IVDA and PICCs

[billypilgrim37]

We all seem to get really nervous to send home folks with problems with IV drug abuse with PICC lines from a medical setting. This seems logical enough. But does anybody have a sense of whether sending these patients home with a PICC actually changes their behaviors? I could imagine someone who didn't typically shoot up using a PICC to experiment with things they usually didn't, but for folks who chronically use IV drugs, I'm guessing that access is the least of their concerns. They're the best phlebotomists in town.

So, I can imagine sending these folks homes with PICCs isn't the best thing to do, but does it really matter that much? I could imagine for casual users and those in recovery (seems awfully tempting, and I imagine having a line in could be quite the reminder) there could be a problem, but for those actively using, I just don't know if it's the right battle to fight.

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[BobA]

We all seem to get really nervous to send home folks with problems with IV drug abuse with PICC lines from a medical setting. This seems logical enough. But does anybody have a sense of whether sending these patients home with a PICC actually changes their behaviors? I could imagine someone who didn't typically shoot up using a PICC to experiment with things they usually didn't, but for folks who chronically use IV drugs, I'm guessing that access is the least of their concerns. They're the best phlebotomists in town.

So, I can imagine sending these folks homes with PICCs isn't the best thing to do, but does it really matter that much? I could imagine for casual users and those in recovery (seems awfully tempting, and I imagine having a line in could be quite the reminder) there could be a problem, but for those actively using, I just don't know if it's the right battle to fight.

Good point. If they're opioid users I suppose that one could send them home after a Vivitrol injection. . . not that anybody uses that due to expense, and patient preference . . . but it'd be a nice option in a perfect world.

Kind of reminds me about worrying about overdose from someone on a TCA or Lithium. I mean, they could just go out and get some Tylenol.

 

[aphenomenon]

Yeah it's interesting and comes up all the time. I think it's the fear of somehow being liable (because of some positive, active role in providing the PICC) that drives these conversations more than any noted increased risk of overdose or change in behaviors that I'm aware of.

 

[whopper]

An interesting point I've noticed is I've hardly seen anyone give out Naltrexone to opioid and alcohol abusers. I figure why not start someone on this med if they have a substance abuse problem. Studies back it's effectiveness, and I've found it to be highly effective in clinical use. My alcohol disordered people sometimes still drink while on it but often drink less citing their enjoyment of alcohol is to the degree is almost not worth it.

If given appropriately, I don't see a problem with it other than the risk the guy could actually need an opioid for a procedure (e.g. wisdom tooth extraction) once on the med aside from all the other problems that could happen with any med such as an adverse reaction. The injectable Naltrexone as mentioned above is a great option because it stays in the patient's system for weeks. Out of dozens of patients I've treated with Suboxone (that contains Naltrexone), only one guy so far was in a situation where he might've needed an opioid for surgery and he explained to the surgeon and anesthesiologist he was on Suboxone and they managed to do the surgery without an opioid.

In my continuing rants about the poor level of care I often see, I saw a guy who had a doctor who had him injected with the depot Naltrexone injection without trying him on the oral version first to see if he could tolerate it. The guy had a very bad reaction to it but it was now trapped in his system for weeks. The guy developed a very serious erythematous reaction around the injection area and I didn't know what happened to to the guy since. The fact that the doctor's office was on top of a bar on the same order of the Boar's Nest from Duke's of Hazard, and I know this guy to be a pretty lame doctor didn't exactly assuage my anger.

For those of you who don't know, before any depot injection is given, the medication should be given orally first to make sure the patient doesn't have a bad reaction he/she can't live with once it's injected, and once that's done it's not going to leave the patient's body for possibly months. I had a court case once where the treating doctor wanted to administer court-ordered meds and asked for depot shots without asking for the oral versions first and as the neutral expert witness I had to tell the court to not give the doc permission because he wasn't planning on giving the patient the oral meds first.

As for the PICCs, if the patients needs them, they need them. Only alternatives I can think of other than the injectable Naltrexone is to ask the IM consultant if there is anything else that can be done and your concerns. If there is no other way around it, I can't think of anything other than the Naltrexone option. In most cases you can't simply hold a patient in the hospital to prevent them from abusing substances.

 

[splik]

Kind of reminds me about worrying about overdose from someone on a TCA or Lithium. I mean, they could just go out and get some Tylenol.

Not quite, means restriction is pretty much the only method shown to prevent suicides (and possibly lithium and clozapine but in limited populations). Since suicides are usually impulsive you take what you can, TCA od was a common cause of death from suicide in depressives in the 80s and before, there is no evidence for a significant method substitution.


on the other hand, it is actually a lot harder to kill yourself with lithium. Death from lithium toxicity is rare. It is much more toxic with chronic administration and a recent meta-analysis found lithium was a lot safer than made out. Interestingly they found hyperparathyroidism was common complication - I had not heard of this and don't test calcium levels in patients on lithium. www.ncbi.nlm.nih.gov/pubmed/22265699

 

[NoNoNoNo]

Naltrexone is great (or merely the best there is) for alcohol dependence. For opioid depdendence, treatment adherence rates are very poor and there is a markedly increased risk of overdose (including death) after treatment. The only good data for using it are really "motivated" people aka those with review boards over their backs...pilots, physicians, lawyers...

 

[billypilgrim37]

I figure why not start someone on this med if they have a substance abuse problem.

It's an awesome med, but the liver issues are a pretty big deal. I've been very unlucky on that front. Getting insurance companies to pay for vivitrol was a challenge, but I haven't seen an adult addictions patient in a year because I only get to see ankle biters now, so that might be changing. 600 bucks a month for its effectiveness seems like a no-brainer for an insurance company given how much money they could save if vivitrol was just a little bit effective, and it's probably much better than that.

 

[OldPsychDoc]

...
If given appropriately, I don't see a problem with it other than the risk the guy could actually need an opioid for a procedure (e.g. wisdom tooth extraction) once on the med aside from all the other problems that could happen with any med such as an adverse reaction. The injectable Naltrexone as mentioned above is a great option because it stays in the patient's system for weeks. Out of dozens of patients I've treated with Suboxone (that contains Naltrexone), only one guy so far was in a situation where he might've needed an opioid for surgery and he explained to the surgeon and anesthesiologist he was on Suboxone and they managed to do the surgery without an opioid..

Just to clarify a point. Suboxone contains naloxone, not naltrexone. And the opiate blockade due to Suboxone is primarily due to the tighter binding of buprenorphine to mu receptors, not to any blockade from naloxone. The latter only has notable effect if the tabs are dissolved and injected, as it is poorly absorbed via GI.

 

[strangeglove]

Many IV drug users like the sensation of injection, which a PICC line would not provide. And if they are going to inject anyway, why be so concerned about them using the PICC?

 

[whopper]

Just to clarify a point. Suboxone contains naloxone, not naltrexone

You are correct.