Treating Opiate Use Disorder in Primary Care - Interview with Shelby Pope, NP
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Show notes:
We all know what it’s like when a patient needs care and has to go on a 6+ month waitlist to get the care they need. I’m NOT an advocate for overstretching ourselves, or trying to practice as a specialist when we’re clearly primary care providers.
We have more than enough to focus on in the day-to-day of primary care to add more, more, more. AND… sometimes the thing that feels super overwhelming and scary that you cannot imagine managing in-house (i.e. treating opiate use disorder), isn’t actually as difficult or scary as it seems.
Sometimes when we pull back the curtain on those scary things… it actually gets to be super easy and, dare I say, fun?
As a new grad, I was SO overwhelmed by caring for patients with substance use disorders. The clinic had an especially high number of patients with substance use disorders needing care, without access to an addiction medicine specialist or even psychiatrist for a bit there.
I wish I had this interview to help me feel more comfortable back then. I love SO many things about the interview on the podcast/YouTube channel this week, and I think you’ll love it, too.
My guest is Shelby Pope, an original Real World NP student and community member. She reached out to me to talk about opiate use disorder and treatment, and I’m SO THRILLED.
She made me feel SO much more comfortable about approaching opiate use disorder treatment— it feels accessible, so much easier than it seems, and incredibly rewarding.
In this episode, we talked about:
The journey from primary care provider into addiction medicine, and what she absolutely loves about it
What it looks like when a patient is either already taking treatment for opiate use disorder, or is interested in starting treatment
What to assess, treatment options for opiate use disorder, how to know if someone is ready
What “induction” looks like, a.k.a the initial starting of treatment, how to do it, what to watch out for
Medication-assisted treatment (MAT) for opioid use disorder options, including methadone and buprenorphine (yes you can prescribe in primary care safely!)
How to manage patients ongoing, including addressing cravings and harm reduction strategies
What resources can support you stepping into bringing this into primary care
Primary care providers have a HUGE opportunity to make a significant impact on morbidity and mortality in opiate use disorder - I hope you feel as inspired as I do.
Resources mentioned in this episode:
Buprenorphine Quick Start Guide with COWS Clinical Opiate Withdrawal Scale
ASAM National Practice Guidelines for the treatment of opioid use disorder
SAMHSA: Practical tools for prescribing and promoting Buprenorphine in Primary Care settings
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Liz Rohr 00:02
Well, hey, there, I have an awesome interview for you. So I have Shelby Pope who's a nurse practitioner with her doctorate. She's both a family nurse practitioner, and she has her psych as well, her psych degree psych mental health nurse practitioner degree. And she's also certified in addiction medicine. And so we had a beautiful conversation about addiction medicine.
And I'm really passionate about this topic, because, and I touch on it a little bit when we get into the interview. But there's so much stigma around addiction, and how to support patients who are struggling. There are so many facets of Addiction Medicine, but what we're talking about in this interview is primarily about opiate use disorder, the treatment options, and specifically buprenorphine. So we talk about, you know what kind of the journey that brought Shelby from primary care family medicine into addiction medicine. And hopefully that journey can be helpful for you as you're thinking about your own journey and your own decision making in your career. And then we also talked about just kind of like what is so special and so important about addiction medicine.
And I think that what I one of the things I really love about the interview, and what I love to bring to real world NP as well, is just like what is the beauty and magic in medicine, which like sounds kind of funny, like I've talked about it with my other friends who are not in health care. And they're like how I hate going to the doctor's I hate going to the clinic, like how could that possibly be beautiful and magical? But it is. And so I think that she really brings that into this conversation of how special it is and how impactful it is, and how accessible it actually is.
Because I think a lot of times not only because of the stigma, but also because of clinician discomfort, which is like, Oh, I don't I don't think I could prescribe buprenorphine, I don't think I can manage opiate use disorder. But in our conversation, we really break it down in terms of concretely like what does it look like? Right? Like how do we approach these situations? How do we get more comfort, thinking about how to provide Addiction Medicine in primary care?
Really like to the point very clear, what are the resources to look at? How do we learn more? And yeah, I talked about, like I said, I talk about this a little bit in the episode, but there's so much stigma, but it's, and it's a life and death. It's what we're talking about here is life and death. And it's about reducing morbidity and mortality for disease. And we have so much opportunity to be incredibly impactful in primary care. And it doesn't have to be as scary or intimidating as I think a lot of us find whether or not we're like students, or new grads, or even experienced providers or maybe providers that are coming back into primary care or coming to primary care for the first time after being in a specialty like this is such an accessible, wonderful thing. And it has definitely me feeling really fired up about how do I do more of this in my practice. So I hope you enjoy our interview. Yeah, without further ado, here is Shelby and my conversation about addiction medicine, specifically opiate use disorder and buprenorphine.. I'm so excited you're here. Can you introduce yourself for the people?
Shelby Pope 03:55
Yes, for the people. I am Shelby Pope. I am a nurse practitioner. I have my doctorate. Family Nurse Practitioner, I actually just finished my psychiatric mental health NP, the postgraduate certificate as well. And I'm currently certified in addiction medicine as well or I'm a certified addiction registered nurse advanced practice because I know it sounds fancy. There's too many letters. We're really bad about that in the nursing profession, too many too many acronyms. And I currently work in an addiction medicine behavioral health setting. It's an outpatient substance use treatment clinic, we provide methadone Suboxone, like buprenorphine based treatment and do other substance use treatment. I do also have a background in primary care in rural Oklahoma. And I was actually recruited to work here and I've been here for almost a year and absolutely love it. It's just been really, really great. I've been a nurse for going on 11 years now which is really hard. Hard to believe. But overall, I love what I'm doing. And I want to spread the gospel of treating substance use disorders.
Liz Rohr 05:09
I love it. I love it. I have some nosy questions. So did you get your doctorate in a family nurse practitioner degree first and then went back for mental health?
Shelby Pope 05:19
Yes. So right before COVID hit is when I was about maybe a year, year and a half before COVID. I decided to go back to grad school and get my FNP because I thought that I just really wanted to do primary care. I grew up really rural, I wanted to stay kind of in the country setting. Yeah. And, but I didn't I personally, just personal preference. I didn't really care for the online platform. And there was a brick and mortar FNP program here in the Tulsa area. But they only offered a doctoral degree, it was a master's was not an option. So it was kind of chosen for me. But I have no regrets. It was great. I feel like it was a really wonderful program. And I feel like I've done you know, good things. As far as networking goes, that being local. And I've made I made a lot of connections. In fact, I just called up here yesterday that's working in a community health center that I went to school with. So it was great.
Liz Rohr 06:18
Yeah, that's awesome. And did you get your a PhD? Or DNP? DNP. Cool. And then what had you go back to get your psych? Second Degree second? Certification? What kind of led you that down that path?
Shelby Pope 06:31
Well, you can probably relate to this. There's a lot of mental health in primary.
Liz Rohr 06:35
That's why I'm asking because I think like that's been on my mind for Like as soon as I got into family medicine, I was like, oh, boy, I need a second degree now. Yeah, yeah.
Shelby Pope 06:44
Yeah when you work with your peers, you find that you kind of morphed into their prescribing patterns as well. And I found the providers that I worked with, initially, they were so wonderful, they were so great to work with, and they were so supportive. And it was a great learning environment as a new nurse practitioner. But it was their comfort zone was like about this big in terms of mental health IT WAS you try one or two SSRIs, maybe an SSRI, and if that doesn't work, they're resistant, and you need to send them to psych. And then they get to wait for six months before they get in, you know, or if we did add an anti psychotic, the best we could do was like 2.5 milligrams of Abilify. And now it's like, oh, my gosh, I was doing nothing. I was not helping at all. But, um, but yeah, so I realized pretty early on, I'm like, you know, I just feel like there's a lot more to offer as far as mental health treatment goes. But I didn't feel comfortable with just like reading about it, I really felt like I needed more clinical hours in it. And that's what pushed me to do my psych NP as I really wanted to at least 500 hours in clinical settings. And I have no regrets. It was great.
