This Should Never Happen

One of my long-time patients had a problem last week. I prescribe buprenorphine/naloxone 8/2mg tablets, 2 per day for a total of 16mg for her. She’s been in recovery from opioid use disorder for over six years. She keeps her appointments with me, takes her medication as prescribed and is doing well, despite some recent mid-life stresses.

Unfortunately, while walking her dog, she fell. She had immediate leg pain but thought it was only a pulled muscle or tendon. She wasn’t keen on going to the emergency department, so she waited a few days and saw her primary care doctor. The doctor ordered an X-ray of her leg which showed a femur (thigh bone) fracture. She sent her to the hospital right away and the orthopedic surgeon admitted her.

She had surgical repair the next morning, with the placement of an intramedullary rod down the length of the femur, held in place with screws. She was sent home that night and her surgeon prescribed oxycodone and some other medications.

So far so good.

But when her significant other went to pick up her medication at the pharmacy, the pharmacist refused to fill the oxycodone. The only explanation she provided was that she felt uncomfortable dispensing it because she knew this patient was prescribed Suboxone by me.

This pharmacist didn’t call me, though. I knew nothing about all of this until the patient called my after-hours number to explain the situation. The patient said she’d already contacted her surgeon, who had called the pharmacist to ask her to fill his prescription, but she still refused.

No problem, I told the patient, after getting her description of what happened. I’ll call the pharmacist, explain the situation, and describe our treatment plan.

Ordinarily I would continue the patient’s dose of buprenorphine/naloxone at 16mg per day, or perhaps drop the dose down to 4mg per day while she was taking the oxycodone, but she had missed her usual buprenorphine/naloxone for the last two days, what with going to her primary care doctor, then the hospital, then having surgery. So, I told the patient to stay off the buprenorphine/naloxone until she no longer needed the oxycodone, and then we would re-start the buprenorphine.

I didn’t think I’d have any problem explaining our plan to the pharmacist.

I was wrong.

This pharmacist was frosty from the start. She wasn’t rude, but she wasn’t friendly.

I started by saying, “Hi this is Dr. Burson and I’m calling about patient X. She’s just had surgery on her leg and his surgeon sent a prescription for oxycodone. I have been treating this patient for years for opioid use disorder and we have worked out a plan for pain control post- op and we…”

“I have the right not to fill this prescription.”

Caught off guard and only halfway through my explanation, I stopped. “Uh, what?”

“I have the right to refuse to fill this prescription. After all, it’s my license on the line too.”

“I don’t know what that means. But I can tell you that I am an Addiction Medicine specialist and I’m telling you it is OK to dispense this medication and we have a plan in place for her significant other to hold the pill bottle…”

“This patient has been on Suboxone for many years.”

“Yes, I know. If you will look at your records, I’m the one prescribing it.”

“I don’t feel I should fill the oxycodone.”

Like a light switch turning on, I felt suddenly angry. My tone changed. My voice raised, I said, “SHE BROKE ….  HER LEG!” I could see my husband glancing at me, knowing me well enough to see I was about to get salty.

“Ma’am I am aware of that…”

“It is unethical for you to refuse to fill this prescription! Don’t you know that just because someone has the disease of opioid use disorder, you can’t deny them pain medication to treat painful acute conditions like a broken bone??”

“I have already spoken to her surgeon and explained I don’t feel I should fill this opioid prescription.”

“And what did he say?”

“He wants me to fill it, but I told him I would not.”

We went back and forth in that vein for a few minutes, until I saw it was futile to talk further.

“What is your name?”

She gave it to me as I wrote it down with hands shaking with anger.

It was getting late on a Friday night, and the surgeon had to send my patient’s oxycodone to another pharmacy. They were about to close for the night, so she couldn’t send her significant other to pick up her prescription until the next morning.

This patient went over twelve hours, fresh out of surgery, without the pain medication that her surgeon prescribed, and that an addiction medicine doctor (me), who knew the patient very well also agreed she needed, all because a pharmacist was worried about her license if she filled it.

I wanted to report this pharmacist to the North Carolina Board of Pharmacy but after I cooled down, I changed my mind. For whatever reason, she was afraid. She needed information and education. For whatever reason, I couldn’t provide this. She was more likely to listen to another pharmacist. Thankfully, I’m acquainted with a pharmacist who works with the North Carolina Association of Pharmacists. She is knowledgeable about MOUD and part of her job is educating pharmacists. I emailed her and asked if she’d be willing to help. She said yes, of course, and I sent her the contact information.

I felt angry I couldn’t help my patient, and that she had to wait on her pain medication.

This didn’t happen in the rural community where I work at an opioid treatment program. It happened where I have my own practice, where I see patients with opioid use disorder. My office-based practice is in an upscale community known to be progressive. It’s a bedroom community close to an urban area. If it can happen in this location, it can happen anywhere.

My patient is doing well, and her leg is healing. This is the most important thing.

But denial of appropriate medication for acute pain should not happen to this patient or anyone else.

Testing testing testing…for Opioid Use Disorder

As I was pondering what in the world I could write about in my next blog post, a friend sent me an article from the Washington Post about a genetic test that’s just been approved by the FDA. The test, done with a cheek swab, looks at genes in fifteen locations to determine genetic risk for developing opioid use disorder.

https://www.washingtonpost.com/health/2024/03/25/dna-test-opioid-addiction

This test, called AvertD, is manufactured by SOLVD Health, a company located in Carlsbad, California, and the FDA approved the test this past December.

The test is not without controversy. In fact, in 2022, a committee of advisory experts voted against approval of this test, by 11 to 2, but the FDA approved it anyway. The FDA panel of experts who voted against approval were worried about misuse of the test. They worried providers might decide not to provide opioids because of a test that tells only if a patient is at increased risk for developing opioid use disorder. Some went so far as to call the test a “sham” and accused the company of profiteering off exaggerated fears of opioid use disorder.

Scientists have known for years about genetic variants that place people at increased or decreased risk for opioid use disorder. Over time, we’ve accumulated information from genetic studies that shows that roughly half the risk of developing opioid use disorder is due to the genetics we inherit from our parents. This is roughly the same as found in other chronic illnesses like hypertension and diabetes.

For one example, variants of the mu opioid receptor gene, called OPRM1, regulate the expression of the opioid receptor. These variants, called polymorphisms, are associated with either increased risk of developing addiction or decreased risk. These polymorphisms also influence how patients respond to treatment medications such as buprenorphine and methadone.

This means the other half of the risk of opioid use disorder is environmental. We know many of these risk factors too. For example, children who experience traumatic events are markedly more likely to develop substance use disorders of all types, including opioid use disorder. We know that people with mental illnesses have increased risk of developing substance use disorders. We know of a great many other environmental factors that increase or decrease risk.

I say all of this to educate my readers about what we know so far about causes of opioid use disorders. It’s a complex disorder with many causes, both genetic and environmental.

So how helpful is this test of fifteen gene sites?

The package insert for this test says, “Information from AvertD™ provides patients 18 years of age or older and healthcare providers with objective information to be used for informed decision-making prior to the first prescription of oral opioids for acute pain.”

The statement in AvertD’s package insert bothered me, because it says the test is intended to provide data to patient and provider prior to the first prescription for acute pain.

