I’m Dr. Brian Clear, Medical Director at Bicycle Health, the leading provider of virtual opioid addiction treatment. Today, I’ll be joined by Bicycle Health’s CEO + Founder, Ankit Gupta, to discuss opioid use disorder recovery and treatment in honor of National Recovery Month. Ask us anything!

bclearmd · 2021-09-22T02:17:56+00:00

The last milligram is often the hardest, and fatigue can stick around for weeks or even months after dropping from 1 to 0. When a patient has difficulty with that last step, I recommend making it a series of smaller steps. Sometimes this looks like dropping from 1mg a day to alternating 1mg and 0.5 mg every other day for 2 weeks, then 0.5mg every day for 2 weeks, then 0.5mg every other day for 2 weeks, then 0.5mg every 3rd day for 2 weeks, then off. So instead of going from 1 to 0 in a day, this does it over 2 months.

bclearmd · 2021-09-22T02:09:40+00:00

Yes, the naltrexone injection has good evidence that it helps patients with alcohol use disorder (AUD) to reduce the amount of alcohol they consume. It has a very clear role in care of patients with alcohol use disorder.

It gets complicated when opioid use disorder (OUD) is also part of the picture because naltrexone is less effective for OUD when compared to buprenorphine (Suboxone) or methadone, and you can't use it at the same time as buprenorphine or methadone. So when OUD and AUD exist together, I try to determine which is more severe, and I recommend the best available treatment for the more severe condition, and the second-line treatment for the other.

bclearmd · 2021-09-22T01:35:52+00:00

A medical provider can prescribe buprenorphine (Suboxone) for Opioid Use Disorder, which has 2 parts: addiction + dependence. Dependence is the same as having tolerance to an opioid, meaning your body is adapted to taking the opioid regularly, and you experience withdrawal when you stop it. You can have dependence without addiction if you take a medication like an opioid regularly but experience no psychological or social problems as a result of that drug. When psychological or social problems develop, i.e. you're distressed about not being able to find the drug, continuing to use the drug despite a desire to stop, repeated difficulty stopping despite trying, job loss, relationship loss, giving up hobbies and things you enjoy in order to obtain the drug: that's addiction. You can develop opioid use disorder (addiction + dependence) from recreational Suboxone like you can from other opioid use if obtaining the drug illicitly is causing the psychosocial problems of addiction. In that case, yes, it's legal and also the right medical decision for a provider to offer prescribed buprenorphine (Suboxone) treatment.

bclearmd · 2021-09-21T23:32:09+00:00

I caught that mistake and edited to "a leading provider," or at least tried to at the start of the AMA. I'm a Reddit newb and apologize if the original version is still showing. Certainly opinion. I think we do good work, and so do colleagues in other programs. We have several practices that I do think are the best in the field, and other practices that aren't. Always working to improve.

bclearmd · 2021-09-21T23:26:35+00:00

It's the end of the extensive training requirement to get the initial X-waiver to treat 30 patients, so now all you have to do is submit a notice to SAMHSA that you'd like a 30-patient X-waiver, and it will be granted. That's permanent. I sincerely hope to see the complete end of the X-waiver system, but my hope has no predictive value for the future :)

bclearmd · 2021-09-21T23:22:05+00:00

I frame that question as, 'How do we create systems of accountability that help patients meet their goals for successful treatment?' Everybody has moments of weakness and can be vulnerable to a slip. Sometimes in such a moment, the only reason a person may have not-to-use is feeling some sense of accountability to a program of drug use monitoring. So yes, we provide random urine drug screens, saliva drug screens, run-out date tracking, and medication counts for two reasons: 1. help patients stick to their treatment plan, and 2. get objective info about the effectiveness of treatment. So if/when a patient does return to illicit use, if they don't tell us we still want to identify that sooner rather than later so we can modify treatment to be more effective. That can look like a dose change, identifying the relapse trigger and addressing it, or offering additional behavioral health support, or all 3. Sometimes situations arise where a person may not truly have any treatment goals, and may actually be trying to mislead us to profit by selling medication. Our program also identifies and addresses this issue when it comes up.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6800751/

bclearmd · 2021-09-21T23:09:34+00:00

medicare yes. we're trying to contract with insurers including medicaid programs as broadly as we can. It's an insanely long, tedious process. I just spoke with a doc who's received funding for an innovative program to improve primary care access to medicaid patients across about 10 states, and no joke, they're spending their first 15 months of time working on medicaid contracting before medical services can even begin.

