by CASEY L. PENN The Shelby Clinic Medication-Assisted Treatment for Opioid Addiction

pioids do their job,” said “When you must prescribe an opioid, they rec- phine creates a strong bond with opiate receptors in Gene Shelby, MD, of the ommend starting with the lowest dose possible for the brain. Once people transition to buprenorphine, the shortest period possible,” said Dr. Shelby, who they lose their craving for opioids because those opi- way prescription opioids opened The Shelby Clinic about eight years ago now. ate receptors are covered. It prevents their withdrawal like hydrocodone and His interest in providing addiction treatment was from opioids. Withdrawal symptoms are flu-like – oxycodone achieve their piqued when his wife was part of a 2007 UAMS re- sweating, diarrhea, chills and worse – and start 12-24 O search study group that looked into the effectiveness hours after stopping use.” intended purpose of treating short-term of the drug combination buprenorphine/naloxone Dr. Shelby is certified (as required by law) to pain associated with or injury. (under the brand name Suboxone®) as an outpatient prescribe Suboxone®. To be certified, prescribing However, as the majority of are aware, treatment for suffering from opioid depen- there is potential danger in their usage, too, particu- physicians are required to take an eight-hour course dency and addiction. larly over a long period of time. on the and on opioid dependence. At the The clinic utilizes Suboxone®-assisted treatment end of the training, they receive a special DEA num- Dr. Shelby, a former state representative and for its medication-assisted treatment of patients. ber to prescribe buprenorphine/naloxone in an out- past AMS president, practices in central Arkansas (Suboxone® was once the first and only formulation setting. at various MedExpress Urgent Care clinics. With his of this drug combination, which was approved by the To help patients find help,help, Dr.Dr. wife, Faridah Katkhordeh, he also runs a small opioidioid FFDADA 12 years ago. Today, this formulation is mar-mar- ShelbShelbyy is on a list of physiciansphysicians treatment facility three to four days per month. An ex-ex- kketedeted by multiple drudrugg manufacturers.)manufacturers.) aaroundround tthehe state tthathat provideprovide pert on the subject of opioids, Dr. Shelby representsents “A“A synthetic opioid, SuboxonSuboxonee® has somesome thithiss servservice.ice. TheThe listlist isis spon-spon- Arkansas and AMS as a member of the AMA TaskTask ooff the characteristics ooff opioid, but it doesn’t sored by Suboxone® aandnd Force to Reduce Opioid Abuse. pproviderovide ananyy sort of eueuphoria,”phoria,” exexplainedplained Dr. llocatedocated on its website. CCur-ur- “Prescribing physicians must be aware of the Shelby of how the drug works. “The buprenor-buprenorr- rentrently,ly, tthehe clinicclinic treats 60-70 dangers,” said Dr. Shelby. “While many people ccanan take opioids with no dependence, around 20-30%0% are susceptible to becoming addicted or dependent.ent. Opioids do a good job of treating physical pain, but they also tend to provide somewhat of a high. I’ve hadhad patients tell me that they treat psyche pain also. Theyhey feel better when they take it.”

For a while, that is.

“The danger is that with the way opioids work,rk, you can develop a tolerance for them, so that youu start needing more and more. That can lead to ac- cidental overdose and death.”

Addiction can happen rapidly, sometimes within three to four weeks, according to Dr. Shelby. For this reason, the American Medi- cal Association has issued a strong statement encouraging physicians to try other means of treating pain.

