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Topics About 'Methadone'.

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  1. SeasonedOne

    Caring for MAT Patients

    Below is some general information that might be of use for those interested in MAT from the trenches. Let me know what you think.... What is a MAT (Methadone Assisted Treatment) Program? MAT Programs include people who have/had additions to street and opiate prescription drugs. MAT Programs follow specific guidelines on dosing of methadone or buprenorphine. MAT Facilities have to manage/track drug intake and dosing records to DEA standards/regulations. MAT Programs see people from all walks of life, all colors, creeds and orientations. Clients in a MAT program are private pay, covered by private insurance and Medicaid that covers treatment programs. Nationally 55% of clients in a treatment program will be successful. MAT Programs include long-time and short-time (less than 60 days) users. To be admitted to a MAT program a client must see a physician, a counselor and a nurse and have a history of a substance use disorder. What is your perception of patients with substance abuse based on? For the most part, these are good people who made an uninformed decision resulting in a negative outcome. Many were placed on pain meds for chronic pain. Over time, many were unable to get pain relieve requiring more med and then doctors and insurance became worried about abuse and stopped the Rx. (Note: Ask most people with "nerve pain" if ask if the meds helped the pain ... most who are honest will tell not much helps, just let's them sleep.) Some people have been addicted to street drugs for years or turned to these options when prescriptions were no longer available. Different groups use street drugs to self medicate for anxiety, hyperactivity, depression, etc. Some people are functional users meaning they hold down a job that pays enough to supply their habit. Some people are now financially stable and use any means (lie, cheat, steal, intimidate, illegal prostitution, etc.) to acquire the means to afford their drugs. Drug abuse/use is often generational. Other things to know: MAT treatment makes lives safer, decreases criminal activity, and allows people to have productive lives including work, families and communities. Pregnancy outcomes are better with less postnatal problems when on methadone than other drugs. MAT clinics and obstetricians work cooperatively to manage treatment. After birth, MAT treatment for new moms is more successful. MAT clinics offer support groups that improve successful treatment. Some people can get off drugs completely over time. The time it takes depends on the time and amount used. Just like an alcoholic, obesity, smoking...drug use cannot really be changed unless the user decides not to use. Incarcerations often are temporary breaks but doesn't stop cravings for the drug. MAT clinics do frequent drug screening depending the length at that clinic in treatment; success in program; and visual appearance or symptoms. Drug screening that is refused is counted as a dirty result. Responsible emotional, physical, financial support improves the success outcomes. Counseling and "working your program" will help improve the chances of success. "Working your program" requires clients to show up and work through reasons and choices on why they use and interventions to manage their decisions. There is no timeline on how long it will take. Quickly going decreasing doses to "wean you off" without regarding whether a client does or doesn't have withdrawal symptoms, often increases use. It is seldom successful. Clients may be on daily does or split (divided into 2x/d to manage sx) dosing to control cravings/symptoms. Peak and trough levels can be done to determine if dosing is adequate in pregnancy and users requiring higher levels. Physical versus psychological need. There is no one-size-fits-all dose for everyone. Doses can range from 10mg to 300mg. If a client is on daily methadone, they may start having symptoms of withdrawal in 48 to 72 hours of last dose. Most MAT centers dispense liquid methadone to find the most accurate dose for an individual patient. When admitted to the hospital, MAT patients should receive their regular dose to control their addiction and symptoms. Special care should be given on MAT patients and anesthesia since both are respiratory depressants. For a planned admission a MAT patient, the patient will have a take home labeled bottle with their current dose or clinic documentation. MAT clinics are usually open at 0600 to early afternoon to accommodate work schedules. Nurses should try to document/verify the dose by calling the local MAT clinic and advise patient is in ER or unplanned admission. When discharging a MAT patient, patient should be given a copy of their MAR to take back to the clinic to show no break in service on methadone or buprenorphine dosing. Most MAT clinics will decrease the patient dose for breaks in service over 3 days and use of certain med that interact with methadone. If patient has a surgical procedure, that patient needs pain meds to manage the pain. The methadone will have little if any effect on the current pain. Successful progressive MAT patients usually are more likely to refuse pain meds and attempt to tolerate pain rather than take the possibility of regressing. Clients are encouraged to bring in all medications, monthly routine and new, to be reviewed by their counselor or nurse. MAT clinics have policies regarding abuse, physical and verbal actions, use of medications on site, sale of drugs or paraphernalia on site. Some sites require take home doses be locked in boxes on leaving. Initially clients are required to come to the clinic daily for at least 30 days or more. With clean urines and working their program, visits can become less frequent. It is my hope that this information is helpful and gives nurses another perspective of life and addition therapy. As nurses we should be looking at these individuals as people with an illness. We should advocate for them with honesty, education and humor. At times they may try to use your naivety to get around the rules or they may be thankful for your kindness and understanding. Like anything we do, it all makes us who we are as nurses.
