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Methadone and opioid use and misuse. Monitoring & MOA Spring Training 2010 Who is speaking? • • • • • • • • • ACOFP board certified primary care physician Family Medicine educator (Synergy Medical) Joint appointment to Dept. of Psychiatry Credentials in Pain and Addiction Credentials in Forensics/Deputy Med Examiner Armed Forces Institute of Pathology Masters Tox/Pharm U. Missouri at KC/Pharm Active pain consultant & Hospice Director Activist, advocate & addictionologist Conflict of Interest • Speaker’s Bureau Rickett Benckiser, Inc. • HealthPlus pays me to speak on mental health at 1-2 CME events per year. • Employee at Hospice of Michigan. Special Consulting: AOAAM consultant at the White House Office of National Drug Control Policy (ONDCP) September 2009. DrMorrone.com Home About Me Medical/Legal Media Appearances Contact Us Home Welcome to DrMorrone.com. In my world, forensic science, medicine, teaching, law, criminal justice investigation and toxicology explain mystery and discover truth. Universal scientific principles often uncover mystery. What is truth? What is Justice? Sometimes, making complex medical facts simple honest sound bites, is the only true justice. Teaching and knowledge are the only weapons against fear and ignorance. As a practicing physician, teacher, forensic scientist, research scientist, medical examiner, toxicologist, addictionologist and social advocate, I have sought simple truth to help, heal or comfort others for 24 years. Over that period of time, I have watched medical knowledge undergo exponential & dramatic growth, most recently in areas of drug development and DNA application. I have attempted to bring natural justice to every level of “complex science and medicine” that has been too long-winded in the past. This website is to declare my interests as a forensic scientist, toxicologist, real-world practicing physician, and medical-legal consultant. I hope to share this with colleagues and students as well as those who seek my services to explain, teach and investigate. Bring me your mystery. Sincerely, William R. Morrone, DO, MS, ACOFP, CCD For Medical/Legal Consulting For Media Appearances Dr. William R. Morrone Belladonna Medical Consultants Lois Katz Public Relations, LLC Phone: 609-936-0014 Email: [email protected] Phone: 989-928-3566 Fax: 989-891-9199 OBJECTIVES 1. Evaluate the REMS epidemiology; opiates for pain, opiate abuse and unintentional overdose. 2. Opioid "Pharmacokinetics" with antagonism. 3. History/Physical, PMP and urine toxicology. 4. Withdrawal medications in ICU/ambulatory. 5. What about naloxone (Narcan®) ? 6. Methadone for pain vs Methadone clinic? 7. Co-occurring and self-treating in a patient’s psychopathology…….options? REMS • Risk Evaluation and Mitigation Strategies • Understand the epidemiology and problem. • Monitor, PMP, Consent and Psych issues. • Have exit plans and added training. • FDA has determined certain opioid products will be required to have REMS to help ensure that the benefits of the drugs continue to outweigh the risks of: • 1) use of certain opioid products in non-opioidtolerant individuals; • 2) abuse; and • 3) overdose, both accidental and intentional. The REMS will include elements to help ensure that prescribers, dispensers, and patients are aware of and understand the risks. • Pain and Symptom Management for Health Care Professionals • Welcome to the portion of the Pain and Symptom Management website devoted to information for both Michigan health care providers and health policy professionals. This part of the website will provide health care professionals with state and national guidelines, Michigan legislation, educational links and various articles and publications related to pain and symptom management. Health Professionals are also likely to find this website's link to the Advisory Committee on Pain and Symptom Management of interest. • State and National Guidelines Click here for: state and national guidelines for pain and symptom management Palliative Care Click here for: Information about chronic disease and cancer-related palliative care Links to Pain and Symptom Management Information Click here for: