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Medication-assisted treatment (MAT) is the use of medications in combination with counseling and behavioral therapies, which is effective in the treatment of opioid use disorders (OUD) and can help some people to sustain recovery.
More must be done to facilitate treatment options and the development of therapies to address OUD as a chronic disease with long-lasting effects. This means helping more people secure MAT, which requires us to break the stigma often associated with some of the medications used to treat OUD. It also requires us to find new and more effective ways to advance the use of medical therapy for the treatment of OUD.
There are three drugs approved by the FDA for the treatment of opioid dependence: buprenorphine, methadone, and naltrexone. All three of these treatments have been demonstrated to be safe and effective in combination with counseling and psychosocial support. Everyone who seeks treatment for an OUD should be offered access to all three options as this allows providers to work with patients to select the treatment best suited to an individual’s needs. Due to the chronic nature of OUD, the need for continuing MAT should be re‐evaluated periodically. There is no maximum recommended duration of maintenance treatment, and for some patients, treatment may continue indefinitely.
Bunavail (buprenorphine and naloxone) buccal film
Cassipa (buprenorphine and naloxone) sublingual film
Probuphine (buprenorphine) implant for subdermal administration
Sublocade (buprenorphine extended‐release) injection for subcutaneous use
Suboxone (buprenorphine and naloxone) sublingual film for sublingual or buccal use, or sublingual tablet.
Subutex (buprenorphine) sublingual tablet
Zubsolv (buprenorphine and naloxone) sublingual tablets
Dolophine (methadone hydrochloride) tablets
Methadose (methadone hydrochloride) oral concentrate
Vivitrol (naltrexone for extended-release injectable suspension) intramuscular
Workplace drug tests recently have shown a decrease in cocaine positives during the first half of 2007. The positive tests for cocaine dropped 16% as the overall rate was 0.58 percent. This rate is the lowest since tracking the information back in 1997 by one lab. The lowest rate of decline was in the Midwest while the highest rate of decline was in the New England areas. The total tests counted for this tracking included about four and one-half million urine drug tests, which all included testing for cocaine and other drugs of abuse. Some believe the shortage of cocaine and higher costs are driving the decline, while European cocaine abuse is becoming increasingly popular, adding to world-wide demand. As a Medical Review Officer for Work-Place Drug Testing, cocaine remains popular.
In another report on drugs of abuse, marijuana recently was highlighted. It is apparent that reefing the great weed is about 5 times more harmful than one cigarette. The apparent problem is a greater intensity of airway obstruction. This effect may be caused by an increased “holding” of the smoke which is a longer time of interaction with the lung tissue. Another concept is that the smoke is literally hotter, creating a deeper thermal injury to the lung tissue itself. Interestingly, when compared to regular smokers, the marijuana smokers had less emphysema changes.
DAWN, or the Drug Abuse Warning Network, continues to focus on hydrocodone. This narcotic goes with the brand names of Norco, Lortab, Vicodin – but is generic in many prescriptions. Sales of hydrocodone and oxycodone have dramatically increased over the past years. The Pharma industry spends over 3 times as much on advertising as it did a decade ago.
www.castMD.com has written on this plague and the advertising push to addiction by the Pharma industry in past postings.
Despite the pressure to put these dangerous and addictive drugs on a higher schedule of restriction of prescribing, Schedule II, the FDA and DEA has been lobbied heavily to not do so.
With all the Pharma advertising, a push toward better pain management, and the abuse of narcotics, hydrocodone based drugs and combo drugs ranked number 2 in 2006 just behind the cholesterol lowering brand name, Lipitor. From 2001 to 2006, hydrocodone prescriptions rose by 2/3rds.
Hydrocodone is the number one drug in its category to arrive at the Emergency Department. It is also the number one drug of its category reported to the National Forensic Lab Info System.
www.castMD.com says, “Ban hydrocodone or elevate the Schedule.” It is a considerable concern of abuse in junior high kids, high school kids, and patients.” Should it be banned?
adapted: acoem/castMD
DRUGS IN WORKPLACE – ARE YOU TRYING TO SKIRT THE ISSUE?
A month or so ago the Feds released their workplace data regarding use of drugs while on duty in various jobs and employments. These are the newest data compared to previous studies in mid-nineties.
Industries that continue to have high rates of on the job drug use and use of drugs are those industries in general that continue to have high job turnover rates.
Illicit drug usage among the 18-64 year olds working full-time was the highest in food service and accommodation industry, construction work, entertainment and arts, information services, and management support companies.
The highest rate was 16.9 percent of the food and accommodation employees used illicit drugs in the last month, in the survey.
