder

3623768629_d854236b17

by karola riegler photography

. . . in the end, the federal government has very little control over criminal justice. About 90 percent of all prisoners—and a far greater percentage of those in jails, on probation, or who are arrested every year—are handled by states and counties, not by the federal government. And the federal government cannot directly tell states what to do when it comes to dealing with these individuals. For example, they cannot make local governments change their laws, enforce existing laws more aggressively, or determine who is released on parole or who is sent back to prison.

Read the rest here.

 

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