Liz Rohr 07:57
That's fantastic. And then did you bring that degree back with you into primary care? Or did you go kind of is that when you made the transition to addiction,
Shelby Pope 08:04
so I had actually been working on my psych mental health NP while I've been working here. So I actually transferred here as an FNP. So I was working in addiction medicine, initially just as a family nurse practitioner, but I had actually gotten, I did like the 24 hour waiver training while I was in primary care. And I was exposed to a lot of substance use disorders in primary care setting, initially, and that's what kind of sparked my interest and like me, and we're really not doing our patients any favors by not being willing to treat all of these issues. So I'm kind of going to go down a rabbit hole here, so I apologize. But when I was in primary care, while I absolutely loved my collaborating physician, He was very much against any form of controlled substance, like it was a very, it was very much a hard stop. And I'm learning the long arm and practice. It's just not black and white, right? Like we can't be one extreme of the spectrum or the other. There's there's definitely a safer middle ground. And there I had one particular patient who came in from another primary care setting. She was stable on I believe it was like eight milligrams of buprenorphine for opiate use and doing really well and had been doing well for years and wanted her meds continued. And my collaborating physician said absolutely not. You have to refer her out to addiction medicine, she needs to go drive into Tulsa, which was like a 40 minute drive. And get in the waitlist for the addiction medicine clinic that he recommended was six months and I'm like, so what do we do?
Liz Rohr 09:45
I know,
Shelby Pope 09:46
this is real world like that's, that's genuinely what happens. And I see it every single day now. And I'm like, so. So what does she do in the meantime? Yeah, what do we offer? Yeah, and He's like, No, it was a hard it was a very hard No. So then we got through that I was able to, because of my connections of doing my DNP in the Tulsa area, I was able to get her in, but not everyone has those connections, you know. So I, afterwards, I was like, You know what I'm gonna, I'm gonna build up some some proof, you know. So I did like all this research, like how we should be offering this service, and I did the 24 hours training to show him and at the time, the X waiver was a thing. And I may have misunderstood the guidelines, but I'm pretty sure you're collaborating physician also had to carry the X waiver in the state of Oklahoma, in order for a mid level provider or nurse practitioner to prescribe with their ex waiver. So did the 24 hour waiver training, I went to him and I was like, did this whole spiel like I, you know, I've done this, I feel really confident that we can offer this service would you be willing to, to pursue the waiver? And he was like, just still no, absolutely not. Absolutely not. He, he was he the kindest person, and it was just so wonderful. And I'm not sure what, where the core of those reservations came from. But it didn't sit well with me. I had such a moral dilemma with it. And it was such a weird thing. Because I was having like one of those hell, weeks, you know, you I'm sure you, you know, like, it happens, right. And I had literally just walked out of a room about a week or two later, I'd walked out of a room with a patient who was screaming at me because I diagnosed them with diabetes. And I was just like, so overwhelmed. And my watch was buzzing. So somebody had been calling my phone and I thought I had I had a call a cold call out to a psychiatrist on another patient. Yes, putting love it. I'm putting my cold call plug in. They work. They were there. But they were there. So scary. But after you do it so many times, it's like, oh, my gosh, everyone needs to do this. Yeah. It's it really benefits patients so much. And you make so many connections. Yeah. When you need connections, you have them. So I had this call coming in. And I, I ran to my office and answer it expecting it to be the psychiatrist. And it ended up being my current clinical manager. And he was like, Hey, I know, this is really weird. I was a part of the HRSA Loan Repayment Program. And he's like, but I saw your name on the list. And we're currently looking for a nurse practitioner to replace our current provider. And I was just wondering if you'd be interested in working in addiction medicine, I know it's kind of a a stigmatized field. And I was like, universe? Oh, my gosh, it gives me no, no. And I was like, you know, this might be weird. But yes, I am interested. When would you like me to interview? And he's like, can you be here Friday? And this is like, literally a Thursday? And I'm like, Absolutely. I'll fax you my resume. I love that. Yeah. And then if offered the position, and I've been here since and we're doing great. Thanks. I love it. It's good work.
Liz Rohr 12:56
I love that. And thank you so much for telling that story. Because I think what's really helpful, too, for people to hear about is that, like, they're just so many different routes to get to the place that we want to go. Because I think sometimes that we go into primary care, or becoming a nurse practitioner thinking it's going to be one thing, and then we just like can let our path evolve as it goes, right? Like, I imagine you didn't see yourself starting here. When you were in grad school, you maybe didn't see yourself getting a psych degree, you know, like, there's so many different options. And like you were just I mean, before we got on this recording when we talked before, like, you just light up talking about addiction medicine, right? Like, it's just it's so so special. And it's so nice to share with people. It's like, this is an option, which kind of like kind of brings me into my next question about like, I think that what we're thinking about this episode, I'm thinking about the people who are in school, the people who are new grads and the people who are coming to primary care for the first time after being in a specialty. Like if we're like, I think that there's this because like you said there's stigma in this field. And some people are like, Oh, addiction medicine, like, like, like that physician, I don't know anything about your collaborating provider. But I've heard a lot of people that they kind of just have this hard stop because of discomfort. And so I would love to hear from you like what is it that you love about addiction medicine that like lights you up? That can help be an entry, I think it will be a real entry point for people to like, be like, Oh, this is possible. And it is cool. And it's exciting, like what are the things you love about addiction medicine,
Shelby Pope 14:18
I can literally feel the tears coming. So I'm gonna try to help. Welcome all that's an emotional person. It's when I tell you so again, I've been a nurse for almost 11 years, and I've done I've done some really gratifying work. But it doesn't even compare. It doesn't hold a light to this, like on a daily basis. I see people walk through the door and pull themselves out from the depths of hell, like absolutely the most horrific stories. And I see I see a lot of in terms of the spectrum, one extreme or the other. Like I see the generational substance use the generational poverty And the individuals that genuinely just like I want to break the cycle, I recognize that this is a cycle and I want to do better, whether it be their self referred or their court ordered. There, they do recognize it and they want to do better and they're trying, you know, and then I see the people, the other people with strong quotations, the other people that are again, strong quotations, just like you and I, yeah, who had one significant injury? Yeah, one car wreck one surgery, one gallbladder, that colitis ectomy that went bad and had to have multiple, you know, had to have a wound vac, and all these things, and we're on pain management for, you know, a couple of months, and it spiraled out of control after being prescribed opioids by a provider appropriately, you know, and, and then I also see a lot currently with how the guidelines changed as far as prescribing goes, which I could go, another rabbit hole it's gonna hold, I'm gonna try to hold it back, where people are just cut off from pain management. And then they're sent here because they have nowhere to go. And I have many patients that resorted to using fentanyl in the street.
