Pharmacists and Insurance Companies

 

 

Over the past few years, pharmacists have become important allies to my patients in medication-assisted treatment. I’m thankful for that, since it makes my patients’ lives easily, and mine. But recently, there have been some minor bumps in the road, made more pronounced because of their decreasing frequency.

Sometimes, I get cranky.

I got a message from my office staff person that a pharmacy had called because I didn’t write any dosing instructions on a prescription I had just written. “Wow,” I thought, “I must be losing my mind.”

We copy all prescriptions, so I looked at our copy. It looked complete, except under instructions, I’d written 1 ½ SL. I had neglected to write “Qd” which means once daily.

My bad. I should have written it. How else would a pharmacist be able to guess what the instructions are…except I wrote for #45, a month’s worth. And the patient has filled prescriptions for 1 ½ SL qd for about three years now, all filled every month at this pharmacy. Nope, no way for the pharmacist to decipher this riddle.

Well, I can’t really blame them; it was my mistake.

Last night I got a call from a patient who was enraged because the pharmacy was refusing to fill his prescriptions. I know this patient very well, and though he’s been doing well in recovery for about ten years, he can get angry if he misunderstands things. I told him I would call the pharmacy to try to figure out the problem.

I see this patient every two months, and my last prescription was written with a refill. He filled the first prescription a few days after I saw him. When I finally got to speak to the pharmacy manager, he said they had ordered the medication for the patient, and he would be able to pick it up the next day.

OK, I said, but that’s actually five days late, due to the pharmacy not having the medication in stock. The pharmacist didn’t seem disturbed that his patient would have been out of a life-sustaining medication for five days, so I asked why it was that the medication couldn’t be ordered so that it would be in stock when the patient was due to pick it up.

The answer shocked me with its honesty. He said the pharmacy didn’t want to risk getting ‘stuck” with the medication if the patient decided to go somewhere else to fill it, and that “these patients” flew from one pharmacy to another all the time, in order to save one dollar.

What I should have said…was something along the lines of, “You’re an asshole who shouldn’t be in the helping professions. Do you do the same thing to diabetics on insulin?”

What I did say was…nothing. I was so stunned at the lack of compassion that I didn’t say anything. I’m disappointed in myself for this, since I’m usually a little spicier. His honesty took me completely by surprise, as did his naked disregard for the well-being on my patient.

Then there was the phone call last week from a pharmacist who wanted to make sure the patient hadn’t changed the prescription. Again, this was a patient in recovery for years, whom I see every two months. I wrote her prescription for Suboxone 8mg films, one per day, #30, and I printed out “ONE” under the line for refills, as I’ve done for the past four years.

The pharmacist wanted to know if I had written a zero and the patient falsified and wrote the “NE” after it.

I suppose that’s possible, but I except I print very clearly, and the “O” that the pharmacist thought could be a zero was way on the left side of the blank for number of refills.

This problem that will go away after electronic prescribing, mandated by the state of North Carolina, is in place. I’ve stuck with old-school paper records and hand-written prescriptions for as long as I can, but that will be a thing of the past by January 1, 2020.

I’ve saved the most insane for last.

A local pharmacy called, stating that my one-month written prescription for a patient for suboxone films was partly voided because of the insurance company’s decision.

Huh? How does this happen, I wondered.

I’m still not sure, but here’s what I was told that the pharmacist was told by the insurance company representative.

The visit prior to this one, I had written only a two-week prescription. I don’t recall what was going on, but I needed to keep a closer eye on the patient, and changed from my usually monthly prescription.

Apparently, this was the root of the problem. I wrote for #45, a 2-week prescription. Then at this last next visit, two weeks later, I decided the patient could go back to monthly visits and wrote for #90. This caused a red flag on the patient, because he had now was trying to fill #135 films within a thirty-day period. Yeah…except for the patient already took the forty-five films during a two week period that was already past.

I can’t make this stuff up.

So his insurance company said nope, you can only get #45, which will make only #90 in a thirty-day period. And the pharmacy “cancels” the rest of my ninety day prescription.

Insurance companies would make the Buddha want to bitch slap someone.

I told the staff member who took the call, “Please get the insurance company’s physician reviewer on the phone. I’ve got to hear this logic. I also need to speak to the pharmacist. I want to know exactly who thought they had the right to cancel a prescription, written by a physician, for no medical reason.”