Links to Pain and Symptom Management Information • • Pain & Symptom Management State Legislation Click here for: information about state legislation pertaining to pain and symptom management • • End of Life Care Click here for: pain management during the final days of life Publications and Articles Click here for: publications/articles about pain/symptom management March 30, 2010 «First_Name_Middle_Initial» «Last_Name», «Title» «Address_Line_1» «Address_Line_2» «City», «State» «ZIP_Code» Dear Dr. «Last_Name»: In accordance with Rule 338.3132 of the Michigan Board of Pharmacy Administrative Rules, all physicians who prescribe, administer or dispense controlled substances to drug dependent persons for the treatment of narcotic addiction in a drug treatment and rehabilitation program are required to obtain a separate controlled substance license for this practice. Our records indicate you are currently certified with the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration for this practice; however, it appears you do not hold the required Michigan license. If you currently prescribe, administer or dispense controlled substances to drug dependent persons in a drug treatment program, please complete and submit the Controlled Substance License Application-Prescribing Physician for a Drug Treatment Program application to ensure compliance with Michigan law. This application can be downloaded from our website at www.michigan.gov/healthlicense by selecting the Pharmacy link and then Pharmacy Licensing Forms and Applications. Please note that failure to apply for this license within 30 days after receipt of this correspondence may necessitate review of your professional license(s). If you no longer prescribe, administer or dispense controlled substances to drug dependent persons in a drug treatment program, please complete the certification section below so we may take the appropriate measures to update your licensing status. Please contact our office with any questions you may have regarding the above information. Sincerely, Michigan Board of Pharmacy 517-373-1737 [email protected] Please complete the following certification and return in the enclosed postage paid envelope. I certify that I no longer prescribe, administer or dispense controlled substances for a drug treatment program and give the Michigan Board of Pharmacy the authority to contact the certifying agency, the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, to inform them of my decision to inactivate my certification. Name: ________________________________________ Signature: __________________________________________ Select the single best answer • • • • Overdose victims are only new users. Heroin & opioid deaths always increase together. Fatal opioid poisonings doubled (1999-2006). Doctors directly supplied non-Rx use of pain relievers greater than 70% of the time. • Hospitalization, detox and incarceration lower your risk of opioid overdose. • All of the above. • None of the above. Select the single best answer • • • • Overdose victims are only new users. Heroin & opioid deaths always increase together. Fatal opioid poisonings doubled (1999-2006). Doctors directly supplied non-Rx use of pain relievers greater than 70% of the time. • Hospitalization, detox and incarceration lower your risk of opioid overdose. • All of the above. • None of the above. * CDC/NCHS Sept 2009: From 1999 to 2006 fatal poisoning with opioid analgesics increased from 4,000 to 13,800 Source Where Pain Relievers Were Obtained for Most Recent Nonmedical Use among Past Year Users Aged 12 or Older (NSDUH 2006) Source Where Respondent Obtained Bought on Drug Dealer/ Internet 0.1% Stranger More than 3.9% Other 1 4.9% One Doctor 1.6% One Doctor 19.1% Bought/Took from Friend/Relative 14.8% Free from Friend/Relative 55.7% Source Where Friend/Relative Obtained More than One Doctor 3.3% Free from Friend/Relative 7.3% One Doctor 80.7% Bought/Took from Friend/Relative 4.9% Drug Dealer/ Stranger 1.6% Other 1 2.2% Note: Totals may not sum to 100% because of rounding or because suppressed estimates are not shown. 