Liz Rohr 16:16
Because they were on pain medication, because they were on pain meds, yes,
Shelby Pope 16:19
because they were on pain meds and for one reason or another because of really unrealistic expectations, or because someone has drawn this like line in the sand of I will not prescribe over this, but their pain is not controlled, like we're not treating the patient, we're treating the algorithm, you know. And they, so they start supplementing, because who wouldn't, you know, like, I'm hurting, this isn't working anymore, or they were on a regimen and I my collaborating physician saw one of my patients yesterday, because he has one of those, like, heartbreaking cases, was in pain management was kicked to the curb. Because after the guidelines changed, he was cut way down on his prescription that had been well managed before that had no reported history of misuse. And then he got kicked to the curb. And he's like, he could barely walk. I mean, he's, he's honestly to the point of like, has very poor quality of life. And you can visit, like, visualize his discomfort in the visit. And it's so provoking like it's so hard to watch. And my collaborating physician currently is both board certified in pain management and addiction medicine. So it's wonderful. And he saw him and he was just like, I'm so mad, I'm so mad. Because he got kicked to the curb, he started supplementing with poppy tea, and then because of that, so with that termination, he ended up here. And he's like, What do I do, you know, and then I'm supposed to prescribe him Suboxone, which really at the doses we do does not really help with his pain. So it's tough. So as far as like the work, and being gratifying, it's it really, on most days, it really restores my faith in humanity of like, knowing that these people need help. They are appreciative of the help. And it's just, gosh, I wish I just I almost wish I could just like wear a GoPro and like just released the footage, obviously a huge HIPAA violation.
18:24
Battling totally,
Shelby Pope 18:26
I think, if you would have told me five years ago that I would have ended up here, I would have been like you're out of your mind?
18:33
No way. Absolutely not.
Shelby Pope 18:35
I never would have thought I would have done something behavioral health wise, because I think I think we see it, some of us see it through a lens of you know, our history. So I used to work in acute care. And the patients that I would see in the hospital setting were a lot of times with active substance use were homeless, they had like act of psychosis due to either alcohol withdrawal or schizophrenia. So I saw all these extremes. And I'm like, Oh my gosh, like, that's what it's like to treat these people. And that's all I would ever see. Like, you know, I don't want to touch that with a 10 foot pole. But that's not a majority of the cases like those are definitely those do come up. But those for a vast, vast majority of my patient population. They're wonderful individuals that just want to help. Yeah, hell. Yeah. And
Liz Rohr 19:22
so I'd love to. There are so many different pieces of Addiction Medicine, but when, you know coming onto this call, we talked about kind of going over buprenorphine Suboxone. And like, I feel like it's one of those things that there are certain topics in primary care that it's like, people treat it as like, Oh no, it has to be a specialist, like HIV care or certain things like gynecological things. Like I feel like this is an opportunity. I think depending on your practice setting and the supports that you have, it's important to bring this like start thinking about bringing this in. Like if they're like maybe if we can start with that like how Well, I guess I want to before I was thinking about, like, what are some of the things that like somebody who's like, you know, I'm here, I'm hearing this, I want to do better with addiction medicine, I want to think about how to support patients like this. Who are going through this, like, can we talk about like that process of how you see it happened in primary care, or how you can envision it happening in primary care? Like how how it's like, what is the and you talked a bit about x license? So actually, I don't know if you said X license, but I heard X license. But do you want to talk about that? Yeah. Do you want to talk about x license? Before we jump into that? Yes.
Shelby Pope 20:35
So that was removed by the Biden administration? I think it was in 2022. They removed it. So you do not
Liz Rohr 20:45
like what did X licenses for people who aren't? Oh, yeah. So
Shelby Pope 20:48
so there was like an X waiver that was added to your DEA number that showed that you were capable and competent to prescribe buprenorphine to individuals with opiate use disorder. The caveat to that was, there was also a limitation on the number of patients that you could treat. And I don't even remember what those were, but I think it was like, initially for like, the first year, it was a limited amount. And then you could you could apply to increase it to like 250 patients in the second year. And then, you know, eventually, they did realize, you know, this is a huge barrier to treatment. Because I was, and I worked primary care and knew I know what that's like, I know, in terms of how busy it can be the last thing we want to do is like, do another, like 24 hours of training and anything. But now that it's actually I think that's it's everywhere, correct me if I'm wrong, if you know, we have to have eight hours of opiate use. Training to continue licensing, and I think that has to do with our DEA number in the state of Oklahoma. I know it's required, but I don't know if it's everywhere. So there, so those those classes that were actually required initially for the X waiver, there was like an an eight hour and then a 16 hour training, both of those are free online, and they still qualify for the DEA requirement. As far as so that does that answer the question as far as
Liz Rohr 22:24
Yeah, just to kind of apprise people and I'm not I'm not familiar with like the National different rules about like how people were would be getting into this. So I can always like put that in the show notes afterwards. So okay. Yeah. But we don't have that anymore. So people could, yes,
Shelby Pope 22:39
so So X waiver was removed. So anyone with a license to prescribe, depending on what your state's regulations are, obviously anyone would have to do their own due diligence with that can prescribe buprenorphine because it's a very safe and effective medication. But unfortunately, I think the most recent article that I read, it said, buprenorphine prescribing actually plateaued between 21 and 22. Like, so they removed this barrier, I think it is beginning to like slightly creep up. But they removed the barrier. And it just like kind of went, yeah, there wasn't like a rush in the field to like, start prescribing this. But I will give the nurse practitioners a little plug because I was on a journal club out of Maryland, last like two weeks ago, and there was a physician on there that practices in addiction medicine, and he's doing a study currently on the prescribing patterns of buprenorphine. And he said that nurse practitioners are the most rapid profession, prescribing buprenorphine, and so he applauded us for that. And I could go down a whole nother rabbit hole with that, but I won't.
Liz Rohr 23:54
Well, that's wonderful. Um, so I think that like so I think that I want to start by saying a disclaimer of like, if anybody is specially who's listening as like, a, you know, a brand new grad, or even if you're an experienced provider, it's important to get support, especially when you're kind of coming up with like a program, because at least my experience in the clinic that I was in before, there wasn't there was a medication assisted treatment program. And so we kind of had like all these different protocols set up we had a nurse that worked with patients we had, like, there was just it was it was more than just like me and a visit prescribing something. So I actually haven't prescribed suboxone before it's buprenorphine. But that was the container that we had before. So I just want to give that disclaimer that it's not necessarily just like, run out and start prescribing like tomorrow. But let's I just want to I want to paint a picture for people so that it's less scary so that they can feel comfortable taking those next steps forward. And I'll share some stuff in the show notes about like, you know, what are some of the steps that they can do and like organizations, they can look to the education like the regulatory stuff, but if we if we put that aside for a second let's I just want to talk about like the process of Suboxone like, excuse me beeping our friends. So how do you when you're a Say if we put ourselves in like a primary care, and I want to do this for somebody, how do I know if somebody's ready? Like if I have somebody who's like, I really want to start this house? Like, what are the first steps? Like, how do I know that this person is ready? And like, what are those first steps of like, you know, what do we need to assess there? What is the shared decision making conversation? Like, what are those kind of initial things in that first stage? Yeah, where would you advise somebody to start in that? Or what does it look like?