I was riled, and kind of looking forward to what could be a very interesting conversation. But it was not to be. When my staff called the pharmacy, this situation mysteriously resolved itself. No problem now. Patient can come by to get the other #45 films, and insurance won’t give him a hard time when he comes next month with a month’s prescriptions.

Despite these experiences, most pharmacists know how important buprenorphine products are to the recovering person, and are positive and supportive of my patients on medication-assisted treatment. There are far more of these than the pharmacists who have biases against patients on MAT. It’s just that the troublesome ones stand out by their behavior.

I am a peaceful person. I intensely dislike confrontation and can get along with almost anyone. But there are times, large and small, when I have to get out of my comfort zone and make some noise.

 

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Suboxone Patient Wins Lawsuit

 

 

 

 

In Maine, as in most other states in the U.S., patients on medication-assisted treatment for opioid use disorder weren’t allowed to take their life-saving medications while incarcerated.

All that changed in October of this year, when the American Civil Liberties Union settled a lawsuit with the Maine Department of Corrections. The ACLU sued on behalf of Zach Smith, who has been on Suboxone for five years as treatment for opioid use disorder. He was told he would have to stop taking Suboxone during his incarceration. I wrote of the pending case in my blog on August 12, 2018.

We know that if denied his medication, he would go through physical opioid withdrawal and would be at higher risk for overdose death, particularly immediately after release from incarceration.

The ACLU took his case and settled a lawsuit with the Maine Department of Corrections, which ultimately agreed to allow him to continue on his medication. Jailers warn that this was a “special case” and that they would not necessarily allow other prisoners to take buprenorphine as prescribed by a physician. However, this appears to be a clear precedent for other patients and other lawsuits.

I think this is a landmark case for our patients. MAT is the standard of care, and it should be illegal to refuse to provide this treatment to people who are sentenced to incarceration. The diversion of Suboxone films has been an issue for many years because patients in opioid withdrawal can’t access suboxone through any legal channel. This creates a black market for suboxone, and jailers across the country have complained loudly about this situation – that is of their own creation.

The ACLU is supporting patients in their fight to continue medication-assisted treatments during incarceration is other states, too. According to the ACLU website, a similar case is pending in Washington state.

If you are a patient – or know a patient – who is being denied medication-assisted treatment during incarceration, I hope you have a lawyer who is willing for fight for your rights. If you do not, consider reaching out to the ACLU in your state:

For North Carolina: https://www.acluofnorthcarolina.org/

 

Book Review: “Dopesick: Dealers, Doctors, and the Drug Company that Addicted America,” by Beth Macy

Dopesick, by Beth Macy

This well-written book has it all: compact information about how the opioid epidemic started, how our nation failed to act early to mitigate the damage of the epidemic, and how the epidemic shifted into our present predicament. The author did a great deal of research and talked to experts with vital information, but she humanized this data with personal stories about people affected by the opioid epidemic. She told this story not only from the view of the person with opioid use disorder, but also illustrated the grief of families who lost loved ones. The prolonged grief of families who have lost loved ones to opioid overdose deaths is rarely examined as well as it is in this book.

This is a book that will be staying on my shelf for a re-read.

The author is a journalist who works for the Roanoke Times newspaper, so this book focuses mostly on events in the western part of Virginia.

Avid readers on this topic will recall the book “Painkiller,” by Barry Meier, who also covered rural Western Virginia. Ms. Macy’s book picks up where Mr. Meier’s left off. They talk about many of the same communities and the same treatment providers, fifteen years later.

Mr. Meier’s book, published in 2003, could have been an early warning to the U.S. healthcare system. Unfortunately, the book wasn’t widely read, so few people took any note of what was going on, other than those of us already working in the field. I understand Mr. Meier wrote a second edition of “Painkiller” this year, and I plan to read and review it.

The most remarkable theme of Ms. Macy’s book is how the opioid use disorder epidemic grew worse over the past fifteen years. After physicians finally stopped prescribing so many opioid pain pills, these pills were less available on the black market. Many people with opioid use disorder switched to cheap and potent heroin.

In Ms. Macy’s book, she tells the experience of a rural physician, Dr. Art Van Zee, who was also interviewed for Barry Meier’s book. He was one of the brave people who stood up at conferences and raised the question about the ethics of Purdue Pharma, manufacturer of OxyContin, when it wasn’t easy to question anything about that drug company. He’s the first physician I can recall who actively sought answers about his perceived over-prescribing and mis-marketing of OxyContin.

