Source: American Family Physician V.99 No.6 March 15th, 2019
While I am pleased that a new medicine recently FDA approved for mitigating some symptoms of opiod withdrawal (IE sweating, increased heart rate, some of the physical symptoms of anxiety) I am cautiously optimistic at best that this medicine will see much
The pros of lofexidine:
Most importantly it demonstrates that someone / the pharmaceutical industry realizes a need for more medicines to address the current opiod epidemic. This is extremely important given the few resources available for treating opiod dependence so kudos to all who did the work to get this medicine approved seriously.
See point 1
The cons of lofexidine:
It costs about $1,776 dollars for a seven day supply whereas there is an older virtually identical medicine (also commonly used to mitigate withdrawal symptoms) clonidine which costs nine dollars for a 30 day supply.
Dosing is 4 times a day (presuming a patient in acute withdrawal isn’t vomiting everything they try to swallow which is often the case).
I don’t mean to ‘poo-poo’ this medicine and I will certainly prescribed it when indicated. I will be astonished if an insurance company covers it but at least there is one more weapon in the arsenal.
Mr. J.B., a 24 year old male up and coming advertising executive for a NYC start-up looks great on paper. He has a Masters Degree from a reputable Ivy League school. His rowing strength, skills, and discipline landed him an undergraduate scholarship, at least until he injured his back and was prescribed Percocet. He is from an affluent family, the kind that consider yachting a sport.
Issue is, he may be getting drug screened as part of his promotion at work. The recreational once monthly use of oxycodone that started a few years ago has ‘blossomed’ into daily use of what is supposedly heroin–he suspects it is ‘some garbage laced with fentanyl, different high you see’ which he snorts every few hours so he doesn’t ‘get sick.’
Appropriately concerned that his habit may be life threatening, I find him sitting in my office, nose running, pale and fatigued, yawning, and rubbing the goose bumps on his restless legs.
JB is clearly in opiod withdrawal and in New York State medical marijuana is recently approved to prescribe for Opiod Use Disorder.
Why? Because studies show that marijuana reduces the dose of opiods needed by at least 1/3rd and relieves pain.
As my predecessor physicians did during prohibition which began 100 years ago in 1919 when one of the few legal means of obtaining medicinal alcohol was by prescription, so now can New York State doctors prescribe marijuana for various medical ailments from cancer to post traumatic stess disorder to Opiod Use Disorder.
Given that New York like the rest of the USA is in the midst of an opiod epidemic causing countless deaths, any tool we can use to save lives from naloxone to buprenorphine to methadone to medical marijuana should be easily at doctor’s disposable.
This begs several questions:
Why do doctors need a special DEA number and special training to prescribe buprenorphine, a medicine FDA approved for treating opiod withdrawal and dependence which it is virtually impossible to overdose on.
Why do doctors need special training to prescribe medical marijuana as patients drop like flies from illegal pain killer and opiod use?
Why don’t doctors need a special DEA number to write for powerful prescription opiods that are highly addictive and cause respiratory depression and death at high doses.
These complicated questions are based on history dating back to prohibition, reflect lobbying power of ‘big pharma,’ and ignorance that leaves marijuana a Schedule 1 medicine meaning the following according to the DEA:
Schedule I drugs, substances, or chemicals are defined as drugs with no currently accepted medical use and a high potential for abuse. Some examples of Schedule I drugs are:heroin, lysergic acid diethylamide (LSD), marijuana (cannabis), 3,4-methylenedioxymethamphetamine (ecstasy), methaqualone, and peyote. [See https://www.dea.gov/drug-scheduling].
Should marijuana become legalized for recreational use as Govenor Cuomo intends next year, perhaps medical marijuana prescribing will become a relic like the 100 year old prescription for medical alcohol?
For the interim New York doctors can and should, where medically indicated, offer patients medical marijuana instead of opiods.
Testosterone Therapy Part I: ‘I’m On an Opiate [buprenorphine, Suboxone, methadone, morphine, etc] and My Mood and/or Libido are blah’
by Natan Schleider, M.D.
August 19th, 2018
While the USA suffers through another opiod use epidemic (yes, we’ve had them before but I’ll give you the history lesson another time), the focus of press and medical/government powers that be are appropriately focused on preventing overdose and death. Far less attention is paid to adverse effects of chronic opiate use.
Whether used for pain management or for Medication Assisted Therapy (MAT) [IE using buprenorphine or methadone to manage Opiod Use Disorder formerly called opiod dependence] here is an important medical fact: if you are taking any opiate, you are at risk for testosterone deficiency. While not life threatening directly, common signs and symptoms of testosterone deficiency are decreased libido, depressed mood, lack of energy, diminished muscle mass/trouble gaining muscle size and strength at the gym, increased body fat, erectile dysfunction, and infertility.
Opiates reduce leuteinizing protein (LH) and follice-stimulating protein (FSH) production at the brain’s pituitary gland. LH and FSH tell the testicles to make testosterone.
In my practice, 50% to 75% of my male patient’s on opiods have low testosterone and half of them have some of the symptoms listed above.
I would argue that suffering the above symptoms poses risk of relapse to illicit opiod use and should be investigated and treated when indicated.
The good news about testosterone supplementation: it can help many of the symptoms above. The bad news: testosterone supplementation increases risk of prostate disease, prostate cancer, blood clots, and possibly heart disease (depending on the study).
Testosterone is broken down/destroyed by the stomach if swallowed so it has to be supplemented via transdermal gel (that goes on the skin daily) or by injection into the muscle (usually the gluteus) weekly to monthly. A few formulations I am not that experienced with as I can rarely get them covered are available: buccal (melts in the mouth) Striant, intransal gel (Natesto) [has to be given 3 times daily–annoying].
Most of my patients prefer the injectable formulations being least expensive and allowing for the patient and I to optimize how frequently to give the shot. I find weekly injections the best as if given less often, testosterone levels tend to peak for several days after the injection and wear off faster than the manufacturer suggests.
I would love to hear your experience or horror stories or opinion about testosterone therapy in opiate users via Twitter.com @DrSchleider or Facebook or Instagram.
Thanks for reading and stay tuned for part II, testosterone supplementation in women and transgender patients.