Shelby Pope 25:26
I think Okay, so first and foremost, I would start, I want to mention like the in terms of acuity with individuals, like if someone is already stable on any form of buprenorphine, and doing well and have been on that dose for many years, I highly encourage any provider to continue the medication for them and allow access to it. As far as the guidelines go, there's no hard and fast as far as required drug screens, whether they have to be observed unobserved, obviously, that needs to go along with people's clinical judgment. The guidelines do recommend at least six to seven drug screens per year, I typically see patients monthly that are stable. But depending on state guidelines and restrictions, you could prescribe this medication for 90 days. Without a without a visit, we have a restriction the state of Oklahoma, I can only send in up to 30 days of medication. But I could, like put a calendar reminder, you know, to send it another one if people were stable enough, but I like checking in with them monthly, personally, specifically in our patient population, because things come up. And there's a lot of stressors, there's a lot of barriers to care for, for these people. So I see the monthly a drug screen, our clinic specifically does require observed drug screens because we also dispense methadone. There's a lot of controversy on that I don't. And I'll be just very blunt about it. I don't agree with forcing everyone to do observe drug screens, I think it's really intrusive. And for it's specifically for individuals with a history of trauma, which vast majority of my patient population that has some form of sexual trauma. And also, it's just like a mistrust thing. Like, obviously, there's going to be individuals that will falsify a drug screen, it happens, I've had it happen. But when you sit down across from the human, and you have a conversation with them, nine times out of 10 They're just like, I'm so scared that you weren't gonna give me maybe buprenorphine, because I'm on meth. And I'm like, those are two separate things. Yeah, friend, like, it's okay, like, continue to view, the buprenorphine. But I need you to not do that. Let me be honest and transparent, cuz I don't know how to help, you know, totally. So, mainly, so continuing it if they're stable, as far as knowing when someone's ready. First, like, this is the core of being a nurse, right? Like, have the conversation and ask, you know, mainly, and primary care, I really, it wasn't like a huge percentage of patients that came in, and they were just, like, open about their substance use a lot of time. And I'm kind of gonna go off track for just a second, like, specifically with alcohol, like that one wasn't talked about a lot, but their blood pressure would be through the roof. They're tachycardic. They're diaphoretic in the office, and you're like, something doesn't look right here, you know, but they are not open about it. So screening, obviously, like you need to be having a conversation on a regular basis with your patients about hey, any illicit substance use, and obviously, initially, on the first visit, like substance use, tell me about that. And, you know, it's it's amazing when you have the conversation and you open the platform, and you make them not feel intimidated or rushed, which I know is complex and difficult in primary care. I know that they are open to talking about it, you know. And I have had patients come in and a vast majority of my opiate use patients are they desire to get off fentanyl? It's a nightmare. It's a dirty, dirty drug. Oh, I hate it. I've had so many Addiction Medicine, like mentors tell me that they hope for the days of heroin again, because fentanyl is just such a high up and low, low, and it's constantly like that. And patients, a lot of patients really don't like it. They're just like, they don't withdrawal is terrible. And the potency of it, as far as how it binds to the receptor is very intense. So the withdrawal is very intense, far worse than people like I have people that you know, historically used heroin couldn't find it anymore and started fentanyl. And they're like this withdrawal is on a different level. And I don't want to do it anymore. I'm tired of this game. So opening the platform, allowing people to tell you in the ready, you know, and then as far as starting it, fentanyl, starting buprenorphine, there's different treatment options and I and I want to kind of talk about that for a second. There's Three options specifically for opiate use disorder. There's now trexan, which is, to be honest, as far as the new data a little bit controversial, because there's some data. I think there needs to be more time in terms of research on this. But there's some data that shows that there may actually be an increased risk of overdose and death with naltrexone. Because you have it has a high potency or high affliction for the receptor as well. So you would, and I always educate patients on this, they would have to take an astronomic amount of opioids to like push that off the receptor. And it vastly increases the risk of overdose and death. So
Liz Rohr 30:38
so that and then just a pause. So just thinking about the newer people. So with naltrexone, this is like a this is an opiate blocker. Yes, it's a and it's 100 100%.
Shelby Pope 30:49
Yes, like it's a complete antagonist. It's an opioid antagonist. So yeah, it it does, it completely blocks the receptor so that if if an individual were to relapse like, have one slip up, it would block the receptor enough where they would not have, you know, a positive association with use. And it also decreases opioid cravings. It is also used for alcohol. So it decreases alcohol if you have somebody with multiple substance use issues. There's also some data that shows that it may be beneficial as well for methamphetamine use, specifically the injectable form Vivitrol. The injectable naltrexone, that people would do once a month. That's probably getting a little bit in the trenches in terms of Addiction Medicine.
Liz Rohr 31:32
It's nice to know, it's nice to share what the options are, though, because I think at least for me in primary care, it was like those were the two things when people came in with opiate use disorder, it would be, you know, are we talking about naltrexone, like a total cessation? What we're going to do that and it's like a it's like a daily thing until you get to that injectable and then it's an injectable for a month and then that's kind of that nice support for those people because then they don't have to be dependent on themselves to take a medicine every day to prevent their cravings and their use versus a buprenorphine, which is we'll talk a little bit more about but yeah, no, I think it's good to bring on naltrexone.
Shelby Pope 32:02
I think the the most important thing to talk about in terms of naltrexone, if that's something that's on the table of consideration, is that it will precipitate withdrawal if you give it to your patient that's actively using opioids. So if somebody comes in and they're like, Hey, I used fentanyl a couple days ago, I heard about this shot, I want to do it. Yeah. The answer would be no. That day, not today. Not today, we can we can work on it. But they need to really have opioids out of their system entirely, I would honestly recommend a urine drug screen that shows no opioids at all. And then if you're doing unobserved drug screens, you really need to educate the patient, hey, if you've used opioids at all, and you've been using them, and I give you this, and you always do a trial for a few days of the oral naltrexone some say up to two weeks, but honestly, you could do three or four days before you before you start it. If you can get it approved through insurance, that's always the caveat. But you have to you know, really educate them like this can make you really sick if you in most patients don't want to be in withdrawal. So there'll be transparent like, Oh, I'll be honest, Doc, like,
33:11
there's a lot of good ideas and a couple of days.
Shelby Pope 33:15
I'm gonna, I'll take that back. Yeah.
Liz Rohr 33:19
One of the nurses that I worked with used to counsel patients that it's like, you won't die, but you will kind of wish you were that much discomfort. Yeah. So like, a very important way to put it, but it's but it's accurate. So. So yeah, so that so that starting of that naltrexone process is a little bit different than that sounds like the buprenorphine process, which could be somebody's coming in and wanting to continue what they already have, or somebody that's like brand new, and they're like, I have opiate use disorder. I'm using, you know, like, as you said, like it kind of like just to set the scene for people. You know, it sounds like when somebody comes in, you're getting a history with very non judgmentally of like, let's just talk about all the options and nothing. There's nothing wrong here. Just tell me all the things, how often you use, what are the things that you use? When was the last time you used it? And like, yeah, just I guess, gathering that history piece of like what they're looking to do, and it's like, you know, I'm taking fentanyl, and I just don't want to do this anymore. And so you have that conversation with them or the provider PCP does, you know, is it an old trek zone? Is it buprenorphine? Our friend, those are sounds like those are the two main ones that you're really going to think about in primary care versus methadone is kind of, we're not going to really talk about methadone today. But that's another potential option, but which
Shelby Pope 34:27
I do I would like to make a plug for methadone here just because the with the fentanyl era and how potent it is. And now, car fentanyl I don't know if you've heard about that is is on the market and there's a whole other one that's even being added. So car fentanyl is actually 100 times more potent than fentanyl. And I just had a patient today actually a new patient that first thing this morning that said that he knew for a fact he was using carpal tunnel and I don't know if that's something that the dealer was saying because like, Oh, I've got a really bad stash you know, which happens but um So I've had, you know, obviously had people talk about it. And with that we are finding that some of our patients, just the, the potency and extreme nature of fentanyl, many of them do require methadone treatment. I always recommend first and foremost, trying buprenorphine and seeing if we can do an induction and get them on it, and get them stabilized and comfortable. And if not in an outpatient setting, get them to go to detox and tried to go that route. And if those things fail, methadone is always there. But I'm in a setting where I can offer methadone today, you know, like, so if I have somebody coming in, and they're like, I can't I can't do the withdrawal. I can tell you right now, I cannot go more than one day without using fentanyl. I cannot tolerate it. I'll be like, Okay, we've got methadone. That's okay. We can get you on something. And as far as statistics go, I actually, like made it myself a note so that I wouldn't forget to mention it just so people like really understand. So according to the National Institute of Drug Abuse, patients using methadone and buprenorphine are 60% and 40% less likely to die of an opioid overdose. So 60% If they're using methadone 40% If they're using buprenorphine, so it vastly, vastly decreases risk.