This isn’t in the book: I remember Dr. Van Zee at an Addiction Medicine conference called “Pain and Addiction: Common Threads,” that I attended in 2003 o4 2004. I bought the recordings of the conference, because I was so excited to learn more about Addiction Medicine. I remember a recorded session where Dr. Van Zee asked a question after a lecture, asking – as I remember it many years later – why Purdue Pharma was still peddling their OxyContin as a relatively harmless opioid for chronic pain, while he was seeing patients with lives destroyed by this drug.

It was one of those moments where all you hear are crickets. His question wasn’t answered, but rather he was reprimanded by the speaker. He was cautioned to remember our conferences were sponsored in part by Purdue money, and that appropriate prescribing of OxyContin was a huge benefit to patients. He was told it wasn’t the drug, it was the prescribing that needed to be fixed.

Fast forward to 2007. As described in “Dopesick,” Purdue Pharma pled guilty to fraudulent marketing of OxyContin, which was a felony misbranding charge. Purdue paid $600 million in fines. Its top three executives pled guilty to misdemeanor versions of the same crime, and ordered to pay a total of $34.5 million.

So yes, inappropriate prescribing was a big part of the problem, but Purdue deliberately misinformed physicians about potential dangers of the drug, which contributed to inappropriate prescribing. From a 2018 perspective, that speaker’s answer to Dr. Van Zee seems disingenuous at best.

Dr. Van Zee’s perceptions, based on his clinical experiences, were correct. Around that same time, I was seeing the same thing in rural Western North Carolina. I remember having twenty to thirty new patients show up on admission day, all of them were using OxyContin, almost exclusively. This drug was easy to crush to snort and inject, and Purdue knew it.

Purdue Pharma testified before congress in 2003 that they were nearly ready to release a new formulation of their OxyContin pill that was more abuse resistant. As it turns out, that new formulation wasn’t released until 2010. With that change, people with opioid use disorder changed to other opioids, easier to misuse, such as Roxicodone and Opana. Eventually Opana underwent reformulation to a less abused form.

But I digress; back to the book. The author’s first few chapters summarize the history of opioid use disorder and the factors that lead up to the release and promotion of OxyContin. It related how this drug crept into the social fabric of Southwestern Virginia, and how early attempts to sound an alarm about its abuse were met with contempt from drug company representatives.

Chapter Three tells of the “unwinnable” case brought against Purdue Pharma by Virginia attorney general John Brownlee. He went up against the famous Rudy Giuliani, who was one of the lawyers who represented the drug company, and successfully negotiated the eleventh-largest fine against a pharmaceutical company. This chapter contrasts this legal victory with the devastating grief of parents who lost their children to overdose death with OxyContin. The book describes the creation of the “OxyKills.com” message board, which became a sort of a database for overdose deaths. The chapter after that contains depressing descriptions of how Purdue Pharma’s corporation executives and the owners, the Sackler family, distanced themselves from the profound harm caused by their medication and criminal mis- marketing.

The next several chapters contain the tragic stories of people who became addicted to opioids, and their journeys through the criminal justice system, the addiction treatment system, and the pain their families felt, every step of the way. The author illustrates the ridiculousness of our patchwork system of care for people with opioid use disorder, and how ineffective treatments are often pushed as first-line options.

Then the book details efforts to pursue the heroin ring that sprang up in Virginia, and how the ringleader, a man named Ronnie Jones, was eventually arrested, charged and convicted of trafficking heroin from Baltimore to the Roanoke suburbs. Many of Jones’ drug runners were addicted young adults, many female, from Roanoke’s suburbs. Families were shocked when they found out their children were involved with the drug trade. Heroin used to be an inner-city drug, but times have changed. Heroin is now plentiful in suburban and rural areas, as this book illustrates repeatedly.

I was most interested in the author’s description of available treatments. Usually I dread reading writers’ summaries of treatment for opioid use disorder. If they describe medication-assisted treatment at all, it’s often couched in negative terms. However, this author did her homework.

She describes the accurate reasons why medication-assisted treatment with buprenorphine and methadone is the gold standard of treatment, and even writes about some of the success stories. However, she also writes about the more common public perception of buprenorphine: “shoddy” prescribers located in strip malls who don’t mandate counseling or do drug testing patients. She writes about the poor opinion of Virginia law enforcement officials, who criticize doctors for not weaning people off the drug, and for allowing patients to inject the drug & sell it on the street.