That feels unethical. For one thing, it would take time to get this test result back, so it would only be useful for things scheduled in advance, like surgery. And if the patient having surgery takes the test and is found to be at high risk for opioid use disorder, is it ethical to deny opioids postoperatively?

I don’t think so. The provider could be cautious, and prescribe opioids for only a few days, but in our state there’s already a law that limits the amount of post-operative opioids, so how much value would this test add?

Also, how would you feel as a patient, if your test shows your genetic makeup puts you at high risk for opioid use disorder? Would you worry about being denied opioids in the future, based on this test? You should worry.

Times have changed. Twenty years ago, when physicians treating chronic pain with opioids were practically throwing pill bottles of OxyContin at patients, physicians should have been more cautious about their prescribing. They should have been asking about risk factors for opioid use disorder, such as family history, trauma history, and so on.

But now, physicians have clung to a pendulum that’s swayed too far in the other direction. A patient with a broken leg can barely pry a few hydrocodone 5/325mg tablets out of an emergency room doctor’s sweaty hand when being seen for their injury.

I’d love to see a prospective trial of AvertD testing compared to taking a careful history with attention to family history of substance use disorders, just to see which technique fared better at predicting later opioid use disorder. Taking patient histories isn’t as glamorous as genetic testing but what if it’s more predictive?

I’m also guessing the AvertD test will not be cheap. I looked on AvertD’s website to see if I could get that information, but it’s still under construction.

So my questions about this test are:

-is this test more predictive than taking a careful medical history?

-and how much does this genetic test cost?

-will it be used to deny patients opioids for situations that we know are painful?

-will patients identified by the test as genetically low risk for opioid use disorder be given more opioids than usual, thereby placing them at higher risk?

-what will insurers make of this data?

Getting more information about the genetics of opioid use disorder is interesting, and probably useful at some point. However, the science might not be ready for practical use at this time. In the Washington Post article, one the people they quoted who was worried about the practical application of the test said that genetic testing was an “under-developed technology.”

I think that’s a great summary. It might be great…but it might not, and it could be used unethically. Testing gives us data, but do we have the wisdom to apply the data?

Meanwhile, how about looking to change those environmental factors that we know increase risk? Environmental factors should be more amenable to change than genetic factors. Let’s work to reduce the incidence of childhood trauma, for example. That feels like low-hanging fruit compared to evaluating – and mitigating – the risk contained in genetic material.

SAMHSA’s “Medications for the treatment of opioid use disorder: Final rule”

I’ve been doing some light reading: from the Federal Register Vol. 89, No. 23 Friday, February 2, 2024, Rules and Regulations. It is titled “Medication for the Treatment of Opioid Use Disorder” and runs from page 7528 to 7563.

These new rules from SAMHSA apply to treatment provided at opioid treatment programs and are due to go into effect on April 2, 2024.

This document contains historic changes.

Overall, the tone is much more patient-centered and advocates for more provider autonomy to do what is best for each patient, rather than listing a set of rules about what providers can and can’t do for patients at an opioid treatment program. These rules repeatedly mention how patients should participate in decision-making with their provider.

Here are some of the most interesting to me.

First of all, regarding treatment initiation, patients who meet the diagnostic criteria for opioid use disorder moderate or severe no longer have to meet the one-year daily use requirement. In the past, a patient with severe symptoms who had daily use of less than one year could still be admitted to the opioid treatment program, but we had to request an exception from CSAT before we could give the first dose. That didn’t take much time, but it could delay initiation of treatment by a day.

Also, people under the age of 18 no longer must fail two abstinence-based treatment programs before they can be admitted to the opioid treatment program. Because of the reduction of overdose death rate in these adolescents, they can be admitted and started on buprenorphine or methadone at the OTP.

Providers no longer must see patients face-to-face to start methadone at the opioid treatment program. Telehealth is sufficient if they use both audio and visual components that function well enough to satisfy the provider that information being transmitted is adequate. The rules go a step further for buprenorphine admissions: a patient can be admitted with audio only and no visual component of the assessment.

This is epic. Even during the pandemic, providers were not allowed to admit patients onto methadone using telehealth, so this is a big reversal of rules.

Starting dose on the first day of methadone treatment can be as high as 50mg.

Honestly, I thought this was a little nutty but maybe not. Since 2001 providers could give as much as 40mg on the first day but it had to be in divided doses and 30mg was the highest one-time dose. But the new rules allow a total of 50mg on day one and don’t come with any caveats or instructions. If I wanted to give a brand-new patient a dose of 50mg, I could.

But I don’t think I will.

I can’t say I would never do this…but I can say it would be very unusual for me to think this was in the patient’s best interest.

Regular readers of my blog will know I’m careful about methadone induction due to a series of methadone deaths we had at a program I worked for twenty years ago. It was a different time, and patients back then were more likely to use benzos in combination with the opioids they were prescribed. We had no prescription monitoring program (until 2007) to see what other medications our patients were getting. Those rural counties were awash in benzos and OxyContin.

At that program, which had eight or so different locations, we had four lawsuits filed by families of patients who died during methadone induction. I was fortunate I wasn’t named in any of the lawsuits, but two of my very good colleagues were. I saw them go through difficult times as their reputation and judgments as physicians were brutally questioned by the plantiffs’ lawyer (the same lawyer brought all four cases). Three of the deaths involved starting doses of 40mg and advancing by 5mg per day, and one patient was started at 35mg instead of 30mg and died on day 4 after increasing her dose by 5mg daily.

I remember the plantiffs’ lawyer explaining, with lawyer logic, that the physicians should have started methadone at a dose of 5mg per day, which was preposterous. The cases were settled out of court against the physicians and the opioid treatment program.

Times are different now and fentanyl is killing even more people than OxyContin did back in its prime. Maybe higher starting doses are indicated. I’ve loosened up some around my prescribing habits, but only because I can see new patients much more frequently during induction than I could twenty years ago.

 I like to see new patients on the first day and then several times during the first two weeks so I can ask them about sedation and continued fentanyl use. I frequently prescribe an extra increase when I see them, to get their dose up more quickly.

But it makes me nervous.

I don’t want anyone to die. And I don’t want to kill anyone.

Back to the SAMHSA rules…

The most striking changes were in the number of take-home doses allowed under the new rules:

Patients in treatment from zero to fourteen days may receive up to 7 unsupervised take home doses of methadone.

Patients in treatment from 15 to 30 days of treatment may receive up to 14 unsupervised take home doses of methadone.

Patients in treatment for 31 or more days may receive up to 28 unsupervised take-home doses of methadone.

Prescribing a week of take homes to a new patient feels risky to me. Could I increase the dose during the week? Or would they be stuck at one dose for the whole week? How could I know how the patient was responding to the dose I selected?

Maybe these new guidelines are meant to make things easier for patients in supervised facilities like jails, prisons, or halfway houses. In these settings there’s sometimes supervision for dosing.

Also remember that just because a higher number of take homes is allowable does not mean it is recommended for all, or even most patients. Also remember that the risk of take homes for buprenorphine products is much lower than for methadone, due to the pharmacology of both medications.

Here are the other criteria to consider when deciding take home doses:

1. “Absence of active substance use disorders, other physical or behavioral health conditions that increase the risk of patient harm as it relates to the potential for overdose, or the ability to function safely.”
2. “Regularity of attendance for supervised medication administration.”
3. “Absence of serious behavioral problems that endanger the patient, the public, or others.
4. “Absence of known recent diversion activity.”

