How COVID-19’s Stimulus Privacy Laws affected People in Recovery

2020 has been a big year. From the viral pandemic, to the economic shutdown and resultant armed protests, to an uptick in racial violence and the resultant protests and then the resultant severe government response, to increases in drug overdose deaths.

It can feel impossibly overwhelming to try to keep track of every change or significant event that’s taken place this year. But if you’re an addiction treatment patient, particularly if you are utilizing medications for opioid use disorder, there has been one quiet set of changes that you should definitely be aware of.

When the Coronavirus Aid, Relief, and Economic Security Act passed (CARES Act) in March, it included changes to 42 CFR Part 2 of the Social Security Act, the part that covers privacy protections for substance use disorder patients. Passed as a rider to the CARES Act titled the Protecting Jessica Grubb’s Legacy Act, the changes move SUD patient privacy closer to general HIPAA regulations by removing the consent requirements for information re-disclosure. Previously, patients had to consent each and every time their protected health records were shared or discussed with another provider. This meant that if a patient signed a consent for her buprenorphine prescriber to discuss her scripts with her psychiatrist, her psychiatrist would require a specific, explicit consent before discussing her buprenorphine information with, say, a primary care physician.

Now, once a patient signs consent, that information can be re-shared into perpetuity. It may sound like a relatively small change, but it essentially means that all SUD information can be shared without a patient’s knowledge. Many patients have to sign consent forms to their insurance provider, for example, or so that their methadone prescriber can communicate with their endocrinologist or anesthesiologist or any number of other providers. Now, that information can continue being shared for as vague a reason as “healthcare administration.”

Some patients hear this and say, “well, hey, at least we have HIPAA.” But in fact, the Health Insurance Portability and Accountability Act (HIPAA) doesn’t really work the way people think it does. As explained to TalkPoverty by Danielle Tarrino, president and CEO of Young People In Recovery and a previous employee at the Department of Health and Human Services who, while there, drafted the 2017 revisions to 42 CFR Part 2, “HIPAA is not a [patient] privacy protection. It’s actually an authorization to share your info as broadly as a health care payor believes they need to share it, which I will tell you is very broad.”

Zac Talbott, president of the National Alliance for Medication Assisted Recovery (NAMA Recovery), said in the same article, “You’ll hear people say, ‘that violated HIPAA.’ Actually, it violates Part 2, and it’s now gone.”

In addition to this change, the Substance Abuse and Mental Health Services Administration (SAMHSA) also updated their rules under 42 CFR Part 2. This included permissions for opioid treatment providers to include patient records state prescription drug monitoring programs (PDMP). The PDMP exists to help regulate the prescribing of controlled substances like opioids. But many people feel it is a violation of their privacy and that it is used to engage in discrimination based on the substances a patient is prescribed. Law enforcement agencies have even sought and been granted access to PDMP databases, which becomes especially problematic when addiction patients are involved since addiction typically involves an illegal act under current U.S. law. 

Prior to the SAMHSA update, which just took place in early July, opioid treatment providers were required to search for their patients in the PDMP to ensure they were not being prescribed any substances that could negatively interact with their methadone for example, but they could not add them to the database. Now these patients—who already face stigma in the form of criminalization, child removal, employment discrimination and more—are even more likely to face these consequences if their data is leaked through the PDMP or a records redisclosure.

Providers fear that patients will be less inclined to seek treatment knowing their information is not confidential. 

“Why would I go to treatment if they are going to blab my business all over town? We have a conundrum: We want people to go to treatment, but we are going to discourage people from seeking treatment by telling them ‘your privacy is irrelevant,’” TalkPoverty quoted Westley Clark, Dean’s Executive Professor in the Department of Psychology at Santa Clara University and the former director of the Center for Substance Abuse Treatment (CSAT) within SAMHSA as saying.

If you are a patient and you are concerned about your privacy under the new rules under SAMHSA, patient advocacy groups like the National Alliance for Medication Assisted Recovery and others are continuing to lobby for better privacy protections. NAMA-R is accepting members and has local chapters in every state. You can also check with the Urban Survivor’s Union, and your local harm reduction agencies and ask about more ways to get involved in patient advocacy.

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Getting Through An Alcohol Detox

For anyone who wants to recover from a substance use disorder, discontinuing use can be one of the scariest first steps.

That looks different for different people and different substances—for some, it means intense psychological cravings and fatigue. For those addicted to dependency-producing substances, physical withdrawals add another difficult and painful component. Alcohol withdrawal in particular offers serious problems—both serious discomfort, and serious medical risks. But it is possible to detox from alcohol at home, and WorkIt Health now offers a program to help patients begin this crucial first-step if they are seeking alcohol abstinence.

What Are the Risks?

It’s important for those who wish to pursue abstinence from alcohol to realize that alcohol withdrawal, unlike the average opioid withdrawal, can be life-threatening, including seizures. Delirium tremens (DTs) are another highly dangerous symptom of alcohol withdrawal, which occur in about 5% of patients, and can produce hallucinations, delirium, racing heart, high blood pressure, and fever. People with a history of experiencing DTs or withdrawal-induced seizures are not able to participate in the WorkIt Health monitored home detox program. For these patients, it is suggested they attend a medically supervised inpatient detox program. Inpatient programs often monitor patients while utilizing a combination of seizure prevention meds like benzodiazepines.