1 The Other category includes the sources: “Wrote Fake Prescription,” “Stole from Doctor’s Office/Clinic/Hospital/Pharmacy,” and “Some Other Way.” Poisoning Mortality- USA Unintentional, Drug-Related Suicide Undetermined Intent Source: Paulozzi L, et al. Pharmacoepidemiol Drug Saf. 2006 Sep;15(9):618-27. Michigan Poison Control • DeVoss Hosp and DMC confirm in MI approx. 1,000 opioid OD deaths per year. • Wayne Co. (Detroit) alone (pop 2 million): • 602 opioid OD deaths – 2006 • 493 opioid OD deaths– 2007 • 530 opioid OD deaths – 2008 • OD deaths: ½ in Detroit and ½ in non-Detroit Who overdoses? • Often dependent long term users; not in treatment with 5-10 years of experience • 17% occur in new users. Sporer Ann Emerg Med 2006 Major risk factors • Opioid Use following a period of abstinence – Incarceration – Hospitalization – Drug treatment/detox • Mixing classes of drugs – Primarily other CNS depressants – Cocaine is involved in nearly 40% of NYC overdoses Sporer 2006, Can Acad Emerg Med 2006 Death following incarceration Post incarceration is major risk factor for death from OD – Study of deaths in first 2 weeks post incarceration among 30,237 released inmates – 129 times greater likelihood of dying of OD vs. other WA state residents – 60% involved opioids – 74% involved cocaine and other stimulants Bingswanger NEJM 2007 DEA (2005) 22 states Rx in crime other 24% Vicodin 52% MDMD 8% Oxy 16% Allegheny County Trends in Accidental Drug Overdose Deaths (2000-2006)* 2000-2006* *Data is from Allegheny County Medical Examiners Annual Reports and includes all overdose deaths where these drugs were present at time of death, not necessarily cause of death. Scripts Reported in 2003-2006 by MDCH on the MAPS • • • • • 2003: 2004: 2005: 2006: 2008: • Hydro/APAP 12,498,338 13,689,728 14,355,989 15,989,785 17,311,431 5,116,486 30 % Schedule II MAPS methadone info • • • • 2003: 72,172 scripts 2004: 109,869 increase of 52% 2005: 131,524 increase of 20% 2006: 162,736 increase of 22% Medicaid requires prior approval for Oxycontin and not for methadone; there will be a transfer due to this formulary issue. Michigan Automated Prescription System Issue Date Fill Date Strength Xxxxxxxxxxxxxxxxxxxxxxxxxx SAGINAW,MI,486020000 MI,48724 02/27/2008 0697649 02/27/2008 Rx Number Practitioner DEA# Practitioner Address Dispenser DEA# Dispenser Address FALES,THOMAS I PA WALGREEN CO. MF0845644 BW7042877 3566 MADISON APAP/HYDROCODONE BITARTRATE SAGINAW,MI,487061274 101 S JEFFERSON, ADVANCED DIAGNOSTIC IMAG40IN9 GW P GCENESEE AVE, DBA: WALGREENS # 06091 TAB 100.00 750 MG-7.5 MG Xxxxxxxxxxxxxxxxxxxxxxxxxx BANGOR,MI,490130000 MI,49013 02/21/2008 4455762 02/21/2008 AL8119299 24TH ST 3973 M-140 BOX 127 211 WEST MONROE Xxxxxxxxxxxxxxxxxxxxxxxxx BANGOR,MI,490130000 MI,49013 02/21/2008 4455760 02/21/2008 SYR 120.00 WATERVLIET,MI,490980000 10 MG/5 ML-6.25 MG/5 ML SWANSTRA PHARMACY BS9992618 APAP/HYDROCODONE BITARTRATE TAB 60.00 FALER DRUG STORE BO6319013 AF6556457 CODEINE/PROMETHAZINE SYR 180.00 SAGINAW,MI,486020000 10 MG/5 ML-6.25 MG/5 ML PRINCING'S PHARMACY QUARTERS,JACK ELWOOD DO AQ3067825 AK5912402 APAP/HYDROCODONE BITARTRATE TAB 60.00 SAGINAW,MI,486040000 750 MG-7.5 MG PRINCING'S PHARMACY QUARTERS,JACK ELWOOD DO AQ3067825 3566 MADISON 1438 SCHUST RD 333 S MICHIGAN AVE WATERVLIET,MI,490980000 500 MG-10 MG ONONUJU,CHIDOZIE JOSHUA DO 3566 MADISON 1438 SCHUST RD 333 S MICHIGAN AVE Xxxxxxxxxxxxxxxxxxxxxxxxx SAGINAW,MI,486020000 MI,48724 02/13/2008 0774681 02/13/2008 CODEINE/PROMETHAZINE AL8119299 3566 MADISON 1320 NORTH MI AVE WENZEL EDWARD GUSTAVE Xxxxxxxxxxxxxxxxxxxxxxxxx SAGINAW,MI,486020000 MI,48724 02/13/2008 0774680 02/13/2008 BS9992618 LLANTO,ALFONSO GENERALAO MD 24TH ST 3973 M-140 BOX 127 211 WEST MONROE Xxxxxxxxxxxxxxxxxxxxxxxxx SAGINAW,MI,486020000 MI,48724 02/14/2008 0097483 02/14/2008 SWANSTRA PHARMACY LLANTO,ALFONSO GENERALAO MD AK5912402 CODEINE/PROMETHAZINE SYR 240.00 SAGINAW,MI,486040000 10 MG/5 ML-6.25 MG/5 ML Run Date : 3/19/2008 11:21:19AM Warning : This report contains confidential information,including patient identifiers,and is not a public record. Page 1 of 10 Resources at the State of Michigan • Department of Community Health • Bureau of Health Professions • www.michigan.gov/healthlicense Health Investigation Division • [email protected] • http://sso.state.mi.us/ What is a good urine