5. “Whether take home medication can be safely transported and stored.”
6. “Any other criteria that the medical director or medical practitioner consider relevant to the patient’s safety and the public health.”

In the past, methadone initiation required daily dosing for extended time (3 months). This interfered with employment, educational activities, and other life activities. It discouraged people from enrolling at OTPs. These new changes allow medical providers more room to personalize treatment, but we must know our patients very well to make the best decisions.

Rules about split dosing changed, in that there are no rules for split dosing after these changes take effect April 2, 2024. Providers no longer need to submit exceptions to get permission to split a patient’s total dose into a morning and evening dose. Once daily dosing works well for most patients, but one or two percent of the population have the genetics that make them rapid metabolizers for methadone. Those patients usually feel better with split dosing. These new regulations no longer require that peak and trough levels be drawn to demonstrate this fast metabolism, but probably are still a good idea.

The new regulations really took a jump from what felt to me like overly restrictive, to what now feels like too loosy-goosy. But is that just my natural disinclination towards change, which is perfectly normal, or are these regulations really too loose?

Time will tell. I think to do the best job for patients means I will need to get to know them even better and rely on the other people at the OTP to know them well, so we can make the best choices.

A Tale of Two Patients

Please note that I have changed details of these patients’ stories to protect their identities, but the underlying facts are true.

Two patient experiences were so opposite; one had the kind of interaction with our medical community that we dream about. The other had the opposite.

I’ll tell the success story first.

A person with opioid use disorder decided she was ready to enter recovery. She went to see her primary care provider, who was knowledgeable about available treatments, though she did not prescribe buprenorphine. This nurse practitioner called the local non-profit recovery organization, and she also called EMS.

Why did she call EMS? Because a special EMS team now works with a peer support specialist to meet with people seeking treatment for opioid use disorder. They are prepared to start buprenorphine in the field, or in this case, at the doctor’s office, to help the patient. I described this program in my blog dated June 19, 2023. It was funded by the opioid settlement money through our county, and the money didn’t get released until recently, but it is now up and running. So far, I am delighted with the work they are doing. This can be an enormous benefit to our community.

Their protocol is to meet with the patient each day to provide a dose of buprenorphine and monitoring for side effects until the patient can get an appointment with a buprenorphine provider.

The EMS team met with this patient on Friday, Saturday, and Sunday. The first thing on Monday morning, she was at our opioid treatment program and got enrolled in treatment. She meets with her counselor weekly and made a plan for what she wants to accomplish in treatment. She’s on a stable dose of buprenorphine and is getting some take home doses already.

Everything went so well.

Now for the not-so-good patient story:

I’ve been hoping the emergency departments of the hospitals located in small towns in our area would start prescribing buprenorphine, as a bridge to get them into more permanent treatment.

As I told our Program Director, the good news was that one emergency department doctor prescribed buprenorphine… but the bad news was… it was one of our methadone patients. Predictably, he got very sick.

It’s a complicated story, but the patient has been in treatment at our opioid treatment program for several years. We thought he was doing well. During the pandemic we advanced his take homes to monthly, so we weren’t seeing as much of him, but he kept his scheduled counseling appointments and even passed a bottle recall.

When I talked to him much later, he said he was going through a particularly stressful time in his life. While under stress, he started sipping on his next day’s dose of methadone, taking extra medication. He was dosing at 160mg and started taking an extra ten or twenty milligrams. This got worse, to the point he was drinking two bottles of 160mg per day, then running out at the end of the month. He says he got some methadone from people he knew. He didn’t consider telling me or his counselor at our opioid treatment program because he knew he’d lose his ability to get take homes.

One weekend, out of medication and in withdrawal, he was desperate enough to go to the local emergency department. He asked the doctor there to start him on buprenorphine. He said he was sick of trying to take his methadone correctly – and failing – and thought since he was already in withdrawal, he could start buprenorphine.

I haven’t heard of emergency department doctors at this facility to initiate buprenorphine, but this one did. He documented that the patient had not taken any methadone in seventy-two hours, that he was in significant withdrawal, and administered a dose of buprenorphine 4mg to the patient.

The patient later told me that the ER doc told him he had called me and coordinated care with me, but that certainly never happened. I saw no mention of this in the chart when I reviewed it. Maybe the patient misunderstood, maybe the ER doc called someone else, but he didn’t call me or anyone at our facility.

Long story short, he was given buprenorphine 4mg and he got very sick with immediate onset of abdominal cramps, muscle aches, increased blood pressure and heart rate. The buprenorphine caused precipitated withdrawal.

At the opioid treatment program, about half our patients are on methadone and half are on buprenorphine. We have much experience switching patients from one to the other. We know what will work and what is likely to cause withdrawal.

For comparison, when we switch patients from methadone to buprenorphine, we lower the dose by 5mg per week until they are at 30-40mg and stay at this dose for about a week. Then we ask that they miss two days, and we start buprenorphine on the third day. It usually goes smoothly.

Alternatively, we can start low-dose buprenorphine, which I have blogged about before.

But this patient was taking up to as much as 320mg per day on some days, then going several days without. True, he had been 72 hours without methadone and was in withdrawal, but his body was still used to a high methadone dose and the conversion to buprenorphine wasn’t likely to work, done in this manner.

The ER doc, seeing the patient in withdrawal, wanted to give additional doses of buprenorphine. This made sense, since some experts say that if the patient gets precipitated withdrawal, you can pull them back out of withdrawal with additional doses. But the patient, who was feeling miserable, said no thanks and left.

Then next week at the opioid treatment program, we noted this patient had buprenorphine in the urine drug screen and his counselor asked him why. That’s when the patient came to meet with me and told me all that was happening.

I thought that took a lot of courage.

I listened to all of it: his stress, the frustration at not being able to take only one methadone dose per day, and the fear he had of being cut off of methadone.

I told him I was sorry he had been through such a bad time. I told him I knew it took a lot of courage to tell me everything that happened, and that we could figure out how to proceed. I asked if he still wanted to switch to buprenorphine and he emphatically said no that he wanted to stay on methadone, but he felt like it wasn’t going to be enough for him anymore.

I told him I wasn’t sure if that was the case. His body had endured a lot, and his dose had been topsy turvy for so long I didn’t know what dose he needed, but I knew we could get him back to normal. I asked him to dose at the opioid treatment program for at least five days at his usual dose of 160mg, then meet with me again.

That’s what we did. Thankfully when I saw him five days later, he said he felt back to normal. He said he felt better not having take home doses and was relieved not to have to struggle not to take his dose early anymore. He said it was like “the devil got on me” and kept telling him to take doses early, but now with no take homes he didn’t have to worry about that.

He felt he could manage one take home bottle for Sundays and that’s what we did for the first month.

Recently I met with him again and asked how he was doing, and he said much better. He resumed doing the things that brought him stability and comfort in the past: he spent time with supportive relatives and backed away from abusive relatives, and got involved in his church again, and was more patient with himself.

He said he thought he could handle Saturday and Sunday take homes, but I suggested we try Sunday and one other weekday, so that he wouldn’t have two in a row. We’ll try that for a month or so. I told him he could expect that we would do bottle recalls to give him accountability and he was fine with that.

I think he’s made progress in his recovery, though he went through hardship to get it. I plan to continue to see him periodically and we will carefully advance his take homes but with more attention and accountability than we have in the past.