However, it’s clear the author was able to grasp harm reduction principles, and latest research findings, since she said (on page 219) the unyielding opposition to MAT was the single biggest barrier to reducing overdose deaths.

I felt gratified to read this in print. I underlined it.

She also pointed out how some states’ refusal to expand Medicaid when given the opportunity kept many people with opioid use disorder from being able to access treatment. That’s more perceptive than I expect from a writer who isn’t trained in public health or substance use disorder treatment.

But my favorite part of the book was on page 221, where an addiction counselor named Anne Giles said of the opioid overdose death epidemic: “We should be sending helicopters!”

I underlined this too.

She pointed out that if the same number of people dying from opioid overdoses were dying of Ebola, the government would be sending helicopters of medical help to rescue people and contain the epidemic, and she’s right. We ought to be sending helicopters….helicopters loaded with emergency medical personnel and treatment medication. (By the way, per most recent data from NIDA, over 49,000 people in the U.S. died from opioid overdose in 2017. That’s one-hundred and thirty-four people per day. If they were dying from Ebola…helicopters for sure.)

So I heartily recommend this book to anyone interested in this topic. Even if you aren’t interested, it’s so well-written that it will entertain you. I particularly appreciate the author’s talent at describing so many facets of this opioid epidemic and the obvious scope of her research.

Tapering Off Suboxone: Three Patients’ Success Stories

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This year I’ve had three long-term patients taper off the buprenorphine products I was prescribing. All three are doing well and are happy with their treatment outcome. Since tapering off buprenorphine products can be challenging, I thought I’d share their stories, to help other people who wish to taper off buprenorphine. (Note that when I say buprenorphine, I mean to include all the brands and generics: Suboxone, Zubsolv, Bunavail, generic combination product buprenorphine/naloxone and the generic monoproduct buprenorphine.)

The first patient had been on buprenorphine for over ten years. She saw one of the first physicians to prescribe buprenorphine, and I inherited her from this prescriber after he retired.

When she started Suboxone, which at that time were only available in tablet form, she stabilized at eight milligrams. She stayed on that dose for about four years. She saw her prescriber monthly for the first year and a half, then every other month. By the time she started seeing me, she had cut her dose to 4mg per day without too much difficulty. When the suboxone films were available, we switched to those, both because that’s what her insurance would pay for and because I thought she could taper more easily with films.

Over the first year with me, she brought her dose down to 2mg per day, reducing by a half milligram every three or four months. I then switched her to the 2mg films, and she continued to cut off more and more from her films. I gave her some guidance, but she largely managed her taper on her own.

After a year or two, she asked me to prescribe only fifteen films per month, since she was taking half of a film per day. A year later, she had dropped to only a forth of a film per day, and needed only eight films per month. This slowly progressed until she had brought her dose down to one-sixteenth of a two milligram film which she took every other day.

That’s right…she was taking .125milligrams every other day. Her urine drug screen still showed positive for buprenorphine at her visits. I told her I thought she could stop taking that dose and not have any withdrawal symptoms, but she told me she still felt withdrawal if she missed her every other day dose. I didn’t push her; I didn’t mind prescribing only one 2milligram film per month!

She continued at this dose for over a year. When she missed a visit earlier this year, I asked my staff to call her. Sure enough, she forgot to take her dose for several days, and didn’t feel any withdrawal. I offered to see her one more time, to talk about relapse prevention and options to give her insurance against a relapse (Vivitrol), but she didn’t want another visit. I congratulated her and told her if she had questions or problems in the future to call us.

During her last year or so, we talked regularly about relapse prevention. We made plans for what to do if she had a catastrophic medical problem that required pain medication (broken bone, surgery, etc.). We discussed other big relapse triggers, such as strong negative emotions, and being around people who had opioids or other drugs.

This patient was very involved with 12-step recovery. Even after so many years of recovery, she went to three or more meetings per week. She had a sponsor and served as a sponsor to newer members. She had relatives in 12-step programs, and most of her friends were members of 12-step recovery groups.

The second patient also tapered her dose over years. I knew her for around fifteen years, first as a patient at an opioid treatment program, where she dosed on methadone. She did well from the start, though she had some slips with non-opioid illicit drugs.