drug test? What is a good urine drug test? • • • • • • CLIA waivered Temperature and Specific Gravity 12 panel drug test 10 minute developing (POS) Closed system $6.95-$7.95 Only 8 % of primary care use urine drug toxicology Call Poison Control Center • • • • Identify yourself Request a Toxicologist Report patient demographics/data Record orders in chart Morphine Heroin is diacetylmorphine Physiology of overdose • Overdose happens over course of 1-3 hours; stereotypic “needle in the arm” death is only 10-15% • Opioids depress the urge to breath and decrease response to carbon dioxide - leading to respiratory depression and death Sporer Ann Emergency Med 2007 Overdoses cannot be cookbook Heroin Methadone • • • • • • • • • • • • • Active metabolites 6-MAM (short t½) Morphine Half-life: 3-4 hours Often w/ cocaine Narcan Inactive metabolites EDDP Half-life:12-40 hours Often w/ benzo’s Narcan is not enough Often intubated You can’t cheat time! Always make the patient naked. • Look for fentanyl patches or residual glue. • Examine tattoos and look for needle marks. • Rectal exam especially if unconscious and arrest in the field & also look for cut up fentanyl patches in the oral cavity (Chiclets). Progression Treating the acute overdose state. • ABC’s • Oxygen • Narcan • Fluid • Blood pressure Treating the detoxed patient that results after the overdose. • Anti-siezure meds • Nausea • Panic anxiety • Pain (myalgia) • Pysch meds/eval Naloxone Pharmacokinetics Naloxone (Narcan®) • Opioid antagonist which reverses opioid related sedation & respiratory depression and may cause withdrawal. • Displaces opioids from the receptors, then occupies the receptor for 30-90 minutes • No psychoactive effects • Over the counter in Italy • Routinely used by EMS AGONIST DECREASED MAXIMAL EFFECT PARTIAL AGONIST EFFECT Antagonist LOG DOSE Adjuvants • Adjuvants allow easier opioid withdrawal or give analgesia in place of low dose opioid. • • • • • • Gabapentin or Namenda or Amantadine Valproic Acid / Phenytoin*/ Pregabalin Amitriptyline/hydroxazine or Benadryl* Promethazine* or Dextromethorphan Baclofen* or Ranitidine or Clonidine* Carbamazepine 200-1600mg per day. Treat and cover seizures in polypharmacy withdrawal • Carbamazepine: suspension 100mg/5mL given oral or rectal (10mL to 80mL) • Diastat® (diazepam 2.5, 5mg rectal gel) • Lorazepam: 2-4mg I.V. push prn seizures • Phenobarbital: seizure/anxiety/insomnia Heroin Overdose in France Source: Carrieri PM, 2006, Clin Infect Dis, 43: S197-215, data from Emmanueli 49 Select the single best answer • • • • Methadone treatment increased overdose risk. Methadone escalation is greater than morphine. Methadone’s metabolite is more toxic. Methadone overdose deaths are monotherapy greater than 74% of the time. • Methadone has no federal or public guidelines or web page for methadone use. • All of the above. • None of the above. Select the single best answer • • • • Methadone treatment increased overdose risk. Methadone escalation is greater than morphine. Methadone’s metabolite is more toxic. Methadone overdose deaths are monotherapy greater than 74% of the time. • Methadone has no federal or public guidelines or web page for methadone use. • All of the above. • None of the above. * Do not use Methadone unless you are very comfortable with it. Document reasons clearly for using methadone: • Hospice • • • • Allergies Formulary Diagnosis MMTs /MTPs Paid for with taxpayer dollars. • Where do you get your copy? • Internet • Print DHHS publication No. 04-3904 Let us look at Methadone for pain clinics and Methadone for pain in primary care. FAQ • Why do we use methadone? • Is methadone dangerous? • How do I learn methadone? • • • • • • • • • • • • • • • What is the Physician Clinical Support System - Methadone? (PCSS-M) The Physician Clinical Support System for Methadone (PCSS-M) is a free, nationwide program through which health care providers needing information and mentoring on methadone treatment for opioid addiction and/or pain can connect with experts in the field. PCSS-M MENTORS provide telephone, email and on-site support. They come from across the country and work in licensed opioid treatment programs, pain clinics, primary care, and