So that’s how the not so good story appears to be ending better than I feared.

I talked to the Program Manager at our opioid treatment program, and she called a friendly person at the local hospital. We offered to do a “Lunch and Learn” with any/all Emergency Department personnel.

This “Lunch and Learn” is something we’ve done many times in the past. We order food and invite whatever group to come and take a tour of our facility, eat lunch and listen to me give a little presentation on medications for opioid use disorder treatment. That’s what we did with the EMS team last summer, with excellent results. I try not to talk for very long, so we can hear the group’s questions, information, and suggestions, to make it collaborative.

We’ve done this for the Labor and Delivery department of one local hospital, for our county’s probation and parole officers, for the county commissioners, for local mental health providers, and the like. Usually, it goes well.

We will see what happens with our invitation this time.

Urgent Situation for Buprenorphine Patients

  Ukrainian art by Anastasiia Grygorieva

We have an urgent situation afflicting rural areas in North Carolina and across our nation. Patients new to buprenorphine treatment can’t find pharmacies willing to fill their prescriptions.

Here’s the problem:

Last week I tried to switch a patient from dosing on buprenorphine at the opioid treatment program (once every 28 days with 27 take home doses) to filling a prescription for the same medication at a community pharmacy once per month. In other words, he was transferring from dosing under the OTP license to our office-based program allowed under the DATA 2000 law.

This patient has been doing very well for many months and just got insurance which makes it cheaper for him to fill his medication at a pharmacy. This means – or was supposed to mean – that he would have more freedom and flexibility in his treatment, as he could get his medication at a pharmacy once a month when it was convenient for him, rather than having to come to the OTP on a set day every 28 days.

I met with the patient and sent his prescription to his preferred pharmacy, for buprenorphine/naloxone 8/2mg tablets, #30 with no refills.

He couldn’t get it filled at that pharmacy or any other.

The original pharmacy, small and independently owned, said they couldn’t accept new patients wanting to fill buprenorphine products. He called two Walmart pharmacies in two small towns, one Walgreens, and another small family-owned pharmacy. He was told the same thing by each: they could not accept new buprenorphine patients because they couldn’t get buprenorphine products to fill them.

In a panic and starting to go into withdrawal from missing a day of dosing, he called back to our opioid treatment program. I got on the phone with him and told him to come to the OTP and we will make sure he gets his dose. In the meantime, I called pharmacies to see what their issue was.

Earlier this month, I wrote about why primary care providers don’t want to prescribe buprenorphine products for their patients with opioid use disorder. Now we have another hassle to add to the burden of prescribing, which is finding a pharmacy able to fill prescriptions for buprenorphine products of all types. I’ve written about this problem in the past, in blogs late in 2023, but the problem seems to be getting worse.

I called this patient’s first choice pharmacy. I knew the pharmacy manager there, and I knew she was smart and savvy, and has helped our community in the past by advocating for Narcan access. She’s also participated in grant programs for patients prescribed buprenorphine/naloxone. I knew she understood how essential buprenorphine is, and that it is lifesaving.

I called her, and asked what was happening. She was apologetic, and said she knew this created an obstacle for patients to get treatment, but that if she took more buprenorphine patients, she wouldn’t be able to fill the prescriptions of her existing patients. I appreciated that, since some of them are also my patients, and I don’t want them to have problems either.

I asked her why she couldn’t get buprenorphine products. She said she could order them, but she wouldn’t get extra from the distributor. She said each pharmacy was limited in the number of controlled substances they can sell, and they must maintain a ratio of the controlled substances to non-controlled medications that they sell.

I thanked her for her time and efforts but remained puzzled about this situation. She wasn’t blaming the DEA or the distributors, and clearly believed that she was unable to receive more buprenorphine from her distributor.

I searched online for explanations for this bottleneck for buprenorphine supply. I already knew that some pharmacies didn’t order much buprenorphine because they worried it would be a trigger for a DEA inspection, but this pharmacist wasn’t concerned with the DEA.

Patients are facing this difficulty across the U.S.

I found a document titled “Policy Priority Roundtable Summary Report,” published by SAMHSA, from a two-day meeting held in the fall of 2022. This meeting’s participants were leaders from governmental agencies such as the Department of Health and Human Services, Centers for Disease Control, National Institute on Drug Abuse, the ONDCP, and state agencies of Health and Human Services. There were representatives from top universities, from treatment programs, from organizations such as the American Society of Addiction Medicine, the National Alliance of State Pharmacy Associations, and the American Pharmacists Association. There were several representatives from the DEA and two from the drug company Indivior, which manufactures the name brand Suboxone.

I did not see any representatives from the big distributors – Cardinal, Amerisource Bergen, or McKesson – but I did see a representative from the Healthcare Distribution Alliance. After going to their website, it seems likely they could have represented the distributors.

Anyway, people from all these organizations got together and talked about why there are limitations on access to buprenorphine in community pharmacies. They came up with five broad reasons why patients have trouble accessing buprenorphine: stigmatization, patient barriers, classification of buprenorphine in the same category as other opioids, fear of violating threshold rules, and pharmacies losing money of dispensing buprenorphine prescriptions.

The stigmatization we’ve known about for years. Some pharmacists fear dispensing buprenorphine because they think it has high street value and suspect patients sell this medication on the black market. Pharmacists may believe that providers ought not prescribe buprenorphine since this is only replacing one opioid with another. They fear buprenorphine dispensing will bring an undesirable element to their pharmacy or get a bad reputation if they dispense opioids for known drug addicts.

For patient barriers, the problems they list have been discussed in the past, such as pharmacists refusing to fill out-of-town prescriptions or telehealth prescriptions. And some pharmacies will carry only one type of buprenorphine, which forces the physician to change formulations. Some problems relate to early refills.

Some panel participants felt the problem lies with treating buprenorphine as just another opioid, despite it being a schedule 3 instead of schedule 2 like most other opioids. Pharmacies and distributors cap the amount of controlled substances that they distribute and fill, and buprenorphine is lumped in with the more dangerous Schedule 2 opioids.

Participants felt pharmacists feared violating the rules, and that a high number of buprenorphine prescriptions filled meant they would be subjected to extra scrutiny.

Lastly, participants felt the significant regulations regarding storage and paperwork, combined with low reimbursement meant pharmacies lose money on buprenorphine prescriptions.

Really? Surely it doesn’t take more storage and manpower hours for buprenorphine as a Schedule 3 than it does for Schedule 2 opioids? But I know nothing about the reimbursement rates.

This document left me scratching my head. Certainly, this panel discussed obstacles for patients trying to fill buprenorphine prescriptions. But when I talked to this local pharmacy manager, she didn’t have any qualms about filling buprenorphine. I didn’t have to convince her of buprenorphine’s benefits because she already knew about them. She had no worries about the DEA. She knew me and I assume she would have voiced her concerns if she felt I prescribed in a careless way.

Her problem was that she could not get buprenorphine from her distributor.

In other words, none of the causes listed in the paper describing this panel’s conclusions really fit this situation, except for this statement: “Because pharmacies and distributors cap the total amount of controlled substances distributed, this limits the amount of buprenorphine that can be distributed.”

The big distributors – McKesson, Cardinal Health, and AmerisourceBergen – got spanked hard in the Opioid Settlements. Along with Janssen Pharmaceuticals, these companies were ordered to pay $26 billion to settle the lawsuits against them brought by state and local litigants.