Construction workers and miners had the highest heavy use alcohol rates at 17.8 percent. Even CEO’s rate was at 8 percent for heavy alcohol usage.
Marijuana continues to lead the pack on illicit drug use for these surveys.
Over 12 percent of the illicit drug users had three or more employers in the past year! Current drug users had twice the rate of missing one or more days in the last month.
Increased rates of illicit drug use were seen in men and lesser paid jobs.
About half of the full-time workers report that their company does pre-placement drug testing. Protective services had the highest rate (76%) of this type of testing, while legal occupations had the lowest (14%) reported in the study.
Only one-third of the workers reported random drug testing policies by their employers.
ONLY one-third of the workers reported they would be less likely to work for companies with random testing programs in place.
An Idaho case in Boise is coming down the legal pipeline. This case is significant as the plaintiff is support by the Center of Individual Rights group.
According to my understanding these are the general issues.
The baby was presented to the ER for evaluation and treatment. The baby was ill. The baby was five-weeks old. The mother consented to evaluation on this sick infant. The mother agreed to labs and iv fluids. 
The rub came when the baby required a spinal tap and iv antibiotics for evaluation and treatment, immediate or early, to limit the diagnostic possibilities and to provide early treatment for a potential devastating and possible deadly meningitis.
The mother evidently refused.
The Emergency Physician evidently requested protective custody for this infant to proceed. The hospital, the police, the courts agreed with the Emergency Physician and allowed the doctor to proceed.
Now about 5 years later, an entire community to protect this baby is being sued, as the baby and the mother’s rights were violated.
The defense of the doctor, hospital, and police state that the temporary custody allowed the proper diagnosis and treatment of this infant. Infants are tough diagnositc dilemmas naturally.
Courts have upheld even traditional medicine over holistic and alternative methods in cases of seriously or potentially seriously ill or injured children. Of course, that is with needed medical support clinically.
This case will be watched closely by all Emergency Physicians, Emergency Rooms, Law Enforcement Officers, and Courts. If plaintiffs win this case, a significant shockwave will start a sunami of “hands-off” litigation and will create a mountain of defensive medicine procedures, especially in documentation of refusal of treatment and the risks involved.
Who has the right to refuse treatment of an infant and who has the right to treat that infant? Should the law allow medical morbidity and mortality even in the face of “lay person” judgement?
(castMD commentary with EM News review contribution)
AFTER LISTENING THIS PAST FEW DAYS TO SOME NEWS, CASTMD FIGURED THE SYSTEM IS TOO BROKEN NOT TO COMMENT. MIKE MOORE’S DOCUDRAMA OF THE U.S. HEALTHCARE SYSTEM IS AT LEAST A STARTING POINT…AGAIN….
A FRIEND OF MINE SAVED A PATIENT’S LIFE. IN SURGERY, THE PERSON ALMOST DIED. THIS ANESTHESIOLOGIST WANTS TO GET PAID BY THE PATIENT’S INSURANCE COMPANY. SOUNDS SIMPLE?
THE PATIENT HAD TO BE TRANSFERRED FROM THE SMALLER HOSPITAL TO A TERTIARY CENTER (A LARGER TEACHING TYPE HOSPITAL) AND LATER UNDERWENT ANOTHER SURGERY. NOW THE INSURANCE COMPANY WILL NOT PAY THE FIRST HOSPITAL AND THE ANESTHESIOLOGIST. THEY DEMAND MORE PAPERWORK, SAYING IT WAS THE SAME SURGERY. SO THE BATTLE OF HEALTHCARE PAYMENTS GOES ON! GENERALLY, DESPITE THE ONLINE DIRECT SUBMISSION OF BILLING TO MEDICAID, MEDICARE, AND OTHER INSURANCE COMPANIES, PAY IS SLOW.
WHAT HAPPENS THEN, IS THE PATIENT GETS BILLED, THE EXPLANATION OF BENEFITS GOES OUT AND EVERYONE INVOLVED IS SENDING DOCUMENTS AND PHONECALLS TO EVERYONE ELSE. SO IT GOES. SO MUCH LOST EFFORTS, EXPENSES, AND WORK…TO GET PAID.
ALL THAT MONEY COULD BE FOR HEALTH AND WELLNESS AND PREVENTION. INSTEAD YOU HAVE FAMILIES BEING BANKRUPTED BY MEDICAL BILLS. THIS HAS BECOME ANOTHER CREDITOR ATTACKING YOUR CREDIT RATING, YOUR PROPERTY, YOUR LIVELIHOOD, AND YOUR HARD-EARNED DOLLARS. MANY HOSPITALS HAVE LAW FIRMS NOW FILE LITIGATION AND SUE THE PATIENTS FOR PAYMENT.