other practice settings. The PCSS-M is coordinated by the American Society of Addiction Medicine (ASAM) in conjunction with other leading medical societies. PCSS-M offers a national network of trained health care provider mentors with expertise in the clinical pharmacology of methadone and clinical education. Mentors are supported by NATIONAL EXPERTS in the use of methadone and by a MEDICAL DIRECTOR, C0-MEDICAL DIRECTOR, and SENIOR ADVISOR. The PCSS-M MENTORS are members of medical specialty societies and provide mentoring support and educational services based on evidence-based practice guidelines. The efforts of PCSS-M are coordinated by a STEERING COMMITTEE composed of representatives from the Federal government and the leading pain and addiction medicine societies, along with primary care and psychiatric organizations that represent the target health care provider populations. PCSS-M provides educational services to any and all health care providers treating patients with methadone in an effort to increase the appropriate use and safety of this efficacious but clinically challenging medication. The PCSS-M is designed to offer support to clinicians treatment of pain and addiction on a number TOPICS including: Patient assessment and selection Initiating and titrating methadone Conversion from other opioids Dosing and patient monitoring Interpreting methadone serum levels Drug-drug interactions Methadone and cardiac conduction Minimizing risk of diversion and overdose Management of co-occurring conditions This project is funded by a grant from The Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Substance Abuse Treatment (CSAT); grant#1H79TIO20294-01. • • • OPIOID TREATMENT PROGRAM Mentor Name Specialty Location Gavin Bart, MD OTP Minneapolis, MN Mark Jorrisch, MD OTP Louisville, KY Mark Kraus, MD, FASAM OTP Waterbury, CT Edwin Salsitz, MD OTP New York, NY Laurene Spencer, MD OTP Hillsborough, CA Trusandra Taylor, MD OTP Philadelphia, PA Alex Walley, MD, MSc OTP Boston, MA Charles Walton, MD OTP Highland, UT Susan Whitley, MD OTP New York City, NY George Woody, MD OTP Philadelphia, PA • • • • • • • • PAIN TREATMENT Mentor Name Specialty Location Howard Heit, MD, FACP, FASAM Pain Treatment Fairfax, VA Brian McCarroll, DO, MS Pain Treatment Clinton Township, MI Mary McMasters, MD Pain Treatment Fishersville, VA William Morrone, DO, MS, ASAM, ACOFP, DAAPM Pain Treatment Bay City, MI Randy Seewald, MD Pain Treatment New York City, NY William Yarborough, MD Pain Treatment Tulsa, OK • • • • • • • • • • • PRIMARY CARE Mentor Name Specialty Location Jeff Baxter, MD Primary Care Worcester, MA John Brooklyn, MD Primary Care Jericho, VT Anthony Dekker, DO Primary Care Phoenix, AZ Ramsey Farah, MD, MPH, FAAP Primary Care Hagerstown, MD James Finch, MD Primary Care Durham, NC Michael Fingerhood, MD Primary Care Baltimore, MD Adam Gordon, MD, MPH, FACP Primary Care Pittsburgh, PA John Hopper, MD, FAAP, FACP Primary Care Ypsilanti, MI Joe Merrill, MD, MPH Primary Care Seattle, WA How do you get that web page? http://www.pcssmethadone.org/pcss/index.php A free nationwide program (PCSS-M) that healthcare providers needing information and mentoring can connect to methadone experts in addiction and pain management. A similar web resource exists for buprenorphine (PCSS-B). Pharmacology • Efficacy greater than morphine • Full Mu-opioid agonist • Inhibits reuptake of 5HT and NE. • NMDA antagonist resulting in additional analgesia Analgesia similar to morphine • • • • • • Once daily for opioid addiction (MMT only) Liquid used mostly for addiction and HOSPICE 15 mg morphine equal to 5 to 10 mg methadone 150 mg morphine equal to 30 mg methadone Suitable for pain when there is morphine allergy Slow onset helps avoid establishing reward behaviors that can occur with fast acting short duration opioids Less dose escalation with methadone? • N=40, advanced cancer • methadone vs morphine • Doses of both drugs were minimized and titrated to acceptable analgesia with minimal adverse effects. • Pain control and side effects were similar • Pill counts. • Opioid escalation was significantly less with methadone • More stable analgesia over time was seen in patients treated with