My name is Dr. Mary Lynn Ayers.
I practice medicine at the
Rocky Mountain Regional Medical Center
in Aurora, Colorado.
I have been practicing for 32 years,
outside of residency training.
There's not only one place
opioid use disorder should be treated. It can be treated
in primary care. It can be treated in mental
health. It can be treated in the ER.
I think everyone can play a role
collaborating with mental health
and their whole primary care team.
We huddle 30 minutes before my
clinic starts, and everybody has
something to bring to the table. And
so, you need to leverage
everybody's talents, and that will make the
experience better for the patient.
The American College of Physicians
came out a couple years ago
with the 20 worst things
that
internal medicine doctors do. The things we're
worse at-- that don't
use evidence based medicine. Number
one was nicotine.
Number two
was alcohol use disorder.
Substance use disorder
like opioid use disorder wasn't even on the list, because I think people were still
struggling with that, if that
even falls in the realm of internal medicine.
Otherwise it would have been number one!
But I think it was still like an example
of like, 'well maybe this isn't really internal medicine.'
This is internal medicine.
If someone has an opioid use disorder,
It is...
There's no....
It's internal medicine. Causes low
testosterone, causes sleep disturbance,
mood disturbance, obesity.
I mean, you name it.
Increased risk of
heart attack and stroke
for people who use opioids.
It's probably their number one problem, and it's an internal medicine problem.
A couple of years ago when the
CDC came out with all those new
"recommendations" and everybody was
yanked off all those opiates.
You know, there was a
significant uptick
in heroin overdose.
Most specifically, Veterans.
Suboxone, methadone,
naltrexone, they all
decrease the risk of a patient dying. And, in the end,
you just want to make sure that a patient is
safe, and that is our goal for the treatment
of opioid use disorder.
It's a big change. I think anytime
a person is taking a medication every day around the clock
for years,
making a change is going to
be a big decision,
and it's going to be scary for some people.
So I think giving people time to work through it is important.
I think,
in my experience,
this can take
multiple visits over weeks or months.
Now for other patients, it's going to be a little
bit more urgent, and we're gonna need to be
able to be
prepared to meet them where they're at, to move
ahead more quickly. But I think when this goes well,
we're setting the stage and
planting that seed with somebody to
help them feel like they're
making an informed decision and
they're making the right for them.
Suboxone is a good
replacement therapy for opioids. It does have
some pain relief properties, and
it's safer.
It doesn't cause as much respiratory depression.
So it puts the patient in a safer place.
I know that I haven't done one yet,
even though I've had my X waiver now
for awhile and I just need someone
to be with me, shoulder to shoulder.
Buprenorphine for opioid use disorder is
about a harm reduction approach.
Here, our Salt Lake City VA,
I was the only
one on inpatient
from anesthesia and
surgical service that could prescribe buprenorphine. I kind of felt a little nervous.
Like, what happens if,
this patient comes in, and they
have to call me and there's nobody
else? I can't rely on anybody else.
So, having a team that if
there's only one, they
feel like they're a little
vulnerable and that's OK.
Surround yourself with others that
maybe aren't just comfortable as you.
Or maybe you're not as
comfortable altogether,
but at least you can talk about cases, and
you can talk about veterans, and start to
become more comfortable in prescribing.
The first time I prescribed
buprenorphine to a patient,
I can remember the colleagues
that I reached out to. To say,
"I trust your guidance.
I need your help here. Can you walk me through it?"
I think having those
relationships, having those
points of contact of people who
knew this work really well
and could guide me through,
it was really important.
So, when I talk about Suboxone,
I talk about the medication,
treating a chronic relapsing disease.
I talk about this not being a diagnosis
that should hopefully bring on the
shame that a lot of these folks feel,
the embarrassment of not being
able to take care of this disease. You know, 'Why can't they
will themselves to stop?'
And I asked for
permission to
provide them a medication that
may allow them to get to a place.
Where they don't fixate on this substance.
Where they feel that they are able
to focus on other things in life
besides whatever substance of use that
there are presently dependent on.
The substance that they're dependent on.
I try to keep it simple, and I try to
make the medication be exactly that.
A medication to treat a
chronic relapsing disease,
and pull back all those other
layers that they oftentimes
come into the clinic with.
And be very matter-of-fact.