If an inpatient detox is inaccessible, it is possible for heavy or high-risk drinkers to taper their alcohol use at home. This is not part of the WorkIt Health protocol, and it is recommended they not attempt this alone, or at least keep in contact with a trusted friend. From Filtermag.com: “Tapering, if that’s your goal, should be done with the aim of avoiding withdrawal, not getting intoxicated. So drinkers should consume only as much beer as is absolutely necessary to hold off shaking and sweating.”

Milder symptoms of withdrawal include tremors, sweating, anxiety, vomiting, and insomnia. These symptoms do not disqualify a patient from the WorkIt Health home detox program and are generally expected of patients who have an alcohol dependency. Although WorkIt Health will monitor patients for short daily periods, it is recommended that anyone attempting a home detox have a trusted friend or family member present to help monitor them and make sure that a medical professional can be reached should they begin to experience more serious withdrawal symptoms.

How Can Withdrawal Discomfort Be Alleviated?

Unlike opioids, there is not an alcohol-based substitution therapy that fills the same receptors as alcohol and helps prevent withdrawal. Tapering alcohol can help prevent withdrawal by gradually lower one’s alcohol intake, but can be difficult to accomplish for those who have trouble controlling their alcohol intake. The time it takes to fully detox varies by person, but can last up to five days.

During withdrawal, it is helpful to stay in a quiet, calm environment away from lots of people. Have plenty of fluids on hand (and a container to suddenly discharge them in). Music, television, books, or other forms of entertainment can be great for helping get through insomnia without spiraling too deeply into your thoughts and anxiety—but some people may prefer quiet and solitude. It’s really up to the individual.

WorkIt Health patients may be offered gabapentin, which is a nerve-pain medicine that acts on the gaba receptors and has calming properties, as well as naltrexone, which helps block the effects of alcohol. Patients who take naltrexone cannot have any type of active opioid dependency, or it will produce severe precipitated opioid withdrawal. Patients who cannot take naltrexone because they have opioids in their system may be offered Librium instead.

For patients who are not participating in a medically supervised detox, it is important to stay hydrated with water, and electrolyte drinks like coconut water or sports drinks. Healthy food can also help keep your body functioning. You may not feel like eating, but if you can make yourself eat a few pieces of fruit or something simple like yogurt or soup, it will help keep your body as healthy as possible during this time. Anyone who begins to experience significant hallucinations or seizures should seek emergency medical assistance immediately.

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Does Naltrexone Show Up on a Drug Test?

If you are thinking of trying naltrexone treatment for alcohol or opioid use disorders, you might be wondering if it can be detected on a drug test.

There are many reasons why someone could be concerned about a medication being detected on a drug test. Perhaps you are required to take drug tests for work and you are concerned that you might experience discrimination if you admit to being in recovery from a substance use disorder. Or maybe you are on probation or in drug court, and you are not certain whether this medication will be accepted. Or you might simply be curious.

OK, So Can Naltrexone Be Detected?

The short answer is yes: any substance that is metabolized in your body can be detected by a drug test. But in most cases, the functional answer is no. When someone says “drug test,” that can mean a variety of testing types. In the workplace, drug tests are usually administered by taking urine or saliva. In court cases, urine and hair testing are common, though blood and saliva may also be utilized. For alcohol detection, breathalyzer tests are also commonly employed in a variety of settings. 

Sometimes, urine and oral fluid (saliva) tests are conducted onsite, with automatic results. These are immunoassay tests, which use antibodies to detect the presence of a substance in the sample. They are referred to as screening tests because, although they can accurately identify the presence of certain drugs, they are also prone to false positives and other errors. If a screening tests comes up positive, it should be followed with a confirmatory test, conducted in a lab by gas or liquid chromatography-mass spectrometry. 

All of this is relevant because, typically, in order for a drug test to detect a substance, that substance must be specifically tested for. Naltrexone is not included in any of the typical testing panels, so it should not turn up—unless whomever is testing you specifically requests it for their own purposes. If you’re concerned that naltrexone is being tested for, you can always ask what type of panel is being conducted and what substances are included. 

That said, however, it is possible for naltrexone to show up as a false positive on a screening test. A letter published in the Canadian Journal of Addiction Medicine in 2019 discusses some anecdotal evidence that naltrexone has occasionally screened positive for oxycodone or opiates. They attribute this to the structural similarity between naltrexone and oxycodone, but also note that there are no peer-reviewed studies to back these anecdotal findings.

What Are My Rights?

If you are being asked to take a drug test, you can decline to provide the sample, but you will then have to face the consequences, whether that means you don’t get the job you want, or get your probation violated. If you’re having trouble with the particular type of drug test requested, you may be able to request a different form of test, depending on who you are dealing with. For example, if you’re unable to provide a urine sample (which can be particularly difficult in the case of witnessed urine screens), you might be able to ask to do a blood or oral fluid test instead. Generally speaking, however, that request does not have to be granted, and you may need to take the matter to court if it’s serious.

When it comes to the use of naltrexone, it is an FDA approved, evidence-based treatment for opioid and alcohol addictions. This means that if you are taking it as prescribed by a licensed medical provider for a diagnosed opioid or alcohol use disorder, you are protected against discrimination by the Americans with Disabilities Act. That means nobody can, for example, deny you a job or say you’re an unfit parent solely based on the fact that you are taking naltrexone. When it comes to employment, the catch is that you have to disclose your medication in order to be protected. If you were to get one of those rare false positives for oxycodone and then attribute it to a previously undisclosed naltrexone prescription, even if your employer verifies that the screen was false, he could fire you for “dishonesty.” 