She didn’t care for the restrictive nature of the opioid treatment program, so when she’d been doing well there for several years, I told her about the new option of buprenorphine treatment through an office setting. She decided that was what she wanted to do, and proceeded to taper her methadone dose, slowly.

Once she was down to 30mg, which took about six months, she made an appointment with an office-based physician, who started her at suboxone 16mg per day. When that physician retired less than a year after she started Suboxone, she transferred to my office-based program.

By the time she transferred to my office-based program, she was down to 12mg per day. Just like the first patient, she steadily tapered her own dose. She reduced her dose by an estimated milligram of Suboxone every four months.

I say estimated because cutting the Suboxone films is largely guesswork, and the manufacturer says there are no studies to show buprenorphine is evenly distributed over the film. While that’s true, buprenorphine is so long-acting that I wonder how much variation patients get in their blood levels, even with uneven distribution.

Just like with the first patient, we switched her to the 2mg film once she got to a 2mg per day dose. She continued to reduce on her own. She would cut her dose and wait for a month or two before going down again. I saw her only every two months, given her stability. She had negative drug screens, always kept her appointments, and lead a productive life. I gave her as much advice as I could, but I was impressed that she was able to listen to her body and taper only as fast as she was comfortable.

Once she was taking one-eighth of a 2 milligram film (.25mg), she stopped her medication. I saw her for one last planned visit, and we talked about how she felt. At that point, she’d been off buprenorphine for four weeks. She noticed aches and pains more intensely than in the past, but said it wasn’t anything ibuprofen or Tylenol couldn’t fix. It took a little longer to get to sleep, but she was still functioning well as a mother to her four children. She was ecstatic to be finished with medication-assisted treatment, and she knows that – heaven forbid – if she does relapse, to call quickly and come to see me to get back on buprenorphine.

Again, we had been discussing relapse triggers for months. We also discussed naltrexone, available as a once monthly shot called Vivitrol, as insurance against a relapse but she decided against it. She felt she didn’t need it.

She did individual counseling while she was a patient at the opioid treatment program, but hasn’t done much counseling recently. She saw a therapist many years ago, after a traumatic life event, but didn’t feel she needed to continue with this. She tried 12-step recovery but didn’t feel it was right for her.

Initially I worried she wouldn’t make progress in her recovery without continuing to see a therapist, but when I saw how well she was functioning in life, I decided not to push the issue. The only counseling she got was with me, during our 20-minute office visits. I’m not a trained therapist, but I like to think I have developed some skills over the years.

Her life changed completely over the past ten or so years she’s been on medication-assisted treatment. Early on, she let go of drug-using friends and acquaintances. She became focused on what was important to her: her young family and her extended family. She got a part-time job after her youngest child started school, to afford some extras for the family. Her husband is in his final stages of taper from buprenorphine, and she hasn’t rushed him, letting him take his own time, just like she did.

Drug use holds no allure for her; she hasn’t had any cravings or desires for any sort of drugs for years.

My third patient to taper off this year just saw me several weeks ago. It’s been over eight years since she used any illicit drugs. At her last visit, she declared this to be her last visit, saying her last buprenorphine had been taken six weeks prior, and that she felt fine.

She has been at a dose of less than 8mg for about two years, and less than 2mg per day for at least the last eight months. She tapered on the generic combination tablets, buprenorphine/naloxone 2/.5mg, cutting them into quarters. Once she got to one-quarter per day (.5mg), she took one of these quarters every other day for several weeks and then stopped completely.

Again, we’ve been discussing relapse prevention for literally years. Again, she decided against starting naltrexone as a safety net against relapse, feeling she didn’t need this medication. She was happy and smiling and was very kind when she thanked me for helping her these past years. I told her it was truly my pleasure, and I was honored to be even a small part of her success.

These three patients have common themes in their successes. All three had very support families who didn’t rush them to get off buprenorphine or shame them from being on it. I also didn’t pressure them. I said I’ll do everything I can do to help you taper off this medication, but there’s nothing wrong with staying on it either, if that’s what you prefer.

This left the decision in their hands. All three said this was important, since they had control over when/if/how they tapered. Once I told one of these patients to listen to her body, since she was the expert on her body and how it felt. This resonated with her, and she thanked me for saying that. She felt that took the pressure from her to try to meet someone else’s expectations.