  2. I’ve changed many details to protect the identity of the nurse I interviewed. I offered to pay her for her time, but she refused, so I made a donation to the American Nurses Foundation Coronavirus Response Fund in her honor. The Coronavirus Response Fund for Nurses focuses on: Providing direct financial assistance to nurses Supporting the mental health of nurses – today and in the future Ensuring nurses everywhere have access to the latest science-based information to protect themselves, prevent infection, and care for those in need Driving the national advocacy focused on nurses and patients Mental Health RN I interviewed Frannie, a mental health nurse who specializes in addiction medicine. She is a Registered Nurse who works at an outpatient opioid treatment center. I was surprised when she told me that some people wouldn’t describe patients on methadone as being in “recovery” because methadone is still an opioid. Frannie said, “If their story is that they are recovered, then they are.” I have no experience with this type of nursing, so I was fascinated to learn that about 30% of the patients at the clinic will likely be on methadone for life. “These are stable patients with jobs, families, work. They are highly functional.” I asked about access – do you have to get referred? Frannie said, “Anyone can walk in off the street. We have an NP there every day and a doctor 2x week.” For those struggling with addiction to opioids, methadone is prescribed at a low dose. Many start out at 30 mg daily, but some are now at the daily maximum dose. Their tolerance level is extremely high. If they have been doing fentanyl, they need a lot more. You have to not judge a 90 lb. woman who needs 200 mg to function.” Frannie told me many of her patients have been coming to the clinic for 5 years or more. Many of them are at 80 – 120 mg daily. I asked how a maintenance dose could max out. I wondered about tolerance. Frannie said, “A lot of it is psychological. If they miss a dose they feel like they have the flu. Most of them come in once a month or every 2 weeks for their supply. They take it the way they are supposed to and then come back for more.” What about the other 70% of your patients? “At the bottom of the ladder are the people who are unstable with comorbidities. People with higher levels of care do come in and we are trying to keep them off the street. These are the borderline stability folks. 15-20% of them are never going to get to take home doses. They have to come in every day. They are often also still using methamphetamines, cocaine. We test them once a month randomly, but even if they test positive, we still treat them. We keep an eye on their dose. Urine tests get sent to a lab. Sometimes we can’t dose them because there are too many other drugs on board. There’s a small percentage of patients who are freaking out, like they are coming in wearing three masks, but most of them seem to be hanging in there. They’ve already been through some rough S%$#. Even though they are addicts they have some resiliency.” Unique challenges to those with addiction According to the National Institute on Drug Abuse, the pandemic presents some unique challenges for people with substance use disorders and those who are in recovery. I read an interview with Dr. Nora Volkow, the director of the NIDA that focused on the collision of the Covid-19 pandemic and another very real public health crisis – substance use disorder. It really hit home when Dr. Volkow said, “We had not yet been able to contain the epidemic of opioid fatalities, and then we were hit by this tsunami of COVID.” Issues that are exacerbated by Covid-19 The healthcare system is not prepared to care for those with addiction Social distancing makes these folks even more vulnerable by interfering with the support systems that help them to recover The drugs themselves negatively impact human physiology, making those with addiction at higher risk for getting Covid-19. According to Volkow, it’s harder for patients to get access to treatment. Some clinics are decreasing the number of patients, the healthcare system is less able to initiate people on buprenorphine. If you are socially isolated and you overdose, it is much less likely that you will be rescued with naloxone. There are no statistics yet on how Covid-19 is influencing fatalities from drug overdoses. Research into the NIH’s $900 million Helping to End Addiction Long-term (HEAL) initiative came to a halt. Research into bringing medication-assisted treatments to prison inmates has stopped. Some IRBs are closing, making recruitment for research impossible. Dr. Volkow spoke of the need to be creative with virtual technologies to advance the goals of NIDA and the NIH. How have things changed at Frannie’s clinic since Covid-19? “For the patient it’s unsettling. They come here every day and it’s different. They are more stressed. They are constantly asking – are you going to close? They are so worried the clinic will close. It’s their life-line. We’re behind glass. Before we always had half the window open, now we keep it closed. There’s no paperwork due to pen sharing. We are doing it all on the computer. They used to get their own water from a pitcher, now we pour the water for them.” What about infection prevention? “People who in the past didn’t get take home doses are now getting them." I thought that would be a bonus for folks to not have to come in as often, but Frannie said, “People like coming into the clinic, though it’s hard to be responsible for all the medications. If they don’t live in a home, 14 bottles is hard to keep track of. You can’t get more take out if you can’t be responsible for your medicine. I’ve been surprised though that most of the ones who have gotten the extra doses to take home have been bringing back all their empty bottles, which is required if they want more doses. Another change is that we have to call them every other day on the phone to assess how they’re doing. I’m pleasantly surprised. It’s been interesting to call my patients every day. I thought maybe they wouldn’t answer their phones, but they are sober and kind and happy for the check-in. It’s increased my trust in my patients. I have to wear a mask and gloves all day and the patients also have to wear them. We keep their masks in plastic bag with name. It’s now the security officer’s job to let in ten people in at a time. He hands out the masks.” Frannie said previously there were between 20-30 people in the room, “being social and seeing each other, they miss the interaction." I wondered if the patient masks dry out in those baggies. Frannie said, “I have no idea. That’s the policy – it’s what we have to do. I am getting some skin breakdown from the mask. I switch between my homemade and my surgical mask. There are four of us nurses in the pharmacy and our desks are not 6 feet apart. No one is changing their masks. Despite that, I think we’re doing a pretty good job. I think we don’t give them enough credit. We talk about how vulnerable they are, but they are doing okay. They have surprised the crap out of me.” Future interviews I’ve written up interviews with two other nurses, so if you enjoyed this one, check them out: At the Bedside with Covid-19 - Stories from the Frontlines At the Bedside with Covid-19 Part 2: John I hope to continue to interview nurses in various roles. Please let me know if you would like to be interviewed, or if you have any requests! Next up is an interview with an ER nurse.