Liz Rohr 36:17
And yeah, which I love to just highlight there that like, if anybody like thinking or like who's listening is thinking about like, they're still intimidated. They're like, not really sure. And we talked about this before recording, but it's like them, this is life saving, like that's the bottom line. Moral of the story here is that there's a lot of stigma, there's a lot of, I think, education and discomfort and gaps that we need to address for primary care providers. But the bottom line is that if we're talking about reducing mortality, this is reducing mortality. And we wouldn't make we wouldn't. I think it's interesting to think about, because it's like, if we're talking about mortality, mortality reduction in this field, if we're thinking about diabetes, doing something that reduced mortality by that percentage, like, there would be no questions here. So I just want to I just want to be on that little pedestal for a second.
Shelby Pope 37:03
I appreciate the soapbox, because it's so it is it's so important. You know, like, I think the statistics say now that only one in five individuals with opiate use disorder have access to medication. So that means 80% of individuals are going without treatment. And this, I mean, there I think that the statistics are 80,000 people are dying yearly from opiate overdose 80,000. That's, it's so much and, and by and large, all the data is very conclusive. And the fact that if you allow access to medication, it reduces morbidity and mortality. And medication alone decreases the risk of HIV, hepatitis C endocarditis. And if you're going to take the lens off the patient, which I never recommend doing, but if you're going to take and just look at the taxpayer burden and the overall cost to society, those three things alone, if we decrease that, it's a no brainer, right? Like there's so many things that this medication helps with. So as far as the the induction, kind of gonna backtrack a little bit on buprenorphine. So, first and foremost, obviously having the conversation. And then the first question I always ask is, when was the last time you used fentanyl and I say fentanyl, because that's really what most people are gonna see. There's one extreme or the other. In my one year here, I have seen one person that tested positive for heroin. That's how it's just not something people in Maryland that I do that journal club with, they said that they haven't seen anyone using heroin, and they work in an addiction medicine setting. So it's all they see. They haven't seen any heroin in yours. So it's primarily it's, it very much is just saturated with fentanyl. And so with that, there's that and then there's also I do occasionally get an individual that still has access to like prescription pain pills. And those, those two inductions look differently. So if somebody if somebody is coming in using prescription pain pills, the window of time that they need to be abstinent is going to be a little bit shorter. So and you can literally Google like you can find a guideline to follow for buprenorphine induction. It's like super and actually I printed one to like, just like how easy it is to find one online. That the one thing I will say is the one that I found online, it says that you should wait 12 hours before you induce somebody on buprenorphine. If they're using fentanyl, and that is incorrect. You really, anecdotally, I find that you really really, really should have somebody at least 48 hours, if not 72. And if they can push to that fourth day without using fentanyl, that's the best place to start them on buprenorphine. Because if you don't if they started too early, the concern would be precipitated withdrawal and making them more sick than when they started. But if you that the key is educating I don't tell people all the time and I just get really real with him. I'm like, if you start this tour Really, if you walk out of my clinic and you pop this in your mouth, you're going to be in precipitated withdrawal. And I, I personally recommend at home induction, some people prefer doing it in the office, but the data supports that people are more comfortable doing it in their own homes and their own environments. And it's, it's safe to do that. So why not make them more comfortable, but if you're not comfortable with doing it, and you want to keep eyes on people, I don't care how you do it, just do it. Like, yeah, give them access to meds, please. Um, so as far as induction goes for pain pills, really almost any form of it 1224 hours in there needs to, what I recommend going off of is the clinical opioid withdrawal scale cows is what we call it. And there needs to be like a score of 12 or higher on that. And what opioid withdrawal looks like, is, I call it leaky face. So it's easy to remember and I actually had a patient tell me that one time, she was like, oh, yeah, I got that leaky face and I'm like, Oh, that's good. That's good. I'm going to use that because people know like, yet leaky face. They're like, yes, yes, I do. Okay, so tell me more about leaky. Okay. So, runny nose, rhinorrhea lacrimation. So eyes watering a ton, sneezing, like, over, like, over and over again. They'll have tons of yawning. People will feel like this intense urge to stretch and they're like, really restless. They're just moving. They're like I can't I'm coming out of my skin. Most people will be diaphoretic a lot of them feel flu like Like, they're very irritable, body aches, chills, insomnia, those are all the the most common symptoms. Typically with fentanyl, what I'm finding and this is just an anecdotal thing for me, what I'm finding with my patients that are actively using fentanyl once the GI symptoms, and everyone's different. So this isn't a hard and fast. But once the GI symptoms start like if they're having nausea and they're having diarrhea, typically they do well on adduction. There, they can go ahead and start the buprenorphine and feel okay, but but still go off of the cows of 12 or higher. And again, you can print that offline, like literally, it's a checkbox, you can't you can't mess it up, like you just follow it. And the higher the score, the higher the more severe the withdrawal is. And so the data shows at least 12 They should be okay. But there is some data coming out that says people that are using fentanyl probably need a higher score in order to not precipitate withdrawal. So fentanyl Oh, I
Liz Rohr 42:32
understand. So if they're if they have those symptoms, and they they the more symptoms they have, the higher the score, and like but if it's lower than that it might precipitate withdrawal. Is that what you're saying? Okay,
Shelby Pope 42:42
so if somebody comes in and they're just have a runny nose, and you're like, Oh, well, that's a withdrawal symptom. Let me start buprenorphine, I understand you're gonna push them into withdrawal and make them more sick and make them very uncomfortable because you're pushing the opioid because buprenorphine has is has a high affliction for the opioid mu receptor. And arguably more so than fentanyl. So if you take the the buprenorphine, you're pushing the fentanyl off the receptor, and you're putting them in withdrawal. And they will not like you very much if you do that. So, and they will typically self treat, they'll go out and and that puts them at risk, you know, go out, yeah, and they'll go out and you spent all so that's why. And then I tell them that in the conversation, I'm like, if you're going to do a home induction, you really, really, really have to ensure that you're sick and that you have to be sick to the point that you can't stand it anymore. And everyone's threshold is different. But I show them on my piece of paper. These are this the signs and symptoms of withdrawal. You need to have as many of those as you can stand. And that's, that's more than two or three, like you need to really, really be uncomfortable. And honestly, the year that for the year that I've been here, I've really only had maybe a handful of failed inductions.
Liz Rohr 43:52
What to you mean by failed induction? Yeah. what does that mean?