WE SPEND THE MOST ON HEALTH IN THE INDUSTRIALIZED WORLD, YET WE HAVE HIGH INFANT MORTALITY, A SHORTER LIFE EXPECTANCY, AND NEARLY 45 MILLION KNOWN ABOUT PERSONS WITHOUT ANY INSURANCE COVERAGE TO ADEQUATELY PROTECT THE FAMILY OR THEMSELVES.
THE DIRECTOR OF THE G.A.O. (GENERAL ACCOUNTING OFFICE) WAS ON TV THE OTHER DAY. HE SAID IT IS TOO LATE IF WE DO NOT CHANGE NOW. HE IS IMPORTANT. HE IS THE UNITED STATES’ CPA BASICALLY. HE IS MEETING WITH BUSINESS LEADERS, COMPANIES, AND OFFICIALS TO TRY TO GET THE MOMENTUM UP TO CHANGE HOW WE DO THINGS. HE SAID THAT WITH THE BABY-BOOMERS COMING “ON LINE” IN JANUARY 2008, THE GOVERNMENT HAS CREATED A SYSTEM OF INCOMPATIBLE EXPENSE. WITH MEDICARE, MEDICAID, AND SOCIAL SECURITY FOR THE BOOMERS, THE SYSTEM WILL BUST. SOON! 2020 OR SOONER! WHY? HE HAS GIVEN UP ON CONGRESS !!!
IF YOU ADD ON THE NUMBER OF MANDATED ER CARE OF ILLEGAL IMMIGRANTS GOING TO THE EMERGENCY ROOMS, PLUS THE UNDERINSURED, AND THE UNINSURED – IT IS EASY TO APPRECIATE THE PROBLEM. MANY HOSPITALS’ ERs HAVE CLOSED. SOME HOSPITALS ARE BEING SOLD FROM NOT-FOR-PROFIT TO FOR-PROFIT SYSTEMS.
WHAT ARE YOU DOING TO HELP TALK IT UP ABOUT HEALTH INSURANCE RATES, HEALTH INSURANCE, AND THE COSTS.
NO FAMILY SHOULD BE FORCED INTO BANKRUPTCY BY HEALTH ISSUES……
According to D.A.W.N. which stands for Drug Abuse Warning Network the top ten Emergency Department visits were surprising. Although this list is published openly, it does run about 1-2 years behind.
COCAINE………………………..OVER 448,000
MARIJUANA……………………..OVER 242,000
HEROIN………………………….OVER 164,000
METHAMPHETAMINE…………..ALMOST 109,000
ECSTASY (mdma)……………..ALMOST 11,000
PCP………………………………OVER 7500
INHALANTS……………………..OVER 4300
HALLUCINOGENS……………….OVER 3700
LSD………………………………OVER 1800
GHB………………………………OVER 1800
This data is from a reporting system in the United States. Many times, GHB for instance, is gone from detection upon arrival to an Emergency Room. Many inhalants cause death, therefore do not show up in the Emergency Room, but rather the Coroner’s venue. Many times the data is also regionally directed, for instance, in high methamphetamine areas, illicit use might be seen higher in the corresponding Emergency Departments.
To round out this medical commentary today, the United States still has these top ten killers. 
This data is from the 2004 National Center for Health Statistics, the latest full database. Prevention is the key in almost all of these killers. With the severe childhood obesity concern in the United States, these data may get thrown in the air, with new issues on top. For instance, diabetes and asthma may replace the first and second positions due to the issues of childhood health management in general.
HEART DISEASE……………………………………………………………………………27.2%
CANCER…………………………………………………………………………………23.1
CEREBROVASCULAR DISEASES…………………………..6.3%
CHRONIC LOWER RESPIRATORY DISEASES…………5.1%
UNINTENTIONAL INJURY…………………………..4.7%
DIABETES MELLITUS……………………………..3.1%
ALZHEIMER’S DISEASE………………………2.8%
INFLUENZA AND PNEUMONIA……2.5%
KIDNEY DISEASES……………….1.8%
SEPTIC CONDITIONS……….1.4%
As part of my background in pharmacy, emergency medicine, and toxicology, my eye is geared toward new illicit “marketing styles.” One of the latest, yet as usual, older than you think, is “cheese” heroin. This “starter pack” of heroin is REALLY heroin…the DEADLY kind of heroin…the good old toxic illicit heroin.