When it comes to something like drug court or probation, they typically get to make up their own rules. If you have a particularly dedicated attorney, she might be able to fight for your right to take a medication that is not typically allowed in your program. But this isn’t as much of an issue for naltrexone as it is for buprenorphine and methadone. In fact, naltrexone enjoys the approval of many criminal justice and family court systems because it is not opioid-based and blocks the effects of opioids. This is rooted in stigma; opioid-based medications like buprenorphine and methadone are highly effective and do not result in intoxication when taken properly—but in this case, the stigma benefits people who use naltrexone.

That said, admitting to someone like an employer that you use naltrexone essentially means admitting that you have a substance use disorder. While it is illegal to discriminate against someone based on their diagnosis alone, discrimination can be hard to prove, especially in more subtle forms. If you think your work environment would not be supportive of your naltrexone use, but you are required to pass a drug test, it is entirely up to you whether you want to take the relatively small risk of a false positive that might potentially require you to disclose your medication. 

If you’re unsure whether naltrexone is being tested for at your facility, just ask! The reality is that, in most cases, it is not.

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Harm Reduction Tips For Alcohol Use

When it comes to substance use, it is absolutely possible to practice harm reduction for any substance, regardless of legality or reputation. That includes alcohol.

What do you think of when you hear the term “harm reduction?” If the first things that come to mind are syringe exchanges, naloxone distribution, or supervised consumption sites, you’re not alone. To the general public, the term “harm reduction” has become almost synonymous with “making IV drug use safer.” But the actual concept of harm reduction is much, much broader. Even seat belts are harm reduction! 

If you want to engage in harm reduction for alcohol, you already have one positive factor on your side that many other substances do not enjoy in the United States: It’s legal. That wasn’t always true—and when alcohol was prohibited, we saw many of the same problems we are now seeing with other drugs, like tainted supplies. But these days, you can buy legally manufactured, government-regulated booze from the store. So you don’t have to worry that it’s going to be way stronger than expected, laced with other substances, or produced improperly. If you are over the age of 21, you don’t have to worry about running into legal trouble just for buying it, either. 

Here are some other harm reduction tips to help keep your drinking safe and in moderation if you wish to use alcohol:

Drink Plenty of Water

I know, it sounds so basic! But you would be surprised what a huge difference drinking enough water can make, and how often people forget to do it. Staying hydrated will help you better process the alcohol you’re drinking, and prevent a terrible hangover the next day. Try having a glass of water in between drinks; in addition to helping you stay hydrated, this practice will also help you slow down and moderate your drinking. Ending the night by chugging a sports drink like Gatorade or Vitamin Water, or something else high in electrolytes like coconut water, can also help you avoid a hangover the next day.

Don’t Drink on an Empty Stomach

If you’ve ever engaged in chaotic alcohol use, you probably followed the opposite rule. Drinking on an empty stomach can help you feel more intoxicated faster—but if you’re trying to use alcohol in a safer and more conscientious manner, it’s a good idea to eat while you drink, especially food that is high in fat. Yes—you do have a good reason to binge on fries tonight! Having some heavy, fatty food in your stomach will slow down your body’s absorption of the alcohol, which in turn will help prevent alcohol poisoning or other types of over-intoxication. Keyword: help. Eating a burger still doesn’t mean you can then take ten shots in two minutes and expect to be fine.

Arrange Safe Transportation In Advance

The advent of ridesharing has made the concept of designated drivers somewhat of a relic, but it’s still a good idea to know how you’re getting home in advance. Make sure you have your preferred app set up and ready to use, your phone charged, and enough funds to get you home. Or if you are utilizing a designated driver, set that up clearly in advance. It’s a good idea to make sure your designated driver really wants to play that role or at least is genuinely willing not to join you in having a couple of drinks.

Have a Plan—Set a Limit In Advance

If you have a history of chaotic alcohol use and know you might face trouble moderating your use, it’s a good idea to plan for this in advance. It’s going to be a lot harder to tell yourself to stop when you’re already feeling woozy, and a lot easier to tell yourself to keep going. Before you even get near the alcohol, create a plan for yourself. Figure out your safe limit. You can base this on past use or measure it by personal factors like gender, weight, and health. Determine how you want alcohol to make you feel that night—are you going for a buzz, tipsy, or drunk (you’re probably not practicing harm reduction if you aim for blackout wasted)? Pick your goal and then set a limit as to how much you’ll need to drink to reach it, and what you’ll be drinking. If you can, tell someone you trust so that they can help keep you accountable. 

Try to also plan around your potential triggers—what might cause you to drink to excess? Think about them in advance and come up with a response using the tools you prefer; whether that is a mindfulness practice, phoning a buddy, ordering tasty virgin drinks, leaving the party early, or something else.

Don’t Try to Match Other People’s Drinking

If you were using heroin, it would be considered totally crazy and reckless to try to match a more experienced user’s shot. Everybody understands that heroin is based on personal tolerance, and people don’t try to inject each other under the table because they understand that whoever ended up under the table might never get up again. 

But for some reason, with alcohol, it’s super common for people to attach weird bravado to being able to consume more than someone else, and engage in dangerous drinking contests to try to see who gets way too drunk first. It’s okay to play drinking games if you’re able to watch your limits, but don’t try to match other people’s drinking in order to feel cool. It’s not shameful to have a lower tolerance than your friend, or to just not want to get super drunk that night—even if your friends do. There will always be more opportunities to go out, have fun, and drink booze. You do not have to consume all the alcohol in the room in one sitting.