And sometimes, you know,
I think asking those open-ended
questions and that permission to
communicate, or educate, in regards
to the medication can be really empowering,
Because it's not about me telling them what to do.
It's about me providing them
an option to maybe get where they want to get.
We're dealing with a situation
that requires a lot of compassion,
a lot of understanding, and a great
deal of humility on the part of the provider.
It cannot be,
'I am the expert.
You are the patient.'
When I talk about developing a joint
plan of care, I'm really
talking about leveling the playing field.
Patient and provider need to be
equal in their ability to contribute
to the assessment of
the situation, and the solution for
the problem. And the plan of care
needs to meet the patient's goals.
And the goals can be so simple.
I think anytime we're asking somebody
to make an important medication change,
the better we can help them prepare,
that's what we want to do.
Most of the time these patients have been through withdrawals,
they just haven't
put a name with it. "Oh yes, I know exactly what that
runny nose, eye tearing, the
gooseflesh skin, like feeling like I
have the chills. I didn't know
that was withdrawals. I didn't even know what that meant!"
But, I should say
normalizing that. But going over
that, so that they know that that is
a normal response
to opioid withdrawal, then that makes them
not feel scared, or their
anxiety increase, because they know
that that's what they're going to be
Going to be going through, I think is helpful.
Knowing that there's possible
medications that if you feel that could be
indicated, might help with symptom
management.
And going over that with them too, so that they feel that
there's things to feel
supported with that you're able to
offer them.
It takes a little extra time when you're first learning
about the medication and getting used to
prescribing it, and
managing it for the first several patients.
But, after that, I
personally don't feel like
it is a big time suck. It does
require monitoring,
both with toxicology screening,
and
checking the state's drug registry,
when you have visits with patients.
The goal is to establish a working
relationship
with the patient, just like with any other
medical problem, your job is
to make recommendations
based on the data that you have,
and work with the patient to establish
goals and meet them.
If you're a new prescriber, and
you're interested in starting this,
realize that there are a lot of
resources out there, and understand
that it's not going to ever be perfect. Just like anything else.
The best thing about treating this
disease, just like any other disease,
is the
wonderful thing about seeing people
get better an reach those goals,
and even better yet when they're struggling,
and they need you, that
they have that trust to come back.
So I think talking them through just
like you would talk to a patient who's starting
chemotherapy you know,
add chemotherapy and radiation is gonna get
sick and miserable. I'd call them up
and sometimes they're like,
"Yeah, I feel horrible. Leave me alone!"
You know,
I'm not going to take that personally,
I understand they feel horrible.
And the next week, I'll call them back,
or I have my nurse call them.
"How you doing? How you feeling?
You know, this is hard, what you're going through."
So a lot of cheerleading
and a lot of support. A lot
of education.
I kind of think of it like cancer.
A patient diagnosed with breast cancer
is gonna be,
it's going to be some work. We're going to need a
team of people. It's going to be a lot of education.
A lot of patients.
There's going to be a lot of
bumps in the road.
You know, "I'm not doing this anymore! I'm not getting this
chemo, I feel too sick!
I'm not doing it. I hate you guys!"
But that's part of,
we're OK with that when we're dealing with
breast cancer. We need to be
OK with it when we're dealing with people
with addiction.
We were not prepared. We were not
equipped to start
medication treatment for opioid use disorder
in primary care and he came to me, and
asked for help.
and I tried to help and that help involved going somewhere else.
And he never made it there.
And I think that was a real missed opportunity.
So that stuck with me as
a time where I could begin to
envision how that would have gone
if I had been ready in that visit, with that Veteran, to
meet him there.
And it's just unquestionable.
That would have been better. That's a mistake
I don't wanna make again.
I have a very memorable patient who had
suffered with chronic pain for a long, long time,
and in the course of his life challenges,
made some bad decisions along the way.
Bought medications,
abused marijuana,
even methamphetamines occasionally,
and he had a history of substance
abuse as well.
So at one point I just told him,
"Hey, you know, I'm not comfortable
prescribing hydrocodone anymore."
I offered him
some alternative pain treatments.
But he was still,
just miserable most of the time.
And still dabbling in alcohol in particular
and marijuana to try and
take away some of his pain, and alleviate what I later
recognized as opioid withdrawal
symptoms,
and terrible opioid cravings intermittently.