The difference is in the making of it. The manufacturers of the illicit drug geared for the teens is the mixture of heroin and Tylenol PM©. This multi-drug cocktail of acetaminophen, diphenhydramine (better know as brand name benadryl © and other companies brands) and of course heroin creates a deadly risk. Each item in this mix can be deadly.
As the famed Paracelsus, an earlier father of poisoning stated, “It is not the agent, but rather the dose of the agent. And everything therefore is a poison.”
Acetaminophen remains one of the most toxic poisons if taken in overdose and is the lead cause of death for many years in Europe, while diphenhydramine is again a unique poison in overdose. The anticholinergic side-effects of the drug in overdose creates elevated deathly temperature rise, hallucinations, cardiac instability, agitation, and even death. Heroin for years now continues to plague not only the U.S., but nations around the world. It has enormous addictive potential and leads to severe toxicity, criminality, and occasional deaths on the streets.
Say “Cheese” is a deadly form of a multi-drug extravaganza geared to entice, to addict, and to control your kids. Already in the last 1-2 years, especially in the Texas market, over 20 deaths have occurred. The product appears like Parmesan cheese in structure, yet kills with a vengeance.
(grated parmesan)
Say “Cheese” is usually snorted. Why do drug abusers snort? It is because the absorption rate is good. But I have seen those individuals with chronic cocaine abuse, literally rot the nasal septum out…”look Mom, no septum!”
Post-mortem toxicology tests will reveal the deadly three drugs in this mixture…heroin, diphenhydramine, and acetaminophen.
“Cheese” is not a starter-kit for drug use. “Cheese” is a start-kit for deadly teenager activity.
SAY “CHEESE” MAY BE THE LAST PICTURE TAKEN……..
HUG YOUR KIDS TODAY!
This is the time of year when lawn chemicals, yard cleanups, and neighborhood events start to be exposed and available to little hands. Certainly many chemicals, including pesticides, herbicides, fuels, and cleaning agents are ubiquitous in homes and garages. But beware. Many of these chemicals are poisonous and dangerous with regard to flammability, explosiveness, and chemical burns.
Each dollar invested in poison centers saves about seven dollars in expenses not needed if the patients go into their doctor, their clinics, or their hospitals. This is a great public health service.
Over the years since the early 60's, the poison centers have become an integral part of the healthcare network. Now with the terrorism issues, the poison centers have become an integral monitoring source of information, as many times calls come to the poison centers early and often, thereby making a grid of what is happening and where it is happening.
For instance, when the bad botulism toxin product that was being used by spas and clinics that were trying to save money by not buying and using the approved botulinum toxin brand, the poison centers were seeing a problem early. Patients across the country, in pockets, were being paralyzed – not just the muscles of the eyebrow, forehead, and other smaller muscles.
The poison centers across the USA now have a single number. Depending on your area code, your call will be forwarded to the center in your area, or the one contracted by your state officials. For instance, Idaho calls go to Denver's poison center. Alaska's poison calls go to Oregon. Washington's poison center gets all of Washington State's calls. This year that number will be around 150,000 calls! Poison calls are answered by an expert group of pharmacists, nurses, Pharm Ds and have backup by physicians specializing in toxicology and poisonings. It is the number that the experts in all fields, from dermatologists to kidney specialists, call when the patient has been poisoned, or is toxic from unknown sources, or when the patient doesn't act or change based upon "normal" disease states.
The goal of Poison Prevention Week is to reduce illnesses, injuries, and deaths due to poisonings; build safer communities; and reduce unnecessary health care costs for everyone.
Here are some ways to be poison cautious:
Obtain syrup of ipecac and keep it in your home – but use it ONLY if instructed to do so by a poison center or physician
Use child-resistant containers and remember, they are not childproof
Keep products in their original containers
Never call medicine candy or take it in the dark
Return products to storage areas immediately after use
Teach children about Mr. Yuk
Put Mr. Yuk stickers on all poisonous products
Call the Poison Center for a free information packet and Mr. Yuk stickers
Keep emergency numbers next to your phone:
1-800-222-1222
What is National Poison Prevention Week?
Public Law 87-319 authorizes the President to designate annually the third week in March as National Poison Prevention Week. This act of Congress was signed into law on September 16, 1961, by President Kennedy, after which the Poison Prevention Week Council was organized to coordinate this annual event. Congress intended this event as a means for local communities to raise awareness of the dangers of unintentional poisonings and to take such preventive measures as the dangers warrant.
(PC week and listing adapted from WAPC.org website with commentary from castMD.com)