These companies were sued because they “…flagrantly and repeatedly violated its obligation to notify DEA of suspicious orders for controlled substances…” as one document pronounced. In other words, they were taken to task for distributing millions of OxyContin pills to small towns with populations of a few thousand people. (I might be exaggerating but you get the idea).

Are these distributors now being a little stubborn about distributing buprenorphine and other opioids as retribution? I don’t know, but I could understand them being a little cranky about the issue. I have no way to know if this is a factor. But doesn’t it seem as if it might be? Doesn’t it feel like human nature for the distributors to be a little maliciously compliant with DEA rules now, after getting fined such a large amount?

There was an interesting article in the New York Times – https://www.nytimes.com/2023/03/13/us/drug-limits-adhd-depression.html  that gave some interesting insights into this problem, written nearly a year ago. In the article, pharmacists talk about hitting some threshold for ordering opioids and then getting cut off from ordering more. The trouble is, they don’t know what that threshold is.

In the end, we moved my patient back to treatment under the opioid treatment program. He will go back to dosing once every 28 days with us, then get take homes for 27 days. He’s done well with this strategy for months so I hope that will continue.

What do I do for the next patient that wants to get his buprenorphine product filled at a pharmacy? Fortunately I can quickly and easily admit these patients into the OTP…but present distributor policies appear to be limiting the pharmacy option.

Why Don’t Primary Care Providers Prescribe Buprenorphine Products?

Many people in the U.S. have untreated opioid use disorder. Some sources estimate there are as many as three million people in the U.S. with opioid use disorder, and only ten to twenty percent access evidence-based treatment with opioid agonists. This last dismal fact hasn’t changed much over the past twenty years despite governmental initiatives to promote treatment.

In 2023, the requirement for a waiver from the government to prescribe buprenorphine was eliminated, meaning providers no longer had to take an eight- or twenty-four hour training course to prescribe buprenorphine. We all hoped elimination of the waiver would mean more primary care providers would start prescribing buprenorphine.

Why hasn’t this happened? Why don’t more providers – doctors, physician assistants, and nurse practitioners – want to treat patients with opioid use disorders?

I have some ideas:

They don’t know how.

From 1906 until 2000, it was illegal in the U.S. to prescribe an opioid to a patient with addiction with the intent to keep that patient out of withdrawal, even if it stabilized the patient. Doctors went to jail for prescribing opioids to maintain a patient who had developed an addiction. As a result, patients with opioid use disorder, called opioid addicts back then, could not receive care as part of U.S. mainstream medicine. For nearly a century, these patients were excluded from the U.S. healthcare system.

That’s a long time. Attitudes and practices don’t turn around on a dime.

For all that time, most young doctors didn’t learn much about opioid use disorder, or any substance use disorder. It wasn’t part of the job, though doctors spent much time treating the sequalae of substance use disorders.

I went to medical school in the 1980’s, and I learned much about treating cirrhosis, endocarditis, lung cancer, hypertension, atrial fibrillation…all diseases often caused by substances. But I learned little about identifying, treating, or preventing substance use disorders.

When the DATA 2000 Act was passed, doctors had a new option to treat opioid use disorder with buprenorphine, better known under its early trade names as Suboxone and Subutex.

The monumental change of U.S. law allowed by DATA 2000 was met with a giant yawn by mainstream medicine in the U.S. Who could blame them? For decades, mainstream medicine in the U.S. saw substance use disorders as moral failures. Doctors and other providers didn’t know how to treat these issues and preferred patients suffering from these diseases to go elsewhere for help.

Now, more than two decades into our opioid epidemic, we are setting records each year with the number of opioid overdose deaths. Still, the average primary care physician doesn’t know how to use buprenorphine to treat opioid use disorder and has little desire to learn.

Changes in providers’ attitudes are happening, but slowly. Younger practitioners will be better educated than my generation, since medical schools and residencies are training students about opioid use disorder and evidence-based treatments for them.

The DEA now won’t renew a license to prescribe controlled substances until the practitioner completes an eight-hour course on some aspect of substance use disorders. Since DEA licenses must be renewed every three years, and this requirement started in 2023, all providers will get at least this much training by 2026. Will it make a difference? We will see.

They don’t understand who the patients are.

I was talking to my own sweet and well-educated primary care physician. She always asks about my work, and I asked her why she didn’t start treating patients with opioid use disorder. She looked uncomfortable, and said she thought about it, but that she really didn’t want to expose her staff and other patients to that type of patient.

I told her she’s already taking care of these patients, but didn’t know it. They haven’t told her about their opioid use disorder because they’re worried she will judge them harshly, and because they don’t expect help from her with their illness.

I told her those patients were some of the most rewarding I’ve had, because I’ve had the privilege to watch them change and grow out of their addictions and into the people they were meant to be. I told her she was missing out on rewarding experiences.

Readers of this blog know that anyone can become addicted to opioids. This does not make us bad people, just sick people.

Most of my patients are ordinary people. True, I have a few “outlaw” types that I see, but they understand they can’t behave in a way that disturbs me or other patients, and I enjoy seeing them too.

My point is that my doctor didn’t realize patients with opioid use disorder look the same – are the same – as her other patients.

They don’t have time.

I worked as a primary care provider for a total of about ten years. This was a few decades ago but things have only gotten worse since then. Primary care providers are rushed to see more patients in less time. They are asked to cover many topics with their patients. For example, besides any acute illness, the primary care provider is asked to cover preventive health screening. This means talking to patients about getting tests like mammograms, PAP smears, prostate exams, bone density tests, colonoscopies, eye exams and more. Then there’s the list of recommended vaccines. Doctors discuss vaccines for influenza, updated COVID, pneumonia vaccine, shingles, RSV, tetanus, and others. Each vaccine needs a discussion about risks and benefits.

Whew. It makes me tired just thinking about all that.

Primary care providers might ask, “What makes you think I have time to screen for substance use disorders and if I find it, start treatment for it? Can’t you see I’m struggling to get it all done as it is?”

I used to be in that rat race and I don’t think I’d ever want to go back.

They don’t know how well the medication works.

This is big.

I think more primary care providers would prescribe buprenorphine if they knew how much change you can see in the patients for whom it works. Many patients make sudden and lasting life changes when given buprenorphine medication to stabilize their cravings and get rid of withdrawal. We have study after study that shows this medication reduces the risk of dying from an opioid overdose by at least three times. That’s better than almost any other treatment we do in medicine.

Of course, not all patients do well in an office-based setting and some need more intense treatment. They can be referred to opioid treatment programs for more intensive treatment. But most patients change and grow and get their lives back. It’s thrilling to watch them be able to live the life they want without opioids getting in the way. They are the ones doing the hard work of recovery but it’s nice to think maybe I had some small part in their success.

Isn’t that why people go into medicine? We want to make a positive difference. There are no bigger changes in patients than those we treat with substance use disorders.

Primary care providers were burned in the recent past regarding opioids

Several decades ago, well-meaning pain management experts, some of whom were paid by pharmaceutical companies, scolded primary care providers for being “opio-phobic.” By this, these experts meant primary care providers were too afraid to prescribe opioids, in large amounts and long-term. The experts claimed there was less than a 1% chance of a patient developing addiction, but their data was wrong. It wasn’t really even data, just information taken from one letter to a medical journal.