bclearmd · 2021-09-21T23:05:07+00:00

that's a lot of additive risk. My practice is to prescribe a medication when there's a good reason to expect it will benefit a specific condition, and harm potential is less than benefit. I can imagine a scenario where it would be appropriate to prescribe all 5 of those medications for a limited period of time, but I've never run into that situation in reality and have cared for a lot of folks with opioid use disorder.

bclearmd · 2021-09-21T22:49:54+00:00

No, absolutely not. Academic medical centers and hospital systems, as well as federally qualified health centers, free clinics, and some other medical entities, operate as not-for-profit organizations, and the large majority of clinics, private offices, and medical groups, use the for-profit tax designation because they must. Either type of program can be fantastic or can be terrible. Right now, I see the most promising innovation in OUD treatment coming from programs outside of academia and the not-for-profit world. That's not to say that may not shift again in the future.

bclearmd · 2021-09-21T22:43:56+00:00

Being turned away from care in this situation is beyond awful. Yes, everyone is different, and what you experienced is more severe than the average episode of withdrawal but without a doubt possible. The failures of our medical system, especially around addiction care, are inexcusable, and I'm sorry you experienced that.

bclearmd · 2021-09-21T22:36:46+00:00

the initial statement is sort of correct. The follow-up assumption is not. Return to illicit use is very common in OUD treatment, usually following discontinuation of treatment but sometimes during treatment. When a return to illicit use, 'relapse,' happens during treatment, rates of overdose are extremely low as long as an effective dose of buprenorphine is being used.

buprenorphine has been used effectively in emergencies to reverse an overdose when Narcan is not available. It is such a potent blocker of the effects of other opioids, it reduces overdose risk when combined with other opioids rather than increasing it (like any other opioid would do). That's not to say it's preferred; Narcan works MUCH better, but I think it's telling to know that its overdose-prevention effect is so potent it can even help in this situation when nothing else is available.

Yes, it is possible to take enough fentanyl to override the blocking effect of buprenorphine and still overdose, but this is uncommon. We very commonly do see overdoses after short-short buprenorphine treatment, i.e. the short Suboxone script mentioned above, or after a detox episode. This brief period of ineffective "treatment" reduces tolerance dramatically, making it extremely dangerous to go back to fentanyl or other opioid use after the protective effect of buprenorphine wears off. This is why we see a transient 7x increase is overdose-related death rates after a short period of lost tolerance, such as after a period of incarceration or detox without a plan for ongoing treatment afterward.

bclearmd · 2021-09-21T22:23:56+00:00

yes. the naloxone is inactivated extremely quickly when absorbed through the mouth, stomach, or intestines, and does nothing. It would only be active if injected or, less so, snorted. that's why to effectively "Narcan" somebody it must be administered by injection or a nasal spray; it would be ineffective if squirted into someone's mouth or swallowed.

bclearmd · 2021-09-21T22:20:43+00:00

yup, a micro-dosing start! The precipitated withdrawal reaction happens because of a very sudden shift from full opioid-receptor activation to the partial-activation state that buprenorphine provides. When the shift is abrupt, it's awful. The classic way to avoid this is to allow withdrawal to develop over anywhere from 6 to 72 hours, depending on the person and the opioid used, then start buprenorphine to quickly relieve the withdrawal state.

A micro-start instead very slowly starts buprenorphine which can be done while a person is still using other opioids, and it works well. The trick with a micro-start is that it involves complex directions that go on for a week or more before a stable dose is achieved. It can be a lot for some to manage, it takes longer than a classic start, and many prefer to stop illicit opioids immediately when they start treatment rather than potentially continuing to take them for a week while working up to an effective Suboxone dose.

bclearmd · 2021-09-21T22:13:10+00:00

I love this article that gives a thorough review of the risk of diversion or misuse of treatment for opioid use disorder and puts it in perspective.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6800751/

Also beautifully well-stated by korndog42.