30 • THE JOURNAL OF THE ARKANSAS MEDICAL SOCIETY VOLUME 113 patients. Many are from western Arkansas, but some a son, Osean spiraled down to rock bottom, and re- HOW EFFECTIVE TREATMENT WORKS travel from neighboring states. “Patients run the gam- lented to family requests to enroll in treatment. After Before a patient starts treatment in his clinic, ut and most have a long history of opiate use. They going through several treatment cycles, including Dr. Shelby evaluates the person’s medical problems start out for a variety of reasons, sometimes through methadone treatment, and dealing with repeated and history of substance abuse. Not every patient regular trials of life,” he explained. relapses, she found Dr. Shelby’s clinic and his ap- is approved for treatment. “One thing that can be a proach to treatment. ® It can start intentionally (teens experimenting at problem is diversion of the Suboxone . It is sold on pill parties), innocently (extended pain treatment turns “I had heard about Suboxone®. You know, when the street,” said the doctor. “I’ve had people that have into addiction), or somewhere in between. Regard- you’re out there in this life, you hear about things. come to my program that have bought it on the street. less of its start, when opioid dependency or addiction I had heard ‘Hey, there’s this new thing, you don’t For this reason, we are in the habit of closely watching takes over, it’s very hard to beat. Further, withdrawal have to get sick anymore.’ how much we prescribe and being aware of the pos- symptoms can be as bad as or worse than the physi- sibility of diversion. We screen patients extensively to “When I was on methadone, I was still using cal or psychological pain the opioids were taken to see if they’re ready for the program.” heroin – and not just me but my peers who were treat. “People don’t die from opiate withdrawal,” said in the treatment program with me,” she recalled of Once a patient is approved for treatment, the Dr. Shelby, “but they feel like they’re going to. Many ® failed past efforts of medication-assisted treatment. next step is to start him or her on the Suboxone . “A continue to take it because if they didn’t, they couldn’t “It was no good. It was just switching one for the person needs to be in moderate withdrawal before go to work, they couldn’t support their family. other. So when doctors talked to me later about Sub- they actually start the medication,” he said. “Usually, “It has been gratifying to see people with long oxone®, I was hesitant. I didn’t want to go through when we get people started on it, they begin to feel histories of heavy opiate addiction transition to Sub- the horrors of methadone again.” better right away.” oxone®, eventually get off all medications, and go The Shelby Clinic does not employ methadone Dosage is important, as there is some variation back to living a normal life.” as a treatment, as Dr. Shelby believes it to be too of how much a person needs to be on to avoid crav- ® Yolie Osean, 40, is living a changed life as a re- dangerous. “It’s a very powerful opioid,” he ex- ings. Also, if a person who is on Suboxone stops tak- sult of her treatment at The Shelby Clinic. She was plained. “It’s long acting, and the dosage is tricky. It ing it, he or she will have withdrawals just like those among Dr. Shelby’s first patients in his clinic and still is the opioid most commonly seen in overdose death caused by opioids. For this reason, there are those ® sees him on a regular basis. “I started using opioids from opioid.” who reject Suboxone as a suitable treatment. so young,” said Osean, who grew up idolizing a sibling who also happened to be a drug dealer. “I would get into my brother’s stuff – he was my hero – and it grew from there. Opioids were the toughest thing I ever had to kick, but I had to kick pretty much everything at one point in time or another. By the time I was 15, I was a full-blown heroin addict.”

“I think it’s important to make a distinction be- tween addiction to opiates and an addiction to al- cohol, methamphetamines, and other drugs,” said Correct Care Solutions (CCS) is a public healthcare company Osean. “None match the horrors of opiate addiction. serving the healthcare needs of patients in corrections environments, state psychiatric , residential treatment centers and more. There was no facet of my life that opioids did not have Our employees feel part of something bigger than themselves because complete control over – they controlled when I ate, of the care we provide to an often underserved population. when I slept, and if I get out of bed in the morning. You get to a point with opiates where you have to do We are currently seeking dedicated insane amounts just to not get sick, to say nothing of Physicians for Full-Time / Part-Time / PRN opportunities to join our team what it takes to feel normal or to get high. throughout the state of Arkansas. “There would be no way I would be where I’m at Provide patient care the way you have always wanted. today without the Suboxone® and Dr. Shelby. I don’t think it’s an exaggeration to say that the development At CCS, our physicians have the opportunity to practice in a real of Suboxone® has really been a jumping off point in “Patient Centered Medical Home.” Our physicians focus on the patients instead of insurance or billing concerns. the treatment of addiction.” We offer competitive pay and benefits! Now in her ninth year of sobriety, Osean is down To learn more, visit jobs.correctcaresolutions.com or contact to a 3 mg daily dose of Suboxone® – very different Alex at: 615-844-5513 or [email protected] from where she started. After losing a husband, and CCS is an EOE/Minorities/Females/Vet/Disability Employer