Primary care providers were lead down a primose path toward prescribing opioid more freely, only to learn much later that doing so can harm patients. They likely were kicking themselves for not trusting their own instincts.

Perhaps these providers are more cautious about jumping on board to prescribe buprenorphine, given how they were mislead earlier in this century by pain “experts.”

These reasons I’ve listed based on my own observations are also mentioned in studies of why U.S. medical providers do not prescribe buprenorphine.

I found an article by Huhn et al., from 2017 describing their survey of 558 physicians, most of whom had a waiver to prescribe buprenorphine (not needed after the law changed in 2023).

This study found that the top three reasons for not prescribing buprenorphine were lack of belief in agonist therapy, lack of time, and insufficient reimbursement rates. Not surprisingly, lack of belief in agonist therapy was an opinion endorsed by physicians who did not have a waiver to prescribe buprenorphine.

Most of the physicians already prescribing buprenorphine weren’t prescribing to the maximum allowed number of patients at that time. Most of these physicians cited lack of time and insufficient reimbursement as the main reasons they had not accepted more patients.

So what’s the solution?

Education is key. Showing medical providers the evidence supporting medication to treat opioid use disorder is compelling. Most providers are shocked at the data of how medication to treat opioid use disorder reduces the death rate. If they have a scientific bone in their bodies, they react to this data.

Medications for opioid use disorder also improve the quality of mental and physical health, with reduced suicide rates and reduced criminal activity.

As I said above, the younger generation will learn this data during their training. Older providers will learn it along the way somehow or they will retire without this knowledge.

I don’t have any profound answers how to fix the time crunch issue for primary care providers, and I sure don’t know how to fix the reimbursement issues.

Costs of medical care in the U.S. are rising without a corresponding increase in the quality of that care.

In the U.S. we spend twice as much as other first-world nations per person on healthcare. Most of this money does not go to the doctors, nurses, lab technicians, or other professionals on the front lines. It goes to the increased administrative costs associated with insurance, according to people who know about these things. [1]

Our healthcare system is broken. Fixing this broken system is essential to treating people with substance use disorders.

1. https://www.commonwealthfund.org/publications/issue-briefs/2023/oct/high-us-health-care-spending-where-is-it-all-going

Avoid Burnout

A few weeks ago, on our weekly North Carolina opioid treatment program providers’ conference call, our conversation drifted to burnout. The conversation was helpful to me. We talked about what burnout feels like, what contributes to it, and what we can do about it.

It may seem odd to talk about burnout so close to Christmas and other holidays, but I’ve always felt the most burnout right before an expected time away from work. It’s like I know I’m getting days off soon, so doing my job until that date is particularly onerous. Or maybe I’m just peculiar.

On our call, someone mentioned that half of the available Addiction Medicine fellowships remain unfilled and voiced concern about that. Participants of the group said it might be because our job isn’t easy, and we deal with disappointment daily, and our patients tend to die if they don’t stay in treatment.

One person said it’s helpful for providers to get therapy for themselves, and I agreed with that. I told the group to remember there is a 12-step group for friends and family of people with alcohol and other substance use disorders: Alanon groups. I told the group that I’ve learned things at those meetings that help me at home and at work.

I also told the group that when I get depressed about patients not doing well in treatment, I start looking at patient drug screens. I do this quickly, going down the patient list in Methasoft, our software program. When I do this, I am reminded that most of our patients are doing well. About three-quarters of our patients have negative drug screens or are only positive for marijuana. I consider those patients to be successful, considering they all had a diagnosis of active opioid use disorder when admitted.

I never saw success rates like this when I worked in primary care, treating other chronic illnesses.

It reminds me that the treatment we provide – access to medication to treat opioid use disorder – has more evidence to support its benefits than any other treatment for chronic illness I can think of. That’s an antidote for burnout.

Here are some other ideas that help with burnout:

1. Take care of your physical health. We tell patients to do this, but are we setting good examples? Eat right, go to the doctor for routine medical health screens, get to the dentist periodically, and get enough sleep. We all know what to do.
2. Have a life outside of work. This is big. I must remind myself of this one frequently. Don’t let work become your whole identity. When you are at home, is your mind also at home, or are you thinking about a work situation? Try to keep your mind and your feet in the same place.
3. Have a creative outlet. Right now, I make craft items out of recycled materials.

What is your artistic outlet? It could be something you’ve never considered as art:  cooking, decorating your house, or doing home renovations, or something else.

• Don’t have unrealistic expectations. People with substance use disorders often use substances. Some people are lucky to enter treatment and never use drugs again, but that’s not the journey for most. Expect relapse to happen during treatment. Relapse is never OK, but if the patient is lucky enough to live through it, help them figure out why it happened so they can avoid a similar situation in the future.
• Do some kind of aerobic exercise if your physical condition permits. Besides health benefits, exercise can make a dramatic difference in my ability to handle stress. It doesn’t have to be heavy exercise; even going for a walk can reduce stress.
• Nurture your spiritual health. This doesn’t necessarily mean participation in an organized religion, although for some people it may. For me, anything that connects me to other people and to the God of my understanding is spiritual. I feel better and more centered when I regularly make time for prayer and meditation. Obviously, people find different things that nurture them spiritually.

Despite the stresses, many of us prefer to work in the field of addiction treatment, for various reasons. For those people, working in the field of addiction treatment is an avocation, not just a vocation. 

For me, I love to see the positive changes in patients’ lives, and to feel like I had some small part in that. In this field when addicts find recovery it isn’t just their lives that improve; families and then communities benefit, too. I didn’t see that when I worked in primary care.

I have the best job in the world. When I’m feeling burned out, I need to remember this.

I’m Thankful for Thanksgiving

I hope all my readers had a nice Thanksgiving weekend. I did. It was a low-key, small family event but I felt gratitude appropriate to the season.

Those of us who work in the substance use disorder treatment field must take time to feel gratitude. In this job it’s way too easy to be overwhelmed with negative thoughts and feelings. For me, that can be a quick slide into cynicism and pessimism and then I block myself from all the many positive things of life.

The few weeks before Thanksgiving presented challenges to several of my patients, and I felt anger on their behalf. Several patients experienced difficulties with our healthcare system. Usually, I’m able to interact with other healthcare professionals in a friendly, collegial manner to coordinate care for my patients, while trying to educate in a gentle, low-key way.

This last week, I felt like breaking things.

Some things were trivial but so irritating: one patient has been seeing me for fifteen years, with well-established recovery from opioid use disorder. He’s on a relatively low dose of buprenorphine/naloxone film and I see him only once every two months, given his overall stability.

He moved to Tennessee a few years ago. This was during COVID when telehealth was common, and after COVID subsided I told him I could see him every other visit in person and every other visit via telehealth. This meant he’d have to drive to my office three times a year. He still visits friends and family in North Carolina, so this works well for him. That’s what we’ve been doing but last week we hit a wrinkle.

The small family pharmacy he’s been using told him he would have to find a new doctor, licensed in Tennessee, to prescribe his buprenorphine/naloxone 8/2mg film, which he takes once daily. This pharmacy decided they would no longer fill a prescription from an out-of-state physician, even if that physician (me) had been treating that patient for fifteen years.