These three patients all tapered their dose very gradually, over periods of not days or weeks, but months and years. While such slow tapers can be frustrating, not to mention expensive, to people who want a quicker exit off medication, maybe slow tapers allow the body more time to adjust to changes in dosage.

Two of the three patients exercise regularly at a gym. The third is also active, and walks nearly daily. Exercise usually helps us to feel better, both physically and emotionally. I wonder if exercise also boosts endorphin, our body’s own opioid. I’ve started recommended patients start a reasonable exercise program in advance of starting a dose taper.

All three of these patients have faced serious adversity in the past and survived it. This tells me they have skills they can use in their recovery. All three had tremendous resolve to do what was necessary to get their lives back. They kept at it, accepted the few setbacks that came their way as part of the process, and kept moving forward, even though progress was slow at times.

I admire all these patients. All have excellent prognosis, and we’ve talked about how opioid use disorder is a chronic illness. They need to be on guard against relapses the rest of their lives, and if relapse happens, I think they will know what to do.

I have another crop of patients who are dosing at 4mg or less of buprenorphine per day, all in the process of tapering. I’ll update my blog with those stories after they taper.

 

Idle Time and Our New PMP

 

 

 

 

 

 

Usually I stay busy when I work at the opioid treatment program (OTP). Every August, however, things slow down. We see fewer people presenting for admission. I don’t know why this is, but I’ve seen it happen every year for the past seventeen years I’ve worked at OTPs.

This August was no exception. Our admissions dropped down significantly, giving me chunks of time that I otherwise dedicate to doing intake admission histories and physicals. My new challenge was staying busy.

My staff knows I must be kept busy. Otherwise, I tend to Get In To Things.

For example, once when we were slow, I went on a fact-finding mission about why our toilets have no blue dye in the water. Blue dye reduces the risk of adulterated urine obtained for drug screens, yet we had no blue dye. As it turned out, the answer to my question was: it’s complicated. Our toilets have a bladder system that holds water instead of storing water in the back of the tank…well, that’s not important. But it wasn’t under my control to fix, and I only managed to interrupt people with more pressing work to do.

Another time when I wasn’t busy, I wanted to know why there were five WTA vans in our parking lot at the same time. WTA is the transport service that picks up our Medicaid patients to bring them to the OTP for treatment. We’ve asked them to stagger their arrival time, so that we don’t have multiple vans disgorging five to eight people arriving to dose at the same time. This causes a delay in dosing for all of the patients, and no one likes that – not the patients, staff or our dosing nurses.

Apparently, our request to WTA was a river too wide, a mountain too high. I can’t remember the last morning when I’ve arrived at work at 7am when there were fewer than three WTA vans. Their drivers chat amiably amongst themselves while tempers flare because of dosing delays due to a clump of patients arriving all at the same time.

I know I can be annoying when I’m not kept busy, so yesterday I kept going to the lobby to ask if anyone needed to see me. I got to see five or six people this way, a good use of time.

During the other free time, I looked at patients on our state’s new prescription monitoring program.

While I recognize I’m never good with new technology, I have some complaints about our new system.

Last week, I settled in on a Thursday evening to look at the reports of the office-based buprenorphine patients I had scheduled to see in my private office the next day. Every time I entered the patient’s first name, last name, and date of birth, I got an error message.

When technology fails to work for me, I become enraged. Many times, it turns out to be my own fault, which enrages me all the more. But this time, the new system clearly wasn’t working.

There was a phone number listed on the web site to call for problems. Since it was after hours, I expected a machine, but a human answered. I told him of my problems, and he said, “Try entering just the first three letters of the first and last name, and check the boxes that indicate partial name.”

I did so, and it worked. My short-term problem was fixed. However, feeling a little crotchety with this delay, I asked him how any provider could know it only works with the first three letters of first and last name, unless they made the effort to call the help number.

He said as long as it worked, it was good enough. In my mind, I pictured all those “There, I fixed it” photo memes often seen on the internet. I grumbled a little more, but ended with a thank you. To be fair, since then, the system has been working with the full names again.

On our old system, we could adjust our search to allow for an error in the date of birth. That is, we could select the exact date, or options for one to two years surrounding this date. You’d be surprised how many times the date of birth is recorded wrong in our charts or by the pharmacy. With this new system, the date of birth data entry must be entered exactly by the pharmacy and by the physician searching the system.