Home With Young Kids During the Pandemic? Here’s Some Tips and Tricks to Help You Stay Sane

Widespread school closures in response to the coronavirus pandemic means that if you’re a custodial parent or caregiver, you’re probably home with your kids right now. Which means you have a lot more family time on your plate than normal.

Especially if you have young children or children with developmental delays, interruptions in school and daycare means it’s on you to keep them safe and entertained all day, while still maintaining your own mental health. 

Combine Self-Care with Play Time

This is my first pandemic, but living with post-traumatic stress disorder and sometimes severe social anxiety means I’ve definitely been stuck at home with young, energetic kids who needed more structure than being let loose to bounce off the walls. You probably already know that, when it comes to young children at least, they are more likely to stay engaged with a task if you’re doing it with them (the opposite is probably true for many teenagers, but that’s a different discussion altogether). One thing I discovered is that you can often combine playtime with self-care to manage your personal anxiety while entertaining your kids. 

Exactly how you do this is going to vary based on your children’s ages, what they like to do, and what you have access to at home—but it absolutely does not require tons of money and resources. For example, ubiquitous toys like play-dough and Legos can be easily transformed into anxious adult stress-relievers while providing your kid’s activity. Play-dough makes a great stress ball; if you’ve never squished play-dough creations between your fingers while anxious, stressed, or angry, you might think it sounds ridiculous, but don’t knock it til you’ve tried it. The caveat, of course, is if your kids have a tendency to rub play-dough into your carpet, it might end up causing more anxiety, in which case you might want to find a less-sticky replacement.

Toys that click together like Legos can be oddly hypnotic and calming too. That goes for both energetic kids and frazzled adults. Don’t get too attached to whatever you create with them though, because your little one will probably end up smashing it. Or you can smash it…Legos are relatively easy to clean up and smashing things can be really cathartic, especially when they’re designed to break apart and you don’t end up really destroying something.

Family activities that get the whole house moving are also great. Put on some of you and your kids’ favorite tunes (or alternate, if you don’t share taste in music), and throw a mini at-home dance party. Get some of that energy out. If you have a yard, go outside and kick a ball around. It sounds simple, but when you’re stuck at home it can be easy to forget that it’s still important to get up and move your body. Exercise releases endorphins, which help regulate your mood. It will also help tire those kiddos out, and that will lift your mood too. 

Remember that the stay-at-home orders relate to limiting contact with other people. The novel coronavirus is not airborne, so you can go into your backyard, porch, balcony, patio, front stoop, stand next to your open window, and so on if you aren’t sick. Current recommendations are saying we should stay 6 feet from others, although some reports are now saying the virus may be able to travel farther. As always, use your best judgment and weigh the risks versus benefits of spending time outside. If you’re able to keep your distance from others while in your yard you should be okay. Just try not to touch your face, and make sure to wash your hands when you go back inside.

Make Important Things Fun

You’ve been teaching your kids how to wash hands all along, and if your kids are anything like mine, it’s been a struggle all alone as well. I can usually get them to touch a piece of soap to their palm and dip their hands under the faucet, but actual proper handwashing takes direction and reminding. It’s more important than ever now and depending on your child’s age, you might not be there every time they need to wash their hands. 

Kids understand the danger to an extent, but it can be easy for them to forget what they need to do to stay safe in the moment. Telling them to wash their hands and why is important, but probably not enough. So make washing hands fun! I tried to get my daughter to sing “happy birthday” twice as her school recommended, but she just asked whose birthday it was. She was not into it. You might have to get creative. If there’s a song they really like that’s long enough, belt it out with them. Or make up a handwashing song together, extra points if it involves butts or snot or one of the other weird gross things that kids inexplicably love.

If they are practicing numbers or spelling, utilize those skills to help them wash their hands—but make sure they don’t cheat. My daughter likes counting and showing off, so asking her to count to twenty while she washes her hands helps—but at about 12 or so she starts through the numbers.

Utilizing tools like extra-foaming hand soap is also helpful. If kids feel like handwashing time is actually play-with-bubbles time, they’re going to enjoy it much more than they will if they think it’s just some chore. Fun scents also help; that way they can show off their accomplishment by having you smell their hands.

Keep Your Medications Secure

If you have kids and take medication for opioid use disorder, it’s always important to keep your medication secure and out of little hands and mouths. Pink liquids and orange film can look especially attractive to kids, and cherry or orange flavoring might taste yummy—even if the idea that your medicine could taste good to someone might be ludicrous after dealing with it every day. 

If your medicine comes in a fun color or shape, it’s imperative that you make sure your kids don’t get hold of it. If you have a buprenorphine script or methadone takehomes, you should already have a lockbox or other secure storage for your medicine (if you don’t, now is a great time to set that up). But now, many patients are dealing with more quantities of medication at once than ever before, coupled with more time at home with the kids. Vigilance around who can access your medication is more important during this time than ever.

If your kids are old enough to self-administer first-aid, you may want to consider keeping your methadone or buprenorphine in a separate place from your other medications. It’s a good idea to keep them secure in a locked container. If that’s absolutely impossible for you right now, put them out of reach and out of sight. 

You know your child best. Some young people will do anything and everything to defy their parents, and telling them not to take your medication might do more to inspire them to steal it. But if your kids tend to listen, it might be a good idea to let them know what your medicine looks like, that it’s not candy, and that in fact, it is poisonous to kids. I don’t generally recommend scaring kids, but in the interest of safety (and because it’s true), employing a few minor scare-tactics around taste-testing mommy’s methadone might be okay.