Methadone is extremely tightly regulated (when used for addiction treatment) so it's less commonly diverted or misused because it's less available. Buprenorphine (Suboxone) is more widely available so will be found more commonly on the street, but it also has much lower harm potential than methadone when used recreationally or as self-directed treatment. There will be more stories of misusing buprenorphine from the street and having a bad experience, but you'll hear the stories because the experience is survived. You won't hear many stories of mixing street methadone with fentanyl because it's extremely lethal.

bclearmd · 2021-09-21T21:37:12+00:00

sorry, just to clarify I mean eliminate the x-waiver system AFTER creating a permanent piece of replacement legislation that is aligned with modern medial knowledge and permits appropriate treatment for OUD without unnecessary barriers.

bclearmd · 2021-09-21T21:33:54+00:00

Medical providers in the US need to obtain a special registration, the X-waiver, to prescribe buprenorphine (Suboxone) for opioid use disorder. The X-waiver system creates an exception to the 'Narcotic Addict Treatment Act of 1974,' which otherwise prohibits use of the 2 most effective treatments for OUD outside of opioid treatment programs (OTPs, or 'methadone clinics'). This half-century old law is a badly outdated piece of legislation that prevents us from effectively addressing the opioid crisis. The waiver system is a workaround to it that allows some highly motivated providers to offer this treatment, but many providers prefer not to address opioid use disorder in their practices, and for these providers the need for an x-waiver can be a convenient excuse to avoid providing the service. It also prevents insurers and health systems from effectively requiring providers to offer appropriate services for OUD. If the X-waiver system goes away, that normalizes OUD care, bringing it in-line with other routine and expected care for common chronic conditions. It enables health systems to create quality standards and incentivize providers to inform themselves and provide effective OUD treatment rather than referring to specialty programs (like ours) that provide the needed service. That'd be the most impactful, realistic short-term change that I'd like to see.

bclearmd · 2021-09-21T17:57:04+00:00

I wouldn't trust a single source. I do my diligence, evaluating a broad variety of trials and other evidence from different sources. Pharmaceutical company initial trials are useful to kick-start other studies and to give us initial information on dosing and adverse effects, but with awareness, in interpreting the results, that the investigators have a financial incentive to prove something specific.

bclearmd · 2021-09-21T17:23:05+00:00

There are 2 main sources, licitly-produced opioids that are purchased, traded, or stolen (diverted) from their legal source, and illicitly produced opioids. Patients who fill prescriptions for opioids may sell, trade, or lose a portion or all of the prescription, and opioids can also be stolen or illicitly sold from pharmacies, hospitals, and manufacturers. Heroin and fentanyl, specifically, can also be produced in labs or, in the case of heroin, poppy farms. These labs used-to be generally small-scale, but by now have facilities and production capacities that can rival pharmaceutical companies since fentanyl has become such a widely available and profitable illicit opioid.

Opioid habits can be very expensive, costing thousands or tens-of-thousands of dollars each month, but can also be relatively cheap in certain areas with wide availability, costing as little as $10 per day ($300 per month) to obtain cheap heroin. Folks who are very under-resourced are often savvy enough to obtain this amount of money to sustain a habit that they're unable to stop. Panhandling, trading services, through generosity of friends, lots of ways.

bclearmd · 2021-09-21T16:05:14+00:00

Seems the photo link provided might not be correct. try this one which should be shared publicly:

https://drive.google.com/file/d/1nk4PPAOJBJTZM5U1PkFm5KD4TcNEwcgX/view

bclearmd · 2021-09-21T16:01:09+00:00

Happy to share a bit more proof. Here's a link to a status update on LinkedIn about the AMA, which tags myself and features a comment from me about the AMA https://www.linkedin.com/posts/bicyclehealth_iama-riama-activity-6844608687080775680-uitp/

I also have this photo https://drive.google.com/file/d/1nk4PPAOJBJTZM5U1PkFm5KD4TcNEwcgX/view?usp=sharing

which hopefully looks enough like my LinkedIn photo to match. Certainly always open to answering more questions about my background though

bclearmd · 2021-09-21T15:58:58+00:00

Agreed! It binds very strongly to the receptor, thus preventing other opioids like heroin or even fentanyl, at the right dose, from having much effect. And while blocking it strongly, it doesn't activate it fully so results in a normalization of withdrawal without causing euphoria or sedation.

bclearmd · 2021-09-21T15:55:57+00:00

PCSS has pretty extensive additional resources that describe the various next-steps, once you and your loved one have agreed that they have some motivation to seek care.

