Last week I admitted a pregnant patient to one of the opioid treatment centers where I work. She’d only been using for about three months, but had physical withdrawal symptoms, and had more than eight years of intermittent physical dependence. She had a successful pregnancy while on methadone four years earlier, and she knew she’d be at risk for miscarriage if she tried to stop using opioids on her own and went into withdrawal. She also knew herself and her addiction well enough to be afraid she’d relapse even if she was able to stop using opioids in early pregnancy.
She’d been getting prenatal care, but hadn’t told her obstetrician she was addicted to opioids. She’d been struggling on her own, too afraid to tell him about her problem. She was also afraid to tell him she came to our program to get help, but I insisted he needed to know.
Foolishly, I downplayed her fears.
“Oh, I think he’ll be happy you’re getting the treatment you need. As you know from your last pregnancy, forty-plus years of research show better outcomes for the mother and the baby if the opioid-addicted mother is on methadone. And now we have buprenorphine.” Due to recent studies that showed lower severity of neonatal abstinence syndrome in babies born to women on buprenorphine compared to methadone, we decided to start her on buprenorphine, sometimes better known under its brand names Subutex and Suboxone.
She looked at me warily. “You don’t know Dr. B. He hates methadone. He hates this place. He’ll hate Subutex too.”
I smiled reassuringly. “I’m pretty good at talking to other doctors who have concerns about treatment for pain pill addiction. I can give him some information that might help him change his view.” I keep my office stocked with SAMHSA (Substance Abuse Mental Health Services Administration) brochures for medical personnel, law enforcement personnel, and concerned citizens, describing medication-assisted treatment with methadone and buprenorphine and addressing many of the misconceptions people have about these medications.
She was hesitant, but said, “OooooK. I’ll sign a release. I can’t wait to hear what he says. I don’t want to be the one to tell him. He’ll yell at me.” Surely she was exaggerating, I thought.
Later that day, I called Dr. B. Perky as a robin, I said I was calling to touch base with him, to inform him his patient had been fearful and ashamed to admit her addiction, but she did the right thing by seeking treatment, and had decided to start on buprenorphine. I asked if he had any questions or concerns we needed to discuss.
He was not pleasant. “Concerns? Concerns? You bet I have concerns! You people have put five of my patients on that crap. You don’t even call to tell me you started them on the medication! And one of them had been taking opioids for two weeks! Two weeks! I’m…”
I interrupted, “I didn’t start anyone who had been using for two weeks. And I can’t call you until the patient gives me permission to call….”
“You put patients on that crap and you don’t even care about those babies in withdrawal! It’s pitiful!”
As politely as possible, I interrupted. “Is it possible you don’t know that methadone, and now buprenorphine, are the treatments of choice for opioid addicted pregnant women? I can send you some review articles and…”
“You’re not gonna change my mind! All your articles were written by your kind anyway…” (I wondered to myself what kind did he mean? The educated kind?)
“Actually, the articles were written by neonatologists and are in the obstetric literature…”
As he was ranting, I scurried to get a pen and paper, because I wanted to write down his words verbatim. Even as I was being yelled at, I was thinking about how this was going to be good material for my blog.
“You’re not gonna change my mind! You just want their Medicaid! You just get them in there every day to punch their card and make money! You…”
“Um, we don’t bill Medicaid.”
“I don’t care! You just want the money!” (I didn’t ask him if he worked for free)
I trudged on, trying to give him information. I told him how withdrawal places the mother at higher risk for complications like miscarriage, placental abruption, low birth weight…things he should already know….and then he said an even more amazing thing: “I don’t care. That doesn’t matter. My patients aren’t gonna take that crap. Let me tell you now, if my patients become your patients, they won’t be my patients any more. I’ll fire them from my practice.”
He spouted on, completely ignorant of the gold-standard, state-of-the-art care for opioid-addicted pregnant women. As he was squawking, I periodically waxed eloquent, repeating, “Wow,” over and over again.
At some point I realized I wasn’t going to be able to educate this doctor. How sad. He didn’t have the facts, but it didn’t prevent him from having a strong, implacable opinion. This doctor’s lack of information and closed-minded refusal to consider facts instead of personal opinion show the extreme prejudice some patients face in my area of the country, even from their own doctors.
“You’re telling me that this patient can’t come to see you anymore?”
“That’s right! I don’t believe in that crap. She shouldn’t be on it……” and he was off again, now telling me how evil I was to be prescribing methadone. Apparently he didn’t hear or didn’t care that I had prescribed buprenorphine in this case.
“OK. Thanks. I’ll tell the patient.” And I got off the phone.
It’s not much of a victory, but I didn’t resort to obscenity, name calling, or even raise my voice. I remained relatively calm, while Dr. B spewed.
Once off the phone, I felt tired, sad, drained. How long will the medical profession remain in the dark about all the evidence supporting medications like methadone and buprenorphine? These medications are by no means the only treatment for opioid addiction, and they aren’t the best treatment for every opioid addict, but this medication saves lives and helps addicts live more normal lives.
I thought about the top doctors, the experts of addiction medicine who lecture at our national meetings. Do they ever have to deal with this kind of lack of knowledge and implacability? I doubt it. Many of them work in states where the medical profession is more educated about addiction and its treatments.
So now I had to find another doctor for this patient. Fortunately, I’d seen another pregnant women a few weeks back, who named Dr. H. as her doctor. So I called Dr. H, a balm to my weary soul. I asked him if he’d be willing to take another pregnant patient on replacement medication. These are high-risk patients, on or off maintenance medication, so I was asking a favor. He said sure, he’d take them, and that he often had to take patients who were turned away by another doctor in town. I laughed and said yes, I think I may have just talked to that doctor.
I thanked him profusely for helping our patients
For years I’ve told patients on methadone and buprenorphine that they need to develop thick skins. Especially in the rural South, prejudices abound, and friends and relatives with the best intentions can make hurtful and uninformed statements to patients who are doing well on methadone or buprenorphine. Then there are the more vicious members of society who blame and shame our patients, telling them they are just going to a legal drug dealer and that they need to “get off that stuff.” I tell patients that they need to do what is right for their health, and ignore the opinions of other people who don’t approve of the medical treatment you they’ve chosen.
Today I told myself that I need to grow thicker skin, and not to let the opinions of medical professionals like Dr. B discourage me. I know I’m helping people, and I know the medical literature supports what I’m doing. I can share information with other doctors, but only if they’re willing to listen. I also try to maintain a balanced view, and not to dismiss other treatments that have data to support their usefulness. I want to remain teachable if there’s new information about a better way to help opioid addicts. But Dr. B didn’t have information, only opinions. I’m idealistic enough to believe we should base medical care on data, not opinions.
I don’t need to hide or apologize for prescribing methadone and buprenorphine.