Don’t Judge Yourself Too Harshly

We are all under an unprecedented amount of stress and anxiety. So don’t judge yourself too harshly as a parent. If you’re letting your kids utilize more screen time than normal in order to let yourself get work done or just get a break, don’t feel guilty. It’s okay to let your kid have an extra cookie because you want to see her smile (you might pay for it later though when the sugar hits her bloodstream). We are all facing anxiety, uncertainty, and stress. We all feel bad that our kids aren’t seeing their friends. We are all making concessions to get through the day. What’s important is that you and your family stay safe—and sane. Don’t sweat the small stuff. 

Harm Reduction for People Who Use Drugs and Are In Treatment for Addiction During the Coronavirus Pandemic

People in the United States are now contending with the novel coronavirus that has already brought entire countries to a screeching halt, including Italy and South Korea.

The Centers for Disease Control are recommending that everyone engage in social distancing in order to try to stall the coronavirus from overwhelming our healthcare system. Recommendations include staying home as much as possible and keeping a distance of at least six feet from other people. This is far easier for some than for others.

There are some especially vulnerable folks within the category of people who use drugs, including people who are experiencing homelessness, survival sex workers, and people who are immune-compromised from HIV, advanced liver disease, or for other reasons. People who are elderly or immune-compromised are at high risk for developing serious and sometimes fatal symptoms of COVID-19, the illness that results from the virus. The novel coronavirus is highly contagious, spreading from person-to-person contact, or from contact with surfaces that an infected person touched, including cash. People who are not feeling sick can still carry and transmit the virus to others.

Using Drugs During the Pandemic

As a community, we need to look out for vulnerable folks and help each other as much as we can. In this vein, many harm reduction facilities around the country are staying open as long as possible in order to continue to provide care for people who use drugs. Some are utilizing mobile outreach and delivery services to help get supplies to high-risk populations.

While some programs are government-funded, many harm reduction centers are volunteer-run, grassroots efforts with limited budgets. Not all of them have enough healthy staff or funding to keep all their hours, or to stay open at all. If you need specific equipment in order to stay healthy, such as syringes, it’s important that you pick up what you can early, and try to get enough of what you need to last for two weeks to two months. If you are an injection drug user, this means sterile syringes, alcohol wipes, sterile water, and other related equipment. There have been shortages on some essential medical supplies, like face masks, but if you panhandle or otherwise handle cash frequently, it’s worth asking your local shelter or harm reduction facility if they can provide you with gloves to help you stay safe.

If you are going to use drugs during the pandemic, engaging in safe use and utilizing basic hygiene practices are more important then ever right now. Wash your hands with soap and water for at least 20 seconds before and after using drugs; also after handling cash or engaging in a deal. Use new, sterile equipment and don’t share it with anybody. This includes smoking equipment like vapes and bongs.

Social distancing is being recommended by the CDC, and it is important, but so is having someone nearby who can administer naloxone in case of an overdose. Always keep naloxone on hand and use it with another person present. If you must use alone, call a friend or 1-800-484-3731 extension 800. That number will connect you with an operator who will stay on the phone without judgment while you use, and will call for emergency medical services if you become non-responsive. This is available within the continental United States.

Check out the harm reduction coalition’s website for more detailed recommendations about staying safe during the coronavirus pandemic.

Accessing Medications for Opioid Use Disorder

If you are prescribed medications for opioid use disorder like methadone or buprenorphine, you may be wondering if and how you will continue to access your medications. It’s a justified worry, but the appropriate authorities are working on solutions. SAMHSA has now issued guidelines allowing states and clinics to apply for blanket takehome exceptions in many cases, for 14 to 28 days. It will be up to individual states and clinics how they utilize this expanded license, but if clinics are forced to close their doors, they have the means to continue dosing patients.

Telehealth restrictions have also been lifted so that more people can utilize telemedicine at homes and shelters from their regular cell phones. WorkIt Health patients are fortunate in that they are already used to telemedicine, but now some office providers are also looking into utilizing similar means of offering addiction treatment remotely, such as e-prescriptions for buprenorphine, video or phone one on one counseling, and online support groups. This week, the DEA temporarily suspended a law that requires buprenorphine patients to see a waiver prescriber at least once in person before utilizing telehealth. Now, new patients can induct entirely through telemedicine.

During a time of immense uncertainty, when it might become suddenly impossible for users to contact their regular supplier, and when engaging in illicit drug use may put some at risk of contracting the coronavirus, the ability to easily and comfortably utilize buprenorphine telemedicine from the very first visit is crucial to keeping people with opioid use disorder safe and healthy. Many providers are reducing or eliminating requirements like group meetings, one on one counseling, and in-person office visits. If you are opioid-dependent and currently relying on black market drugs, consider engaging in buprenorphine treatment so that you can reduce your social contact while staying out of withdrawal.

Is It Safe to Mix Opioids and Benzodiazepines?

Polysubstance use—the use of more than one drug at a time—is pretty common within the drug-using community. Liz Brico is here to break down if it is safe to mix opioids and benzodiazepines.

Among people who use opioids, benzodiazepines—sometimes shortened to “benzos”—are known to potentiate the euphoric effects of short-acting opioids like heroin or fentanyl, resulting in a stronger high. Even if you’re not sure what a “benzodiazepine” is, you’ve probably heard of them; Xanax, Klonopin, and Valum are three benzos commonly found on the street, and which many people who use opioids take in order to strengthen their high. Billie Eilish famously serenaded/warned against the drug in her song “Xanny,” employing a well-known nickname for Xanax in the title. The warning is merited: When benzodiazepines potentiate the euphoric effects of opioids, they also potentiate the depressive effects. This means that mixing the two drugs increases the likelihood that a user will experience breathing problems and other symptoms of central nervous system depression, including fatal overdose. In fact, a 2017 paper in the Journal of Addiction Medicine identified that over 30% of opioid-related deaths also involved benzodiazepines.