Shelby Pope 43:56
Yeah, so with that, specifically, they just could not get uncomfortable enough to start the buprenorphine. They just not and they would just they would use Oh, yes, they would just use or I have had. I think I've had one patient that used the buprenorphine too early and said that they got precipitated withdrawal from it. But I was actually just listening to a podcast the other day and I think a lot of providers are gun shy with the buprenorphine because due to fear of precipitated withdrawal, but I just listened to an addiction medicine doc that said, you know, I think there's far more like mistreated patients as far as dosing goes, like not actually giving them access to enough medication, rather than actually causing this much precipitated withdrawal. Because she was like, she's treated 1000s of people she's, you know, in the Northeast, and she's like, I've treated 1000s upon 1000s of patients with buprenorphine, and I see far less precipitated withdrawal than people talk about. So it's really not that common to cause it and if you provide for appropriate education, it'll be fine. Like, and if they don't, and my patients that didn't do well on the induction, I just encourage them, like, obviously I gave them access to Narcan. I sent them home with it. And I was just like, you know, if this doesn't work out, that's okay, come right back and see me, you won't be in trouble. I won't ground you for medication, it's fine, like long back and then methadone, you know, or I give them the option, you know, of, of getting them access to case management and helping them get into a detox center so that they can do it in a controlled environment where they have access to medications to support their symptoms. And to make them more comfortable with withdrawal, you can absolutely prescribe, like clonidine, 0.1, twice a day as needed for anxiety that really helps patients cut the edge off, I sometimes will give a little baby dose of Trazodone to help them sleep because a lot of people complain of insomnia, you can tell them to take Imodium for diarrhea. I mean, there's a lot of supportive things that you can do to help make them comfortable. And these things really do work.
Liz Rohr 46:01
That’s wonderful. And I so I guess just to recap for people, so like if somebody's coming in, is using opiates, typically it sounds like fentanyl. We're doing an assessment of how long they've used it for how often they're using it. Like I guess the route we didn't really touch on that is like they're injecting or other routes. And then when did they last use? Do you ever ask about like the, like the amounts that they use? Or is it really just the frequency?
Shelby Pope 46:26
I do? I personally asked because just and I don't know that it would be super important to nail that down in a primary care setting. I know how limited the time is I do it here just because like, like Yeah, a couple days ago, I had a new patient who said that he was using 5050 fentanyl tabs per day, which that's a lot. Yeah, that's a lot of fentanyl.
Liz Rohr 46:48
Do most people talk about tablets? How many tabs they use?
Shelby Pope 46:51
Yes, they it's usually they call it like there's all sorts of names some blues, and I think it depends on what region of the country you're in totally. Um, some people just call it Finn. I mean, there's all sorts of names, but it's usually in a format of tablets or powder. I have a lot of people that smoke the powder. And they will usually tell me in grams, like I do a quarter gram, I do a half gram, I do a gram. And you know, obviously the higher amount I know it's going to be a little bit more of a ride to get them on buprenorphine. Yeah. And the ones that are on higher amounts I start, you know, I kind of opened the platform of methadone to I'm just like,
Liz Rohr 47:31
Yeah, well, I guess this is what I'm thinking about in primary care. It's like when there's somebody's doing an assessment. They're trying to figure out like, what is their use pattern and like, how, how long they could go before they could not use? Because that those are the determining factors. It sounds like if like they have to not use for as many days as possible to get to that cows score. So usually about four days, I think is what you said 72 hours up to four days or four days plus, but if they can't do that, and they use every single day, then it's the decision making of do they need detox or do they need? I don't know, I don't know where the where the status of primary care is on methadone. But it sounds like if somebody the higher the use that they have, the more likely they're going to need methadone. So they can go from Naltrexone is like step one. Buprenorphine is kind of in the middle. And then methadone is the higher amount. If they have more use or they cannot. They cannot wait for the withdrawals. Or they go to a detox. So it sounds like that's kind of the triage approach for the starting and then I we didn't I meant to clarify at the beginning, but the word induction just means the first time that you're starting it.
Shelby Pope 48:36
Yeah, and what that even looks like so it varies, but typically, I'm going to just do the very standard induction if that's okay, if I know Yeah, go for it before we were on camera. Previously, when we talked. I don't want to be super specific as far as dosing but there's a pretty much a standard as far as this realm goes. With fentanyl, we are noticing it requires higher doses to be comfortable. So like in the northeast, like it's pretty much across the board that insurance approves three tabs a day, which would be three tabs of the eight milligram buprenorphine, which would be 24 milligrams that people morphine daily. Statistically, patients are typically comfortable between eight to 24 milligrams. Oklahoma, unfortunately, is not very progressive. So insurance only really covers two tabs a day. So that's usually what I start with, with my fentanyl, by people that are using fentanyl. And how induction looks is okay. So you say that that that withdrawal is is moderate to severe, you're got that at least that score of 12 on the cows, you're really uncomfortable. I'm going to send you home with just a couple of days of buprenorphine because we're going to do a really close follow up because I want to see you back in office and ensure you're doing okay. And when you're at home, you're that uncomfortable. What you're going to do is split one of those tablets in half, you're not going to take the full amount, you're only going to take four milligrams, and that's also to prevent worsened, precipitated withdrawal. So this keeps the person even more safe, you know, you take that and then the way that This medication is absorbed and I'm actually I'm gonna do a little sidebar for a second to describe the difference between buprenorphine and buprenorphine Naloxone because there's a there's a lot of misconceptions, misconceptions with that, even with patients specifically. So buprenorphine plain, buprenorphine is just buprenorphine. Obviously buprenorphine naloxone is the most common like, that's when people say Suboxone. That's what it is. It has a Loxone component. So it has the buprenorphine, which is the partial opioid agonist and then it has the opioid antagonist with it. The bioavailability of the Naloxone sublingually is very minimal. But buprenorphine absorbed sublingually, it has a high bio bioavailability. So for anyone that's not aware, these patients have to dissolve the medication under their tongue or like between their their lip and the mucosal membrane in order for them to get the high bioavailability. Because I've had patients that have been on buprenorphine, and they're swallowing it, and they're like, it's not working. And I'm like, Well, you're not taking it correctly. The naloxone is actually there when it was originally designed, it's there to protect patients that want to divert this medication and use it IV. So it would prevent them from overdosing and dying, that and that's how it gets, like activated ultimately, like if they if they're shooting up Suboxone, it won't really work. They're not going to get high from the buprenorphine. And that's a whole other conversation I can have. But so that's the difference between the two. Anecdotally, what I find his patients sometimes experience like headaches or nausea with the combination. And those patients, we kind of have to trial like just doing buprenorphine. But I always try to start with buprenorphine Naloxone component, because that's what's FDA recommended. And it decreases diversion. So that's where I would recommend starting. So back to starting to split it in half, take four milligrams sublingually. See how you feel after about 45 minutes. If you don't feel worse, you're not precipitating withdrawal. So you'll be okay, you can take the other half. Yep, just pop the other half in, wait about four to six hours. If you're still having withdrawal symptoms, go ahead and take the other full tab. So I start with a half, half full tab on day two, take two. It's that simple. And then come back in a couple of days, see how you're feeling. And then, depending on there's some controversy about whether or not you should increase dosing based on opioid cravings, opioid cravings do equal increased risk of relapse. So for individuals, I will taper up the or titrate up on the on the buprenorphine to up to 24 milligrams. If they're continuing to have opioid cravings without withdrawal symptoms. There's controversy with that everyone has a different comfort level. But for me, I know medication equals less mortality. And if your cravings are putting you at risk for relapse, I'm willing to put you on 24 milligrams, because I'm hoping that will keep you more safe. So yeah, I probably said way too much in that.
Liz Rohr 53:04
I think that's great. Sorry. No, no, that's totally great. Because I think that kind of brings us to the next piece of like, I'm just trying to understand, like build a picture for people who haven't who haven't been in this setting before and working through so that that induction I think is the way you described it. Is this really clear. I can hear a question of what if somebody is precipitated in is? Well, what if somebody dropped? Yeah, what if somebody is in precipitated withdrawal? Then what has it happened to you? or what have you actually seen it in clinical practice?