It was actually
several years, unfortunately,
between the time that I told him
that I was
no longer willing to prescribe opioids,
and learning about buprenorphine
for the benefit of my patients.
I suggested that it might be something that we would
try. He was eager to to give anything a
try that might help with his pain.
The induction was easy, because
he hadn't been on opioids for a while.
Within two weeks, he said
he felt
better in all
respects than he'd felt in years.
Since the last time he could remember.
I questioned him on that, and what
he really meant was that his pain was better controlled, he wasn't
experiencing withdrawal
symptoms
any longer, he wasn't craving opioids.
He
finally started making some appointments that I had
been working with him
to keep for a long,
long time. One was
with a rheumatologist,
to try and figure out why he was having
these terrible dermatologic
issues in his extremities.
He finally got in for a
sleep study, which made a huge difference
once he got his CPAP. And his
diabetes suddenly was much better controlled,
because he was actually taking his medications,
and engaged in the process.
And so, you know, this veteran's
total world turned around
by the fact that I learned about a new tool,
that I could use to his benefit.
He is experiencing positive things in
his health care. And not just one realm,
but multiple realms.
It's part of what
influenced me to
continue on, and to think about using this tool when it's appropriate.
They try and get them to tell me their story.
I don't think I've ever asked a
patient in my life,
"Do you use drugs? Do you use IV drugs?'
Straight up.
I don't think I've ever asked them that.
It's a loaded question.
There's a lot of trust issues.
I have lots of patients who one
positive urine drug screen, and they
can go back to prison for five years.
They can lose their kids, all kinds of things.
So I try and get the patient
to tell me their story,
their path to to me. How they got to me. Sometimes I can get
their story over two or three visits.
I don't even
make a move, I don't even
mention opioid use disorder.
Now obviously, if I have a heroin
addict coming in withdrawal,
we talk a lot about that.
you know we talk a lot about that, and we them started on
Suboxone or methadone at that first visit.
So you have to again figure out where
this patient is coming from,
and work on
getting their story,
getting what's going on, engaging
family members if they're willing to,
and trying to figure out how this
substance, opioids or alcohol,
are affecting
their health, their function,
their daily life.
I have countless patients that have had
this incredible
transformation, and for whatever reason,
gotten to a place in their lives where they were struggling.
They were needing a higher,
more frequent follow-up or more support.
And, what I find transformative
for myself, is
understanding that journey. And that
there is no absolute. Just like there
is in any other chronic disease.
That it is this back and forth, and the
patients will come in and say,
"You know, I'm doing OK right now. I feel... this medication's
doing well. I'm doing well with my family.
I'm going to work." Whatever it is! That laundry list
of goals that this individual
has that they've been able to succeed
in achieving, or
are continuing to pursue
with this medication.
And then, they'll have
moments where, "I'm struggling."
You know, they'll come back, or "I used." Or,
"I'm having thoughts of use," or
"I feel like I need to reach out, and I
want to call that person that was providing me with
XY&Z substances."
That we then re-address it, and revisit
it. Now of course, lots of
people yelled at me, but you know what? A year later,
they were happy. They were happy that
they weren't taking that medicine anymore.
And they
weren't constipated, and they didn't feel
mentally confused. And guess what?
And guess what? Some of them got their drivers license back.
Understanding that everybody is
there for the,
for the purpose of serving
an individual that is
is needing assistance.
And, it literally gives me chills,
and all of us coming together and of being able
to facilitate that is
just so incredibly empowering.
And it's exciting because
it's something you can share,
and sometimes they're really hard moments that we share.
There are patients that don't sometimes
make it through this journey and they leave us
early. And we share
that, and as well as we share the successes, and
when patients are ready
to move on and do other things, or,
"I'm doing well."
The change that occurred that made me feel
more comfortable with treating
opioid use disorder was the
collaborative approach that the
VA provides between primary care,
mental health,
pharmacy, rehab
medicine, and that
everybody comes together to treat
the patient. As physicians,
we are complicit in creating this problem and
I think it's incumbent upon us to do everything that
we can to help to solve it.
Suboxone (or buprenorphine), it does
save lives, and improves
Veterans quality of life, and
improves their
families quality of life.
Suboxone is safe.
Check it out. There's so much to learn,
in primary care, in general medicine.
Now is a good time to learn more.