But What About Prescriptions?

We know that combining non-prescribed benzodiazepines and opioids is really unsafe (even if it feels good sometimes), but what about people who have prescriptions? Benzos are typically prescribed for anxiety or seizure disorders, and sometimes also for sleep problems like insomnia. People who have clinical anxiety or post-traumatic stress disorder (PTSD) may be prescribed fast-acting benzo like alprazolam (Xanax) or lorazepam (Ativan) to help as-needed with anxiety or panic attacks. In some cases, like extreme anxiety or seizure disorders, these drugs may be prescribed for daily use. 

Like opioids, benzos are dependency-forming, meaning that anybody who takes them on a daily basis for long enough will develop a physical dependence, even if they are not misusing the prescription. Unlike opioids (typically), the withdrawals can be fatal in otherwise healthy adults. Many treatment facilities, especially those with a detox component, will not admit patients who turn up positive for benzodiazepines due to the danger and liability associated with a benzo detox. 

Patients who are prescribed both benzodiazepines and opioids face an increased risk of serious complications like respiratory depression and death. It is not uncommon for methadone clinics to have blanket policies disallowing the use of benzos, and many clinics will drastically reduce a polysubstance using the patient’s dose until he no longer tests positive for benzos. 

These policies are problematic, especially for patients with legitimate prescriptions for benzodiazepines. It is possible for someone to be safely co-prescribed opioids and benzos, but their doses must be carefully monitored by the prescribing physician, and the patient must be careful to follow dosing instructions precisely. If a patient is prescribed these medications by separate providers, it is important that she let all of her prescribing physicians know about the medications (and any changes that take place), so that any dose adjustments take into account the other prescription(s). This is generally true about any medication, but especially important when it comes to receiving benzodiazepine and opioid prescriptions.

The Food and Drug Administration (FDA) recently expanded its warning regarding the concurrent use of benzodiazepines and three medications commonly used to treat opioid use disorder: methadone, buprenorphine, and buprenorphine/naloxone. The FDA warning includes informing patients about the risk of excessive sleepiness, respiratory depression, and death, and now also advises patients on how to minimize the use of both drugs. It is also noted that opioid-replacement therapies are often the best options for patients with opioid use disorders. 

As with any medical condition, a physician needs to individually assess each patient’s needs. Due to the risk of combining opioids and benzos, it is a good idea for physicians to work with patients on alternatives if at all possible. When the benefits of co-prescribing opioids and benzos outweigh the risks, physicians should carefully counsel patients on proper dosage and administration, and on the importance of following these instructions. They should also send the patient home with naloxone.

Safer Practices for Recreational Use

When it comes to recreational or non-prescribed use of opioids and benzos, the safest action is abstinence. But if someone chooses to mix these drugs, there are a few basic steps they can take to reduce potential harms. They should make sure not to use alone, and to inform whomever they are with about what drugs they are mixing and at what doses. This will make it easier for medical professionals to treat them should the need occur. Users should always make sure to have naloxone (Narcan) on hand and to make sure that others around them know where it is and how to administer it. If they are mixing street drugs, like heroin and Xanax, it is a good idea to test for fentanyl. Because fentanyl is typically stronger than heroin, combining it with benzos is even more dangerous—and a great contributor to the recent surge in overdose deaths. Pills bought on the street are turning up that look like pharmaceutical benzodiazepines, but end up being pressed pills containing any number of other ingredients alongside or instead of the benzo—including fentanyl. Testing a small piece of the pill before ingestion can prevent the accidental ingestion of fentanyl, and possibly save a life—maybe even your own.

The Ultimate Guide to Transitioning from Methadone to Buprenorphine

Opioid addiction can feel all-consuming. In addition to obsessive thoughts and compulsive use, people who are addicted to opioids also have to contend with physical dependence.

Fortunately, there are medications on the market that help prevent users from experiencing withdrawal, while also treating the cravings and helping to decrease compulsive use. In the United States, the two medications that have seen the best results are methadone and buprenorphine. 

Methadone has been used as a treatment for addiction since the 1960s when traumatized soldiers were returning from Vietnam addicted to heroin and in need of care. Buprenorphine has been available to addiction patients since the early 2000s. Both medications are considered the gold standard of opioid addiction treatment and have been shown in numerous national and international studies to decrease chaotic use, overdose deaths, and other use-related complications. But some patients fare better on one medication than the other, similar to what you find in treating virtually any condition. For example, because buprenorphine has a ceiling effect and is a partial opioid agonist instead of a full opioid agonist, some patients find that it does not resolve their cravings and withdrawal as well as methadone. On the other hand, some patients get sleepy from methadone no matter the dose and do better with buprenorphine.

Besides side-effects and tolerance issues, there are many other reasons why patients might prefer one medication over the other. Sometimes, patients who do well on methadone decide they want to take buprenorphine because they are tired of the restrictions associated with U.S. methadone clinics—which require patients to dose daily and rack up “take-home” doses over the course of several months. 

If you’re a methadone or buprenorphine patient and you are not responding well to your medication or find yourself no longer wanting to take it, you don’t have to discontinue treatment altogether. It is possible to switch medications. Switching from buprenorphine to methadone is pretty straightforward;  vice-versa, however, is a little trickier. But it is possible.