Shelby Pope 53:31
And I was actually just listening to a podcast the other day about precipitated withdrawal. And there's some data that shows like, and this is kind of going down a rabbit hole like micro dosing buprenorphine, which it's not really I haven't seen it done in an outpatient setting. It's usually in an inpatient setting. Mostly though, and I hope somebody chimes in and like corrects me on this, but for precipitated withdrawal. I think most patients will self treat, they'll, they'll go and they'll use to fix the withdrawal that they're in. Or they can try to, what I recommend doing is is like, if it does happen, try your absolute best to write it out and give it a couple of hours and then try a very small amount of the buprenorphine again, do another half to like a quarter tab, half of a half and see if that will help cut the edge off and obviously doing all the supportive measures. clonidine, Trazodone. Yeah, everything. And then if I can get them to come back in, I would, I would do everything as far as like helping them get comfortable and then and if they have access to methadone, I would probably just say like, let's get you a dose of methadone and get get you figured out as far as getting you more comfortable.
Liz Rohr 54:46
Do you ever refer them to the hospital or do you find that I don't know if that patient had to?
Shelby Pope 54:51
I haven't had to, but I mean, obviously like it, but I've been in primary care and felt like I knew nothing. So if if I was in that setting, and someone came into into my office As in precipitated withdrawal, I would do anything to ensure that they're more comfortable and I absolutely would refer them to the ER at that point. I don't necessarily recommend that for everyone. Really try to avoid precipitated with Yes, in the first place. Yes, right out of the gate. People out of the ER for sure. But if it's to a point where you're like, absolutely panicked, and you're like this person, because if you see true fentanyl withdrawal, I have not, oh, my gosh, I would never wish it on anyone, anyone at all like it, they are very sick. If it's really bad, I mean, and they literally look like they're coming out of their skin. They're sweating through their clothes, they're just like, can't be, it looks like the worst flu you could ever imagine. times probably 10. Like, it's just, it's, it's bad. It's really bad. I've had so many women that have, you know, that have gone through childbirth that said, I will deliver a child without any pain medication 10 times before I put myself through physical like withdrawal from dental again. So yes, like if that. If that happens, then yeah, I would probably if you feel really uncomfortable, always higher level of care. Yeah.
Liz Rohr 56:11
I'd be curious. Like, I'd love to talk to you. I haven't worked in the ER, but I'd be curious to maybe I can snag an ER provider at some point and ask them about how they're how they approach it. Because I think that's another thing in primary care. It's like I just, I really just one of the things I love about talking about specialists like you, it's like, it's we don't always know what happens on the other end. And it's like this is the thing we're supposed to do is like seek other care. But it's like really nice to hear kind of like what what happens from there, I guess I would love to transition into talking about. So like, So phase one is kind of like shared decision making your assessment, what does induction look like knowing that there are actual like, very clear protocols of how to do that. And then, like we have addressed the early phase risk of precipitate withdrawal, with risk of withdrawal, how to manage it. And then when it comes to ongoing assessment, you've kind of already touched on the fact that some salt you're doing an assessment of how they're feeling, if they're having cravings and your practice, is because there's sounds like there's controversy of like, do you go up on the dose or not to help with cravings? What does that ongoing management looks like, look like after they've started it? They're doing fine. What does that look like in terms of like how you said, you see them monthly, but like, what are the things you're asking about? What are you assessing? things?
Shelby Pope 57:24
You know? No, that's actually a really great question. I recommend so in terms of the guidelines, so for resources, I recommend ACM and SAMSA. As far as like helping people kind of navigate those things. As far as like the patients sitting in front of you, every follow up I ask for Okay, so for the after induction, I see them weekly for four weeks, and then I go, we kind of do like little baby steps. And then I do bi weekly for two visits. So for one month, I see them every week, the next month, I see them every two weeks, and then monthly thereafter, as long as there's no other illicit substance use. If illicit substance use continues as far as other substances, not opioids like methamphetamine, alcohol, all those things. We continue weekly, until patients more stable. And then on every single visit, I walk in, you know, obviously do the intro and then ask them you know, how are you doing? How are you feeling? In terms of meds? Are you experiencing any withdrawal, any cravings, any relapse since last time I've seen you. And the vast majority of patients will tell me especially the ones that have been using fentanyl if they're apt to on that initial visit. They're like, I'm not comfortable. Like, I'm, I'm okay, I'm not having a lot of physical symptoms, but I'm not sleeping well. I'm still having some body aches, and I'm still having some breakthrough sweating. I typically try to like, like mess with the dosing where, in terms of the guidelines initially, whenever you know, heroin was the thing, they want you the guidelines really wanted you to take all of the suboxone or buprenorphine in the morning. They're like this has a long half life, you should be able to take it once a day and it lasts all day and you don't have to worry about it anymore. Anecdotally, that doesn't really happen. Most patients like to split their tabs and take it like every four hours every six hours. And that's typically on the two a day dosing I typically recommend one in the morning, one in the evening. And then for the individuals that are continuing to experience cravings, I call it white knuckling. They're like, I'm literally just like, any, they're one bad day away from using ultimately, you know, and I'm like, Okay, so what's your thoughts on going up on the dose? I mean, I have found anecdotally that it decreases opioid cravings, which could decrease your risk of relapse. But just know that this will increase your physical dependence on the medication, I mean, you will be physically dependent on this medication without the medication, you're going to have withdrawal. So you always have to ensure that they're making an informed decision to pursue a medication like this, you know, and they, they usually opt to go up. They don't want to feel like this, you know, they don't want to use so I am on increase. You can increase by a quarter tab, you can increase by half a tab. I typically go up by half a tab because the tabs are so Small it's hard for them to cut it. That's one thing I wish these pharmaceutical companies will do score these apps if you want us to prescribe at the lowest possible dose to keep people comfortable, make the tabs easy to split like that. No, gosh, it's so frustrating.
Liz Rohr 1:00:17
The chlorthalidone I don't know if you're, if you were prescribed for chlorthalidone, but it's like the tiniest little pill and you're like, the starting dose is like 12. And you're like, how do you…?
Shelby Pope 1:00:23
my whole 80 year olds in primary care, like do I have it there?
Shelby Pope 1:00:31
Yes, so increasing into and then I would typically do a week follow up if I do any adjustments. Okay, come back next week. Let's talk sooner if you're really struggling. And then always, always, always every visit. Do you have Narcan? Do you fit in test strips specifically for people that are using methamphetamine, I want them to test their supply. Because most of what we're seeing in Oklahoma is contaminated with fentanyl. Most designer benzodiazepines on the street are contaminated with fentanyl. Most cocaine is contaminated with fentanyl. So no one's safe. No illicit substance use is safe, really, you know, it's safe is very relative in quotation marks. But as far as fentanyl goes, so I always recommend no matter what you're using to always use a fentanyl test strip, um, you know, as far as harm reduction goes. So that's increase until comfortable. And then as far as continued monitoring, once they're stable. Like I said, I see them monthly, you could push it out further, if you have a really busy practice, you know, once you feel comfortable. There is a lot of argument from people in legislation specifically down here that say that. And even we get it from insurance companies that we need a documented taper, like telling patients, Okay, we're coming, you can take this medication for a year, but now it's time to come off. And I was just gonna ask Do you ever have people come off of it? Yeah. Um, yes, to answer the question, just like, straight up? Yes, I do. I have patients that are able to come off of it. Statistically, though, the rate of relapse within one year of coming off of MIT is anywhere from 80 to 90%. So, thanks. And I always I always have I mean, in terms of the abstinence programs, you know, like, and I'm not not, this is not me harping on AAA at all, because I think it's a great platform for many individuals, not It's not great for everyone, but there are some people that really find benefit from it. The rate of opioid specific relapse is about 90%. So, you know, just like telling a teenager, you can't have sex, you have to practice abstinence. Yeah, we all know it doesn't work. Yeah. You know, yeah, we know.