NUMBER 2 AUGUST 2016 • 31 “Really strict people that treat addiction, and needed a sponsor who would accept Suboxone® as How careful should a be when con- some places with NA (Narcotics Anonymous) pro- a valid treatment.” sidering prescribing opioids? “It’s a balance,” said grams see Suboxone® as subbing one drug for Dr. Shelby. “I have heard stories about PCPs being another,” Dr. Shelby readily admits. “That’s not my NATIONAL PUSH FOR AWARENESS nervous to prescribe them for pain, but on the other philosophy. It’s an effective treatment, with many dif- AND TREATMENT hand, there’s a reason that the CDC guidelines em- ferences from the regular opioids. Weaning ‘cold tur- When the FDA set up regulations for Suboxone® phasize finding other ways to treat pain.” key’ off opiates is a miserable time and carries with clinics, it limited each prescriber to 100 patients. He asks simply that physicians make an ef- it a great possibility of relapsing, particularly without There has since arisen a national push to make the fort to understand the risks opioids pose to some 12-step programs and counseling. Buprenorphine, treatment more accessible. Dr. Shelby credited Pres- patients and that learn all they can about outpa- on the other hand, is a synthetic opioid. If you take ident Barack Obama for legislation currently before tient treatments for dependence like Suboxone®. too much, it doesn’t stay in your system. It doesn’t Congress that, if passed, will expand the number of “Doctors need to know about this treatment,” he have the side effects of regular opioids.” patients one prescriber can have. stressed. “They may well encounter a patient that “Our goal is to gradually wean people off the As he carries out his work related to opioid ad- is taking Suboxone®, and they’ll need to know a Suboxone®, but that is a long, hard process. I gen- diction, Dr. Shelby is glad to see awareness increas- little bit about how it works and its interactions.” erally see the patients about every 4-6 weeks after ing. “Local and federal government response keeps Dr. Shelby hopes that as physicians learn they are stabilized. Even from low doses, it’s diffi- growing,” he said. He added that most recently here in more about addiction to opioids and associated cult to get off completely. Some patients may need Arkansas, legislation passed (Act 1208 of 2014) that treatment, some will consider treating patients as a maintenance dose for life. They’ve been on opioids defined chronic non-malignant pain and put in place he has. For him and his wife, helping patients like for so long it’s kind of skewed their opioid receptors requirements for physicians prescribing at levels Osean recover is more than reason enough to con- enough in the brain and they’re not able to grow new reaching that defined threshold. The Act also clarified tinue working diligently through The Shelby Clinic. ones and they’re going to need long-term treatment. the definition of an opioid to include hydrocodone, By far, most patients, once they’ve seen how addic- oxycodone, morphine, codeine, heroin, and fentanyl. “The cycle of obsession and compulsion that tion can mess up their lives, they’re anxious to stick needs to be broken in order for an addict to stand Organized medicine is responding, too, accord- to the program.” a chance at recovery doesn’t happen overnight,” ing to Dr. Shelby, who has credited the AMA for put- reflects Osean. She credits Dr. Shelby and his wife Ideally, they don’t go it alone. ting the word out to its membership of the serious- for having the love and patience to care for her ness of prescription drug abuse in the . Successful treatment is two-fold, both physi- through that cycle, which can take months or years. ological and psychological, Dr. Shelby emphasized. Here in Arkansas, there’s much going on. Dr. “Addiction treatment is not for the faint of , For this reason, he requires that patients participate Shelby commended the AMS and the Arkansas State but Dr. Shelby has dug in his heels. He sees people in some form of outside counseling or 12-step pro- Medical Board for increased awareness of the prob- through thick and thin. It is obvious how much he gram in addition to their buprenorphine treatment. lem and praised UAMS for its related efforts, too. cares. What he and physicians like him are doing “Without that, it generally won’t work. The FDA re- During the recent AMS annual session, Dr. Shelby through Suboxone® treatment impacts lives in tre- quires that, and studies show that for someone to be stated, “At UAMS, Dr. Richard Smith, former dean of mendous ways.” successful in this type of treatment, they need help, the School of Medicine and professor of , The Shelby Clinic is located at 1801 Central so that when they experience stressors in their lives, and Dr. Rahn, the chancellor, have both taken an Avenue in Hot Springs. For more information about they can learn ways – besides opioids – to deal with interest in the educational process, particularly in the clinic and its treatment methods, contact Dr. those stressors.” training new physicians (and retraining current phy- Shelby at [email protected]. “For me, a real change occurred when I used sicians) on the seriousness of prescribing opiates.” Suboxone® coupled with a 12-step program,” said Smith later confirmed. “UAMS is committed SUGGESTED READING: Osean. “Drugs aren’t the problem, it’s really an in- to helping physicians safely and effectively reduce http://www.Suboxone®.com ability to live life on life’s terms. But until that cycle of the overuse of prescription opioids in our state,” he mental obsession and physical compulsion is broken, stated. “Through multiple avenues, UAMS hopes to there is no hope. Suboxone® restores that hope.” be of help to doctors and their patients to deal with CDC’S GUIDELINES FOR PRESCRIBING OPIOIDS FOR CHRONIC PAIN After Suboxone® removed her cravings, Osean this perplexing problem.” (supported by AMA and AMS): was free to work with her NA and AA sponsor to deal http://www.cdc.gov/drugoverdose/ with underlying problems. “Counseling couldn’t do A FINAL CAUTION FOR PHYSICIANS prescribingresources.html that for me,” she elaborated. “There’s something Physicians of all specialties have patients for about a bunch of addicts that want to stay clean get- which they write large doses and, in some cases, ARKANSAS EMERGENCY DEPARTMENT ting together to see what we can do for each other. have for a long time. Sometimes opioids are needed, OPIOID PRESCRIBING GUIDELINES: That said, the 12-step program wasn’t enough. To Dr. Shelby understands, but he feels that prescribing healthy.arkansas.gov. keep me clean for long periods, I needed both, and I them must be an informed decision.

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