Start At 30Mg Or Lower

Beginning buprenorphine always requires a short period of abstinence from opioids. If you take it while another opioid is still filling your receptors, it will throw you into a state of precipitated withdrawal. Essentially, you’ll feel like three days of withdrawal were condensed into a few hours. That’s why you have to wait until you are in withdrawal before taking it. When it comes to methadone, not only is it a full opioid agonist, it is also a long-acting opioid. This means that it will stay in your system for a long time, in some cases up to a week or longer. 

If you want to switch from methadone to buprenorphine, most clinics advise that you taper down to as low a dose as possible before making the switch—at least 30 milligrams. Work It’s policy also reflects this recommendation; if you’re transferring from a methadone provider or have methadone in your system because you were purchasing it on the street, you have to taper down to at least 30 mg before beginning buprenorphine treatment. In this post from At Forum, SAMHSA Medical Advisor Anthony Campbell notes that some patients may need to taper to an even lower dose. This can be frustrating for patients on high doses of methadone because tapering comfortably can take several months to a year (or longer) depending on your dose and how well you tolerate the decrease. If you are in this position, it’s important to exercise patience. Trying to decrease your dose too quickly will only increase your likelihood of relapse, and cause you unnecessary discomfort.

Essentially, you’ll need to get well enough below your therapeutic dose of methadone to begin to experience withdrawal within 24 to 48 hours. It is important that, if you’re a patient, you work with your clinicians to measure your withdrawal symptoms accurately using the Clinical Opioid Withdrawal Scale (COWS). This checklist of symptoms can help you determine how severe your withdrawals are, and whether it is safe to take your first dose of buprenorphine. Work It advises that, when switching from methadone to buprenorphine, you should be scoring a 12 or higher using COWS. 

Low Doses Help Make The Process Safer 

Another important precautionary measure is to begin induction with a low dose. While patients going from a short-acting opioid like heroin are typically safe to begin at 8mg of buprenorphine (as long as they are in withdrawal before they take it), because methadone is long-acting, patients are advised to take smaller doses. Work It recommends starting at 4mg, but if you feel more comfortable taking a smaller dose, do what feels safest for your body. When using this method, take your beginning dose, wait one hour to see how you tolerate it, and then take your next dose at the same amount if there are no side-effects. This is important because if there is still enough methadone in your system to trigger precipitated withdrawal, the smaller dose will ensure that it is less intense than it would be if you took a full 8mg.

Some researchers have experimented with administering microdoses of buprenorphine on patients taking full opioids like methadone and buprenorphine in order to transfer them to buprenorphine without any withdrawal. The doses were small enough that they were unable to knock a significant portion of the opioid out of the receptor. As the low-dose buprenorphine built up, doses of the full opioid were brought down, until the patients were ultimately able to discontinue the methadone or heroin and take only the buprenorphine. This method is still in the experimental stages, so please don’t try it at home! Misadministering the buprenorphine could be dangerous, as you could send yourself into precipitated withdrawal with too high a dose. But it’s great to know that there are folks out there working on ways to get patients transferred from full opioids onto buprenorphine without any withdrawal!

If you no longer wish to be on methadone but do want to continue using pharmacotherapy to help manage your opioid use disorder, you can safely transfer to buprenorphine. It is not a fast process, but it’s worth the wait to avoid precipitated withdrawal and start your medication right. Just think of it as a new way to practice that fiendish trait known as patience!

Things You Need to Know About CAPTA

It’s a cliché, but it’s true: pregnancy is a confusing, emotional time. Even in the best of circumstances, pregnancy is marked by uncertainty and—for many women—anxiety.

For women who are dependent on opioids while pregnant, fear and worry can become overwhelming. Although policymakers around the country are slowly learning about the efficacy of methadone and buprenorphine for opioid use disorder (OUD), many continue to base decisions on misinformation and stigma. For women who are pregnant while using these medications, the lack of education among policymakers, social workers, and judges can be especially worrying. Many women fear child services involvement after their children are born, and are concerned that they might lose temporary or permanent custody as a result of using opioid-based medications. Unfortunately, there is some merit to these concerns. But patients who use their medications as prescribed generally have less to fear than those who self-medicate or misuse substances during pregnancy.

Under federal guidelines called the “Children and Safe Families Act” (CAPTA), states are required to enact plans of safe care for infants identified as having been exposed to substances in utero. This includes timely and appropriate referrals to child services. State responses differ, which means some states and jurisdictions will open investigations on women who use opioid-based medications as prescribed. We don’t have the space to go into each state’s interpretation of CAPTA by detail. Instead, let’s take a look at the states where WorkIt Health currently operates: Michigan, California, and New Jersey.

Michigan

In Michigan, all mandated reporters are required to notify child protective services if they have reason to suspect a newborn has been exposed to illegal drugs or alcohol. Hospital staff and other mandated reporters are not required to report in utero exposure to prescribed medications, including methadone and buprenorphine—even if the baby experiences neonatal abstinence syndrome (NAS). Mandated reporters are required to file a report with child services if an infant tests positive for any non-prescribed controlled substances. 

Michigan reporting guidelines adopt a stigmatizing view of drug use while pregnant and parenting. They state that homes, where illegal substances are used, sold, manufactured, or distributed, are likely to have conditions of “criminality,” but don’t offer further explanation for what that means. Michigan also claims these homes are prone to unsecured weapons, violence, squalor, not meeting a child’s basic needs, and unsafe adults. Caseworkers are specifically advised to seek the assistance of law enforcement personnel in cases where parents are suspected of manufacturing or distributing methamphetamine, being in contact with carfentanil, or may be involved in butane-based extraction of marijuana hashish. 