Liz Rohr 1:02:41
Yeah. And then I think also just really underscoring because there's so we, before we started recording, we're talking about bias, and I think there is a lot of bias still of like people not believe like they're like humans used to make choices, but this disease, and it's not yes, it's not just like, I feel like doing this today.
Shelby Pope 1:02:57
Yeah, I'll be honest, I've gotten a little spiteful with my communication with insurance companies. Yeah, I'm like, I will write back to them in this like, templated letter of this would be you forcing a taper on this patient would be like you forcing a diabetic patient to come off their insulin. Yeah, like you get it for a year, we're gonna cover your blood sugar for one year, and then you don't get it anymore, and you get DKA. You know, like, that's not how this works, you know, so So and in terms of tapering, I do bring it up occasionally, I don't do it every visit, because I think it seems forceful to patients. Initially, when I always mentioned it initially, on the first interview with patients on the induction, I'm like, as far as tapering goes, I want you to know, the progression in the goals. If you ever desire to come off of this medication, I always recommend you bring it up, and we have the conversation. Statistically, I would not recommend even considering tapering until you've been on this medication for at least 12 months, because the people that have been most stable and have had the best outcomes were on it for at least a year before they came off. So at least Yeah, so at least one year before having the conversation and then what tapering looks like is very, very slow. Yeah, it's not a I've had paged so many patients tried to like, just they want to be done with it. They don't want to tie to the medication anymore, you know, and I get it, nobody wants an anchor. So they'll cold turkey quit. And then they're in my office within a few days in complete crisis, you know. But as far as tapering goes, I say, you know, let's try I always put the patient in the driver's seat because that's what we should always do as a provider is. I, I've seen it done other ways, and that's where you have to have the conversation with a patient ultimately, like we're providers will automatically say, Okay, well, you're on two times a month, I'm gonna go ahead and cut you to one and a half, and I'm gonna send the script in, and you're going to take one and a half. And I'm like, hold on. Yeah, well, let's not do that. That's a little extreme. So I always just tell the patient I'm like, you know, I would like the goal to be that you reduced by a quarter tab, if you're able to cut it that small, if not try to do half tab. I'm gonna give you the same script. I'm not going to change anything about your prescription. And then at the end of the month, bring your leftovers if you have four core There are tabs left, even if that's one whole tablet will just cut the script by one tablet. And it takes so much fear out of the tapering process for them. It seems to, it seems to work a lot better. And then I have patients that will say it at that same dose for three months before they're interested in tapering more. And if we're decreasing by one tab every three months, I'm fine with it. Like,
Liz Rohr 1:05:21
I love. I love you sharing that perspective, because I think so, yeah, I guess it's just like a personal Share, Like I take Adderall for ADHD. And so and, and there's so and it's because it's a controlled substance, there's so there's like, and it's not even in the same realm at all. But just like having of having a substance that has these, like, rolls around it, it's or this medication, it's like, I feel the anxiety of like you being like, of them, like don't take away the medicine, because it's like, it's so hard to get in the first ones
Shelby Pope 1:05:51
yet. But you know, that makes lives that makes you such an empathetic provider, you know, and just sitting across from the patient and having that share and telling them like, I'm human, just like you, you know, like, I and I always tell them, I'm not going to take your medicine away. Like, there are rules, there's laws I have to follow. But my top priority is to ensure you have medication, I have seen on the opposite end of this what it looks like, and I don't ever want to put you in that position. And you'll find this patient population, like, it's like they take a deep breath when you have that conversation like, like, what a relief. Oh, you know, because they're so they're, they have so much trust issues with the man with the system. And they've been stigmatized for so long. It's so sad. And I have one patient, you know, he, he was actually a, in some form of law enforcement that specialized in drug treatment or in drug law enforcement. And he did the injury thing, you know, had a back injury got started on pain pills and went down the whole rabbit hole was on heroin, the whole deal. And he sits across from me on our first visit. And he's like, if you would have told me 10 years ago that I'd be sitting in this office, like, I would have told you you're he just blatantly said I would told you that you're an effing idiot. Like, I would never be that person. And I looked at him and I was like, It's humbling, isn't it? And he's, like, so humbling. And that's what I tell patients, I'm like, you realize I could be sitting on that table, like, I could be in your position tomorrow. So I do not judge. And whenever they, whenever they hear that, and then feel the you know, the authentic, you know, communication with it. They're, they're just great. And that's where the gratifying part comes from, like, on a daily basis, I know that what I'm doing is making a difference. And I think that's what I struggled with in primary care. Like, obviously, I knew it made a difference, but it was the long haul, you know, like, you're prescribing a statin, you're prescribing insulin, you know, you're modifying risk. And you might prevent my collaborating physician, you know, put the spotlight on this for me, and it just like, blew my mind. He's like, but you don't get the dopamine hits every day of like
Liz Rohr 1:08:04
start to finish. There's no, I love procedures, because it's like, I did I did that. That thing done. Yeah. Yeah, that was so
Shelby Pope 1:08:11
gratifying. But in primary care, it's like that, like, you know, you probably prevented 15 heart attacks this year. Will we ever? No, no. But I can honestly say like, from week to week, I see somebody come in, in full, full blown homeless have no hopes of having their children back has, I mean, in the worst possible shape, they could be in the next week, we're working on getting them into sober living, where we're helping them find employment. They're working on getting stable transportation, we're supplying bus passes. I mean, it's,
Liz Rohr 1:08:41
it's like so good. I love that it's good. It's good
Shelby Pope 1:08:44
work, man. And that's why like, I know what primary cares, like I've done it. I'm like, get some of that gratification
1:08:49
in there. I know, are prescribing
Shelby Pope 1:08:52
totally, and they're quick visits for the most part, like especially when people are stable. It's like they're in and out. They you see them so frequently, you're doing check ins, it's actually a really easy thing to manage. And now like I do it, I'm like, Man, why wasn't my initial collaborating physician on board was because this would have actually, like, light up his load a little bit.
Liz Rohr 1:09:10
Yeah, it's like, but when I build in the procedures during the day, it's like, Oh, I get a break. But it's still it's this. It's still hard work. And it's just it feels lighter. It's yeah, absolutely. Love that. That's so beautiful. Well, thank you so much. I feel like I could talk to you forever. And I know I'll do some more chats about other other Addiction Medicine things but are there any like kind of like last pearls that you want to share for people? Or? I don't know I don't feel like you have a social presence, like a social media presence. I just offer that to people who have like a like some sort of accompany thing but is there any sort of like you already mentioned some resources which I'll which I'll drop in the show notes as well. But like any other kind of like, parting words, words of wisdom to share?
Shelby Pope 1:09:46
Yes, one thing. Curbsiders podcast,
Liz Rohr 1:09:50
love them.
Shelby Pope 1:09:51
They have an addiction medicine series. They have two seasons. And it's wonderful. I mean, it's a really, really, really good resource. And you actually get CME and I forget how it works. But But you, you listen to the podcast and then you log into the they always mentioned it during the podcast. They give you the link and you log in and you get CME and those CME actually count towards DEA requirements for if that's a requirement in your state. So
Liz Rohr 1:10:15
it's an easy way to start. Yes. And it's great.
Shelby Pope 1:10:19
And they cover everything, every substance use disorder, they talk about the social aspects, they talk about legal ramifications, all the issues, so it's great. It's a really good resource.
Liz Rohr 1:10:29
Well, thank you so much. This has been so fun. You're awesome.
Shelby Pope 1:10:32
I appreciate that so much. You're awesome.
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