We all have bad days and I’m no exception. Today I feel like I’d rather be back in primary care, convincing people with viral upper respiratory symptoms they don’t need antibiotics.
Ordinarily I enjoy my work with patients recovering from opioid addiction, and I still do, but today I feel tired of dealing with the stuff that sometimes comes with it.
One patient blamed me for causing her to be addicted to Suboxone. In my defense, I didn’t kidnap her off the street, pull her into my office and force Suboxone under her tongue. My consent forms, which she read and signed, clearly explain Suboxone is an opioid, and we use it as a substitute for the opioids being misused. The consent form explains that if Suboxone is stopped suddenly there will be an opioid withdrawal, possibly severe. It also outlines my office charges (less than most of the doctors in my area) and what I expect in the way of getting counseling for addiction.
I show her this form to remind her we discussed these things before she started Suboxone, but she doesn’t remember this. Says she didn’t know Suboxone was an addicting drug, and she regrets becoming addicted to it because now she’s a prisoner to Suboxone.
I reviewed with her the information she gave me upon admission eight months ago. She was snorting 150mg of oxycodone per day, just lost her job, and had a minor criminal charge relating to her addiction. Over the past two years, she’s had one brief relapse to hydrocodone use, which didn’t make her high since she was on the Suboxone, so she used illicit opioids only one day. She met a nice man, and is now engaged. She has an office job making a modest salary. She has health insurance, and has been able to get several medical matters taken care of, including extensive dental problems. She regularly participates in family outings with her parents and siblings, who disowned her during her active addiction. She’s balked at getting counseling, and has done just enough counseling to keep me from dismissing her from my practice, and did this with much grumbling.
And now she’s angry about being addicted to Suboxone. I acknowledge her feelings, and I suggest a plan to begin a taper over four to six months. She balks, saying this really isn’t a good time to come off Suboxone. She leaves after paying only half of my office charge, and says she’ll send a check for the rest.
My receptionist gets a frantic phone call from a patient who says his insurance company wants me to call them for a prior approval on his Suboxone. He’s leaving town in four hours but his pharmacy says the insurance company won’t pay unless I call, and complete a questionnaire about the medical need for Suboxone. I know he can’t afford the medication on his own and I don’t want him to be in withdrawal while on vacation. So I call his insurance company. I’m on hold for eleven minutes. I hear my next patient in the waiting room, sighing audibly. A representative comes on the line and asks me if I knew I could complete the prior authorization online, thus saving her time. I said thanks that’s nice to know but I have you on the phone now so giddy up.
She asks me why I’m prescribing Suboxone and I tell her. There’s only one FDA-approved indication to prescribe Suboxone, by the way. She asks me do I have “X” number to prescribe Suboxone. I say yes, and in fact, I put that right on each Suboxone prescription that I write, including the one I wrote for the patient in question. She doesn’t acknowledge my sarcasm and I’m glad because I know I’m starting to behave badly. I hold it together long enough to get the prior approval number, write it down and give it to June, my office manager. June calls the pharmacy with the number while I see my next patient who is peeved that I’m now 20 minutes late.
Two hours later my desperate patient calls back, angry because the pharmacy told him they didn’t have the prior authorization number yet. I overheard June call it in, so I know that’s not true. June has to call the pharmacy again, to straighten out a miscommunication between their employees.
My next patient is positive for benzodiazepines on his drug screen. He acknowledges he takes for anxiety, but he completely minimizes the risks of mixing these illicit benzodiazepines with Suboxone. He says he knows what he’s doing and he’s positively not going to overdose. He says he used to shoot heroin and take Xanax, and it never killed him. Therefore, he knows this little bit of Suboxone won’t hurt him along with Xanax.
I start to feel a twitch in my right eyelid.
I tell him I’ve known five addicts who said the same thing, all of whom are now dead of drug overdoses. My patient becomes angry because he thinks I’m being overly dramatic. I quickly check myself. Am I? No. this is potentially fatal disease and he’s not taking it seriously enough. He laughs at me until I tell him I’m not going to write for a month’s worth of Suboxone, but only one week because I’m worried about him. I tell him he has to make some changes, and give him specific options for increased counseling. He’s less than gracious and he leaves the office, but he does make a follow up appointment for next week.
My last patient is fifteen minutes overdue for his appointment. I catch up on paperwork while I wait, but at 20 minutes after, I ask June to call him. He answers his cell phone and says he’s running a little late. I have a hair appointment which I am not going to miss since my gray roots are waving at folks, so I ask June to ask him where he is. He gives a location that’s at least 30 minutes away. I tell June I have to leave, so the patient must re-schedule, plus I’m going to charge him for a missed visit. She relays this to him, and I hear him shouting at her.
I snatch the phone away from her and our conversation quickly deteriorates. He accuses me of being “all about the money.” I find this particularly insulting, since I worked to get him free medication from the drug company that makes Suboxone. Granted, it’s not coming out of my pocket, but still, I did make that extra effort for him. He tells me he’s going to see a doctor who is more reasonable and I say that’s a good idea.
It’s enough to make Gandhi want to bitch slap someone.
I’m gonna get my hair colored now.