Although in utero exposure to prescribed medications should not warrant a maltreatment charge, the state does give caseworkers a license to verify these prescriptions. The recommendation extends to anti-depressants, anti-psychotics, opioid pain medications, and opioid agonist medications for OUD. If you are engaged in MAT during pregnancy in the state of Michigan, you will likely be asked to verify your prescription. This process involves showing your caseworker or investigator your written prescription, the prescription bottle, and providing your prescriber’s contact information. You may also need to sign a consent form allowing your provider to divulge your prescription details. Once your prescription and treatment compliance are confirmed, your case should be closed, unless other safety concerns have been identified.

Unfortunately, Michigan’s harsh stance toward illegal drug use means that pregnant women who buy buprenorphine or methadone on the street will very likely be penalized—even if taking a therapeutic dose. A fetus does not know the distinction between legally versus illegally obtained drugs. A mother who keeps her body from experiencing withdrawal during pregnancy by taking a stable, effective dose of buprenorphine or methadone (but never at the same time) is doing what is healthiest for her child. That remains true whether or not she is able to obtain her dose by prescription. Of course, obtaining a script from a trusted provider is safer than buying on the street; it ensures she will have regular access to her medication, and that she is taking what she thinks she is taking. For these reasons, and because illicit consumption of MAT may lead to maltreatment charges, it is advisable for pregnant, opioid-addicted women living in Michigan to obtain a prescription for MAT when possible.

California

In California, children enter foster care or kinship care (family-based out-of-home care) as the result of parental substance use much less than they do in other states. While the national average hovers around 35%, California saw just 12% of cases enter care due to substance use in 2015. Part of this may be due to the way caseworkers are given the option of reporting substance use; unlike in many other jurisdictions, it is optional for caseworkers to include parental substance use in a report. Practically speaking, this gives caseworkers the license to exclude mention of parental substance use when it does not appear to be problematic or a maltreatment factor.

In relation to pregnancy, the state of California does not consider a positive newborn toxicology to be an indication that maltreatment has occurred. This means that a mother cannot be charged with abuse or neglect solely because she used drugs while pregnant, regardless of legality. Furthermore, the staff is not required to report substance-exposure if the only indication is a positive drug screen. However, if a mother presents with symptoms of an active substance use disorder, the California health code mandates that she undergo an assessment. Should the findings from that assessment indicate child maltreatment concerns, then a report will be made to child services—but not to law enforcement (if the concerns relate to drug addiction). 

California’s vague language has the potential to offer comfort, but can also be cause for concern. Substance use-related removal rates in California are promising. Well below the national average, they indicate that the state generally does not view parental substance use through the same punitive lens shared by many states. But California is a large state with a lot of variance between jurisdictions. The same lack of definition that allows harm reduction-oriented staff to ignore a positive newborn toxicology also gives a more conservative social worker license to, for example, claim harm has occurred when an infant shows signs of withdrawal. Because the law as written allows for enormous discretion, it also includes the potential for biased assessments. This lack of strict definition means caseworkers can define “harm” subjectively, which can result in the criminalization of certain cultural or social behaviors that deviate from the assessor’s own experience.

Because California does not define substance use alone—whether illegal or legal—as maltreatment, and because other actual harm must be demonstrated in order to warrant child protective action, it is unlikely that a pregnant person engaged in MAT will be penalized solely for that reason. 

New Jersey

The state of New Jersey interprets their CAPTA obligation as a need to report any newborn showing indications of having been exposed to controlled substances during pregnancy, whether or not they were prescribed—but such a report does not necessarily equate to a maltreatment allegation. This means that, for example, if an infant experiences withdrawal from her mother’s prescribed buprenorphine, a report stating as much will be generated. This will likely trigger an investigation, in order to verify the mother’s prescription and treatment compliance. An investigation may also include an assessment of the child’s home, treatment compliance, criminal background check, and consultations with hospital staff who have worked closely with the family. It will not, however, trigger an allegation of abuse or neglect.

When I was working on a story for The Appeal about the impact of child services on mothers with OUD, I had the opportunity to interview Loretta Finnegan, a renowned neonatologist who developed the scoring system most commonly used to assess NAS, and who also lives in New Jersey. She described to me her experiences over the years speaking as an expert witness defending mothers whose infants had NAS from prescribed medications. These mothers were being charged with abuse because of the “harm” caused by their medications. But Finnegan adamantly maintained these charges were not based in science. In 2013, the New Jersey Supreme Court finally decided that prenatal drug exposure alone was not enough basis to charge a parent with maltreatment.

Some recent measures have been taken to legally clarify terms like “substance-affected” and “substance-harmed” in New Jersey, in order to help make a distinction between the expected side-effects of certain substances versus actual harm to the child. This may be of particular help to those women who are unable to obtain MAT legally, though there are currently no such protections codified into New Jersey law. 

Help Is Available

If you are a pregnant or parenting person who is undergoing child services intervention and/or facing family dissolution as the result of your opioid-based medication, you may be facing illegal discrimination. 

You can file an Americans with Disabilities Act complaint online if you feel a decision about your case has been made as the result of stereotypes about your medication or condition.

You can also check out Legal Action Center or National Advocates for Pregnant Women for resources, information, and possible legal assistance.