methadone. – Mercadante S et al. J Clin Oncol 1998;16:3656-3661. Methadone Pharmacokinetics • Metabolized in liver NO active metabolites (EDDP). • Elimination half life of about 22 hours but varies in each person. • Duration 8-12 hours with repeated dosing. • Minimal renal excretion primarily fecal excretion. Methadone Dosing • Package insert advised dosage of 2.5 to 10mg every 3-4 hours as needed • 40-50 mg/day can be deadly for new patient • FDA black box warning • 18 deaths - Kent county, 11 deaths - Bay County (2006) • 2003 DAWN data from ME’s in Detroit identified 64 deaths from methadone • Benzos found in 74% of deaths related to methadone • Marked drowsiness (side effect) add methylphenidate • Duration of analgesia about 8 hours (6 to 10 hours) • • • • • 2 Vicodin q 4-6 hours 800 mg IBU q 8 Valium 5 q 8 Percocet 5 q HS Restoril 30 q HS Hospice White Male end stage liver chirrosis, type2 NIDDM, HCV, tibial ulcer & LE DNP • 5mg methadone po q 8 to 12 • One Vicodin q 24 prn • 250mg (bed time only) carisoprodol q HS • 600mg gabapentin q 8 • 25mg nortriptyline q HS • 10mg baclofen q 8 Hospice White Male end stage liver chirrosis, type2 NIDDM, HCV, tibial ulcer & LE DNP Honest talk about addictions. People Treated for Opiate Use in Vermont by Fiscal Year 1800 1600 People 1400 1200 Heroin 1000 800 Other Opiates/ Synthetics Non-prescription Methadone 600 400 200 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 State Fiscal Year Substance Heroin Other Opiates/ Synthetics Non-prescription Methadone 2000 2001 2002 2003 2004 2005 2006 2007 2008 256 140 3 439 156 4 546 219 2 693 340 8 671 513 15 710 719 26 722 1139 36 631 1425 57 617 1602 53 Data Source: Vermont Substance Abuse Treatment Information System (SATIS) This reflects only people receiving treatment at state-funded treatment facilities. Methadone and mortality • Prospective study of opioid dependent patients applying for methadone treatment in Norway • 3,789 subjects followed for up to 7 years • Clausen Drug Alc Dep 2008 Results Pre-treatment In treatment Post-treatment Total mortality Odds ratio 1 0.5 1.43 Total overdose Odds ratio 1 0.20 1.40 Percent of deaths due to overdose 79% 27% 61% Clausen 2008 Send recovered patients to treatment CBT/individual/group Maintenance therapy prevents overdose Since the institution of buprenorphine and methadone maintenance in 1996 in France heroin overdose dropped 79% French population in 1999 = 60,000,000 600 No. of deaths 500 400 Patients receiving buprenorphine (1998): N= 55,000 300 200 Patients receiving methadone (1998): N= 5,360 100 0 1969 1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 Year Auriacombe et al., 2001 Selecting treatment modalities Consider: Patient expectations of treatment Patient goals (detox vs maintence) Stages of change Current circumstances Available resources Past history of treatment outcome Evidence regarding safety, efficacy and effectiveness Need for pain management Outpatient and Inpatient • Victory Clinical Services: 989.752.7867 • Recovery Pathways, LLC: 989.928.3566 • Michigan Behavioral Health Institute: Dr. Douglas Foster: 989.894.3000 • Detroit, Flint or Mt. Pleasant methadone clinic • White Pine / HealthSource (inpatient) • Bay Regional Medical Center (inpatient) “End Game” examples • Opioid overdose w/ pain management should change to buprenorhine/naloxone or methadone clinic and therapy.” • Heroin overdose should go to methadone clinic for structure and therapy. • Street opioid overdose should go to methadone clinic for structure and therapy. • Opioid overdose with multiple outpatient failures go to methadone clinic. BIG TAKE HOME POINT • Do not try to be a methadone clinic in your office. • Dependence must be separated from pain. • Keep methadone pain management patients and make your charts absolutely 100% unambiguous with supporting documentation with reassessment . Naltrexone Core Slide Acknowledgements • Alice Bell • Melinda Campopiano, MD • Sharon Stancliff, MD Call any time. Director of Hospice and Palliative Care: Hospice of Michigan - 989.790.7352. Assistant Director Family Medicine: Synergy Medical Alliance - 989.583.6800. 24 hour Answering Service: 989.891.8979 Any question. Any medicine. [email protected]