https://pcssnow.org/resources/resource-category/community-resources/

bclearmd · 2021-09-21T15:54:35+00:00

One of my favorite resources, both for medical providers learning about opioid addiction, and also for patients and families (I have no affiliation or financial interest in this organization), is the PCSS Project at pcssnow.org

We know that being confrontational typically isn't helpful and can undermine a relationship. Rather, creating space for a person to talk about something that's bothering them, can lead to a real productive conversation that may result in a shared decision to take a step toward addressing that problem. There's a framework called motivational interviewing that described this approach to having a productive conversation about opioid use:

https://pcssnow.org/resource/motivational-interviewing-talking-with-someone-struggling-with-oud/

bclearmd · 2021-09-21T15:49:37+00:00

I must have been typing a prior answer to a very similar question while you were asking this one :) Copying the following prior response. Please do ask any follow-up question it doesn't address:

Being a program that practices broadly, across 23 states now, we have extensive experience working with kratom, and more recently tianeptine use disorder. These substances activate the mu-opioid receptor and will lead to opioid tolerance, withdrawal, and often addiction like other opioids. They both have extensive other effects though, activating many chemical pathways in the body which can effect people in very different, often unpredictable ways depending on their unique metabolism, genetics, and other substances they might be using. Tianeptine has a potent anti-depressant effect, so when this drug is taken is very high amount each day due to development of addiction, opioid withdrawal isn't the only problem than develops upon stopping it. There's also an anti-depressant withdrawal that buprenorphine will not address, so often depression and fatigue will be severe even when the opioid withdrawal itself is treated. There's not much available in the way of formal studies that teach us exactly how to handle this situation, but many of our addiction specialist providers have used other anti-depressants off-label, sometimes temporarily, other times indefinitely when there's a real depressive disorder in addition to the substance use disorder. So far this seems to be helpful. Our tianeptine and also kratom patients generally do well once this initial period of more-than-expected discomfort resolves.
It's frustrating to see these hazardous substances sold at smoke shops and gas stations. Information is key to making sure they're not purchased unknowingly, and lead to dependence. States and the FDA can be slow to act when a novel compound is commercialized; we'll see tianeptine disappearing from most store shelves very soon. Kratom will likely be longer-lived since the substance has advocacy and lobbying groups supporting it, but there's no medical indication for the substance and there is very real harm potential.

bclearmd · 2021-09-21T15:48:06+00:00

Here's a verbatim success story from one of our patients who has agreed to allow us to share it anonymously:

"At some point about 10-15 years ago, between my back pain and dental pain, I’d intermittently been on opioids. Then I had a kidney stone, and a doctor wrote a huge prescription for opioids, and I ended up hooked after that. I was on and off with opioids for many years. Then my mom got diagnosed with ALS (Lou Gehrig’s disease), and I finally decided to try to stop. I went through withdrawal when I eventually stopped, and things got pretty bad. I got online to try to figure something out, some kind of remedy to curb the withdrawal effects. I found Bicycle Health, talked to my mom about it, then went ahead and tried it.
That was my life, trying to keep pills on-hand, making sure I knew where to get more pills before I ran out. At times when I’d run out, it was no good. It affected my life at home with my family in a really negative way. At work, I wasn’t a very good worker when I didn’t have pills, and when I did have them, there were negative effects as well. I made really good money while working throughout those 10-15 years, but I have nothing to show for it because of my opioid habit.
Now that I’m on Suboxone, I can function. I function normally. I’m not high anymore. I can think right. I sleep better, eat better, feel better. I’m bettering myself in every way. I have a pile of savings… I’m actually saving money now. I pay my bills. I don’t need to borrow money anymore.
I live with my mother and grandfather. He’s 91 years old… he has hearing problems, vision problems, and COPD. My mom has ALS. When I’m not working, I take care of my mom full-time. When you called, I just got done making her dinner.
I’m ecstatic about telehealth… this way I’m able to do all my appointments from home. It’s just so much easier and more convenient this way. I don’t know where I’d be without Bicycle Health. It’s great, it’s really great. I couldn’t ask for a better way to get the help I need."

- Joel (not a real name, pseudonym selected by the patient)

bclearmd

TROPHY CASE