He switched to this pharmacy after having problems with the Walgreens in his town. They told him they could not guarantee they would have his buprenorphine/naloxone films in stock on the day it was due to be filled, because of limitations on the amount they could sell. (I talked about this in an earlier blog). He had to wait a day or two and then they might have only five films and he’d have to return for more. We told him that small pharmacies seem to have less problems filling prescriptions on time, so we recommended he go to this small family pharmacy.

When he called my office to ask what to do about this latest, I told him it was his decision. I’d be happy to keep seeing him under our arrangement, but he’d have to find a pharmacy willing to fill my prescription. Or he could find a new prescriber. Tennessee has dose limits on buprenorphine/naloxone but he was well under that, and he wasn’t on the monoproduct, which is also regulated in Tennessee.

He called around and found a friendly pharmacist just over the border, in North Carolina, who says he’s willing to fill the prescription and stay stocked for refills. It’s a forty-five-minute drive for my patient but he’s happy with this solution.

We’ll see how this works out.

Another event happened with a patient who went to our local emergency department with trouble breathing. He walked into the ER and told someone in triage that he was short of breath. During the assessment, he mentioned he was on methadone. He says the moment he said that everything changed. He says policemen were summoned and he was told he would be receiving a dose of Narcan and if he refused, he would be held down and given the Narcan anyway.

He said he thought it would be easier to agree to get the shot, even though he knew it would make him sick. Of course, the Narcan precipitated withdrawal. Now he was still short of breath but had a bunch of unpleasant opioid withdrawal symptoms, such as nausea and vomiting, headache, and intense body aches with pronounced restlessness.

Why did the provider force him to take Narcan? The provider claimed in the record, when we got a copy, that he had to give Narcan to see if methadone was suppressing his respirations, giving him hypoxemia (low oxygen).

Many of my readers, unlike this medical provider, will already know that with opioid overdose, patients become so sedated that breathing slows, decreasing oxygen in the bloodstream due to hypoventilation. But this patient was sitting up and talking to them. He was ventilating just fine. He was not oxygenating, though, and the reason for this showed up on his chest x-ray: he had pneumonia.

I was livid.

I talked to my colleagues about this event, puzzling over how to prevent similar future episodes. One colleague knows some friendly contacts at the hospital. Perhaps we can try to use this contact to engage Emergency Department providers. This patient is also considering legal options, which may promote change.

My challenge is staying open to my patients and their problems while not holding on to a negative, nasty attitude towards other providers. Because of my own issues, I sometimes already feel inferior to many of my fellow doctors, so I especially love to indulge in a little self-righteous indignation on behalf of my patients. That fits right in with my existing character defects. But self-congratulation at another doctor’s expense doesn’t help anyone including the patient.

When I’m in a good place spiritually, I’d rather see if there’s a way to educate the other doctor in a pleasant manner. If there’s not, maybe I need to accept it’s not my job to change their minds or educate them. Maybe my patient needs to pursue legal means to push back against stigma.

For example, last week during a routine yearly assessment, a young patient to whom I prescribe buprenorphine told me he was accepted for a job at a local factory but when they discovered he’s on buprenorphine, they told him he could not work there. I asked him if they put all that in writing and he said they did.

I smiled like a hungry crocodile eying a slow-moving wildebeest. I told him that though I’m no lawyer, I strongly suspect that’s illegal discrimination. I gave him the web address and toll-free number of North Carolina’s disability rights program: https://disabilityrightsnc.org/  and 1-877-235-4210. I encouraged to call this agency for help and information.

I feel like I helped him by giving him information that he could act on if that’s what he decides to do.

I have one more sad example from last week.

I was seeing a new patient who was relatively stable compared to most new patients. He had opioid use disorder but had been taking a steady dose of buprenorphine for years, piggybacking on a relative’s prescription that was going to be ending. He wisely wanted to get his own prescription, and already knew the dose that made him feel stable. He wasn’t using any other drugs except marijuana and had only a few minor medical problems. He had no mental health issues, was in a stable marriage and employed full-time.

At the time of his first visit with me, he said he had a primary care doctor whom he’d been seeing for years and had a great relationship with. I informed him of the recent change of law about who could prescribe buprenorphine, and suggested he ask this primary care provider about prescribing it for him. I told him I’d send in the first prescription and at his follow-up visit in a week we could see if he could get all of his care with this doctor.

The following week, he told me he had called his doctor’s office, and was rebuffed. That was his word: “rebuffed.”

He couldn’t talk to his doctor over the phone but talked to the nurse who worked with his doctor, and she called him back. He says she sounded angry and told him that he should know their practice rarely prescribed any narcotics. He said yes, he knew that. Then she said that he should know better than to ask his doctor to prescribe something like buprenorphine. He said he felt as if he’d done something wrong just by asking his doctor to prescribe it.

I felt bad for suggesting my new patient even ask his primary care doctor, but I honestly thought it was the most logical course of action. Of course, I will continue to see him and that’s not a problem. I just hate that he was made to feel bad for asking for appropriate medical care.

In this situation, I’m not going to try to change the other doctor’s mind. If that’s his position perhaps it’s better if I manage the care of this young man.

With all these situations, I need to keep a positive attitude because slipping into anger and cynicism does not help me or my patients. I want to do what I can to advocate for them, and I want to know where to point them for legal help. Things are getting better in the field of opioid use disorder treatment, even when it feels like the pace of change is glacial.

Death for Fentanyl Dealers?

Harvie does not approve of this ad.

I was watching TV when an ad for a guy running for North Carolina governor came on. It grabbed my attention when I saw the politician say, with a hard look on his face, that he wants people to know if they sell drugs in North Carolina, they will be put, “In jail…or in the ground.”

Wait what?

Is he saying drug dealers need to be executed? Yes, he is.

I knew about legislation that allows prosecutors to seek the death penalty for a dealer if they sell to someone who subsequently dies from the drug. But this is the first I’m seeing a politician advocating death for all drug dealers.

I know people feel helpless and angry about the increases in opioid overdose deaths, due mostly to fentanyl and its analogues. I can’t imagine the pain and grief of people who have lost a loved one to drug overdose. But executing all drug dealers seems extreme to me, maybe something they do in a land where thieves get their hands cut off for stealing and people are stoned to death for adultery. According to Wikipedia, Iran, Saudia Arabia, and Singapore have executed the most people for drug offenses in 2022. Does the U.S. really want to be in the company of these countries on this issue?

Before I started working in the field of opioid use disorder, I held a common misperception that drug dealers and drug users could be easily placed into separate categories. I envisioned evil drug dealers, kingpins who never use their own products, who enslave hapless addicts.

Reality is messier. Talking to my patients over the past twenty years showed me it’s not that simple. Many drug users also sell small amounts of drugs, or assist their dealers in some way, to help finance their own use. People don’t often fit neatly into one category or another. There’s a lot of overlap.

For example, I remember one patient who had a car and a driver’s license, and he funded his addiction by running errands for his dealer. Sometimes this included delivering drugs. He was caught up in a drug sting and was charged with some sort of drug trafficking offense. After being arrested, he decided he needed help for his opioid use disorder. He started treatment at our opioid treatment program.

He stabilized on methadone at around 90mg per day. He stopped using everything but marijuana, got a job, and started paying overdue child support. His life was much improved, but then his case finally worked its way through the court system. He took a plea deal and was sentenced to several years in prison. He couldn’t continue his treatment (a whole other problem) during his incarceration.