I also don’t care for the first page of this report, dedicated to overdose death risk and MME of the patient. MME stands for morphine milligram equivalents. This gives an “overdose score” which may be helpful to some prescribers.

But it annoys me, since it gives big scores to patients who are only filling prescriptions for buprenorphine products. Buprenorphine isn’t translatable into MME numbers, and MMEs were never meant for this purpose. In the fine print, the MME score for patients on buprenorphine is zero, but there’s still a high overdose score. This glitch doesn’t cause any harm so far as I can see…except for the annoyance it causes. I want my patients to get credit for being on buprenorphine, arguably one of the safest opioids in existence.

This mess of data on the front page, in large type, makes it harder to find what I’m looking for, which is the actual printout of all controlled substances filled by the patient, the date they are filled and the prescriber. While the front page must have that overdose score in a font of twenty-six, the actual data is printed in – I’m not making this up – in ten font.

I’m on the shady side of my fifties, and ten font is unsatisfactory to me.

We’ve also encountered another problem, which is that the patient’s name is only listed on the first page. Some of these reports can run to six or more pages, even with the ten font. It’s a real problem to figure out which sheets go with which patients. It’s not a huge problem at my home, where I’m the only person printing. But at work, my papers can get shuffled by other personnel getting their printed papers. I’ve had loose sheets with no name on them, which had to be discarded because I couldn’t tell for sure to which patient they belonged.

No system is perfect, and the new system has some improvements – I can print the page I’m viewing, rather than the two-step process of the past, when I had to select the option to create a pdf, then go back in a second step to print that pdf file. So it’s not all bad. Plus, we can search more states. Now providers can select our own state, plus all of our bordering states. We can select a total of eighteen states.

As August turned into September and then into October, my brief problem with free time resolved. We are busy again, though not as busy as we will be later in the year. Being busy is a good thing for everyone; more patients getting admitted to treatment means more people are getting their lives back. That’s always an awesome thing to observe.

And I am prevented from bothering staff members with more important things to do than figure out how to put blue dye in the toilets.

 

Update

 

 

 

 

 

 

I have an update to my blog of September 16. The patient, who was hospitalized with life-threatening endocarditis (infection of the heart valve), was finally granted the right to have visitors – about fourteen days into his hospital stay. Mission Hospital administrators gave no reason for the change of policy, but I have reason to believe they were feeling some heat from the many people advocating for the patient.

Since this was the patient’s second admission for endocarditis, the chart said cardiovascular surgeons were not going to do a second heart surgery, per hospital policy, because the patient had continued to use drugs intravenously. The patient was told no other hospital would accept him in transfer because he had no insurance. The palliative care team was called in to manage his case, which appears to mean his physicians thought he was going to die without surgery.

Thanks to the efforts of several very tenacious providers at the opioid treatment program where the patient had just been admitted, this case got the attention of many people. Emails flew about the state. The outrageousness of this case got people involved, who got other people involved. Besides the patient’s providers at the OTP, advocacy efforts were undertaken by personnel at the NC State Opioid Treatment Authority (SOTA), the Medical Director of DHHS in NC, the General Counsel for DHHS, and out-of-state help from a lawyer with the Legal Action Center in New York. Patient advocacy groups were helpful, and several other people whom I won’t list by name but know who they are.

Thanks to advocacy efforts, the patient was transferred to Chapel Hill last week, to be evaluated for surgery of his infected heart valve.

I have good reason to believe Mission Hospital had complaints filed against it with the Joint Commission. The Joint Commission is an independent, not-for-profit organization that gramts accreditation to hospitals if they meet certain standards. Accreditation is important, because it affects payment from payers, including Medicare and Medicaid.

I have also heard that a complaint was filed with the Department of Justice, reporting that the hospital violated the patient’s rights under the Americans with Disabilities Act.

A big meeting was scheduled for October 2, with hospital administrators and the patient’s many advocates, people who were upset with their handling of this patient’s case. Unfortunately, the day before the meeting, Mission administrators canceled, saying it hadn’t been put on their schedule, by some oversight.

By this time, I felt those administrators lacked credibility.

I hope this case gets the attention of hospital leaders. I hope the time has come where hospitals will be held accountable for their mis-treatment of patients with opioid use disorder (OUD). OUD is a completely treatable chronic illness, not bad behavior that deserves the death penalty.