Technically he was charged and pled guilty to dealing drugs. I guess the politician with the TV ad would have had him executed. Thankfully, that did not happen.

When he was released from prison a few years later, he returned to treatment to avoid relapsing back to heroin use. Once he re-stabilized and his addiction was no longer running his life, he was a normal citizen.

 He’s a hard worker, and gladly working sixty or more hours per week at his job. He loves his children and is trying to make up for the years he wasn’t in their lives by spending more time with them now. He’s made amends to his ex-wife, and they are now on friendly terms, trying to co-parent in a consistent way.

He’s active in his church and works with a few other men of the church building wheelchair ramps for people who need them. The church buys the material, and they provide the free labor. He says that’s his way of giving back and making up for his past.

He says he still has shame about what he did in his lifetime, but he is trusting that the god of his understanding has forgiven him, and he has served his time.

This person was never a drug kingpin. Far from that, he was trying to get along and keep the amount of money he had to spend on drugs to a minimum. He did break the law, and I am not advocating that he be off with no punishment.

But the death penalty seems extreme.

It’s easy to demonize people with opioid use disorder, but most of them are likeable and non-violent. They have gotten caught up in crime, but were it not for their own addiction, they would be as law-abiding as the average U.S. citizen. Most of the people caught and charged with selling drugs sell to family and friends who are also drug users.

Getting back to how we presently deal with fentanyl dealers, I did a little research. The government calls them “fentanyl trafficking offenses,” and they are tracked by the United States Sentencing Commission.

According to data on their website (https://www.ussc.gov/research/quick-facts/fentanyl-trafficking ), in 2022 there were over twenty thousand drug offenses and nearly twelve percent of the drug trafficking offenses involved fentanyl. This is an over 400% increase compared to 2018.

Of all the offenders, 82% were male, and 88% were U.S. citizens. Around 41% were black, 38% Hispanic, and 19% were white, with an average age of 35 years old. Forty percent of these offenders had little or no prior criminal history and only 6% were career offenders.

The average sentence for fentanyl trafficking was 64 months. Around 53% were sentenced to less than five years, 29% to between five to ten years, and 18% got more than ten years sentence.

We’ve known since the 1950’s that putting people in prison doesn’t treat their substance use disorders. If we really want to prevent recidivism of these people, we will offer evidence-based treatment. Instead of implementing the death penalty, we could offer medications for opioid use disorder, along with counseling.

I hate the type of fearmongering I saw in the politician’s ad. It doesn’t help, and it pushes people to overreact. Reality is rarely as black and white as his simplistic ad suggests; some drug dealers are nice people and good citizens once their substance use disorder is treated.

Maybe instead of executing our friends and neighbors with substance use disorders, we should offer them treatment.

It’s sad that advocating a “tough on crime” approach in election campaigns is a way to get votes. It’s easy to pose as a tough guy on TV and say you’ll “put them in the ground.”

Meanwhile, real and workable solutions to difficult problems are hard to articulate in a 15 second sound bite.

More Phun with Pharmacies

This week was difficult for several of my patients trying to fill their buprenorphine prescriptions.

A long-time and very stable patient suddenly lost his pharmacy in mid-October, when they told him they were closing their store and weren’t accepting any new prescriptions.

This patient has been seeing me for about fifteen years. He’s so stable that I only see him once every two months, which means I send an electronic prescription to his pharmacy, and I put one refill on it. He filled the original buprenorphine/naloxone 12/3mg prescription for sixty films and wasn’t due to get the refill until after the store would be closed for business, making that refill unavailable to him.  After he called me to explain all of this, I told him it wasn’t a problem; I canceled his refill at his old pharmacy (even though it was now closed) and sent another electronically to the next closest CVS pharmacy to him.

A few days before he was due to pick up this prescription, he called this second pharmacy to make sure they had it in stock. They told him no, and they could not fill his prescription until after the first of the month, since they had already filled their “allotment” of buprenorphine products and could not get any new buprenorphine in their store until November 1st. It did not matter, they said, that he had been a CVS patient at another pharmacy that closed.

I’ve heard this kind of thing from many patients. I’ve called a few of their pharmacies to inquire and pharmacists told me that the DEA limits the amount of buprenorphine products they can fill per month, and that they cannot take on any new patients because of these limits, and sometimes don’t have enough to fill for the patients they have.

Obviously, this is a problem.

At a national level, public health workers at all levels are trying to get more people with opioid use disorder to start on buprenorphine products. More than eighty percent of these people aren’t in treatment, which means their risk of dying is elevated three- fold compared to people with opioid use disorder who are in treatment with either buprenorphine or methadone.

But it won’t help if patients can’t find a pharmacy that will fill their buprenorphine prescriptions.

I saw another patient yesterday and started to send his usual prescription, for buprenorphine/naloxone 8/2mg twice daily to his usual pharmacy when he stopped me. He said he needed to call them to make sure they would have it in stock. He called them on his cell phone and sure enough, this Walgreen’s said they wouldn’t have any more buprenorphine until after November 1^st, and that they were unable to tell him if any other Walgreens in his area had it in stock.

In the end, I didn’t send in an electronic prescription for him. I’m still waiting for him to tell me where to send it, after he finds a pharmacy that has it in stock and is willing to dispense to a “new” patient…who has been on this medication for fifteen years.

I’m fortunate that I also work with an opioid treatment program. Recently one of my office-based patients switched to the opioid treatment program because she was so tired of having anxiety about getting her monthly prescription filled at a local pharmacy. She lives in a small town to our north, about thirty minutes away, and the pharmacies are frequently out of her medication, saying they have already dispensed their “limit” for the month. Sometimes I’ve had to send her electronic prescription three times before we found a pharmacy to dispense. It caused her much anxiety, and I wasn’t too happy with the problem either.

Now that she is treated under the opioid treatment program license, she comes in once per month and gets twenty-seven take home doses. She knows we won’t run out of medication. She knows that on the day she’s due to pick up her medication, we will have it for her. That is a great relief to her, and it saves me time.

We order stock bottles of both buprenorphine products and methadone liquid. We must account for every milligram of both medications that we give to patients, on-site or as take homes doses. Our OTP keeps meticulous records and we’ve never had any problems with the DEA. They periodically inspect the facility, as they do all OTPs. I’ve found them to be helpful and professional, eager to answer any questions. So far as I know, we have never had any problems ordering the medications we need for our patients.

Congress is now considering new legislation, called the Modernization of opioid Treatment Access Act, which seeks to move treatment of patients with opioid use disorder from opioid treatment programs to community providers and pharmacies. The routine occurrence of difficulties like I’ve described above make me skeptical if the Act would be of any use, even if it were passed. Maybe it’s different in large cities but around here, if we can’t even get pharmacies to remain stocked with enough buprenorphine to meet patient demand, methadone will be out of the question.

The DEA disagrees with what pharmacists tell me about buprenorphine. They say they do not set limits on the amount of buprenorphine pharmacies can order and dispense. So why do pharmacies seem to be convinced otherwise? I don’t know. I do know both the DEA and retail pharmacies have been criticized for their inaction during the early days of the opioid epidemic. I think both are being cautious now, not wanting to make that mistake again. But it hurts patients seeking recovery.

I wish someone could get the DEA to sit down with the people running CVS and Walgreen’s and work out this misunderstanding.