Who Is Nadine and Why Do I Need Her Number?

Ukrainian art from ETSY – by Dmitry

“Babe, remind me what your Nadine number is?” yelled my husband, who has a Master’s degree in Addictions Counseling, provides counseling for all of my own office-based buprenorphine patients, does patient scheduling, takes payments, reads drug screens, and takes random pharmacy calls.

That last chore is by far the most vexing.

Regular readers of my blog will recall my mystification when I first learned of NADEAN (pronounced “Nadine”), which stands for Narcotic Addiction Drug Enforcement Administration Number. I posted a blog about this on March 1, 2020.

So now, a CVS pharmacist was calling my office to get my NADEAN information. I had typed it onto the prescription in my electronic medical record, but probably didn’t get the format just right. My husband, because the pharmacist told him so, thought Nadine was a separate and special number but it is not. It’s just the usual DEA “X” number typed in a special format.

I see office-based patients at two locations. One is at the opioid treatment program, and I use a completely different software system called Rcopia. That system automatically enters NADEAN:XB1234567 (obviously not my real DEA number) on all buprenorphine-containing prescriptions. The system I use in my own office does not have that feature.

Only CVS pharmacies have the peculiar NADEAN format requirement. I asked my husband to please see if we could switch vendors, so that CVS pharmacists would stop calling about Nadine.

But we discovered Rcopia costs significantly more than my present system. I’m basically cheap, and I run a very lean office so I can charge my patients the lowest rate in town. I’m going to stick with my cheap-ass electronic medical prescribing system, and I’m trying to accept that I will be talking about Nadine with CVS pharmacists for the foreseeable future.

Our next phone call was about a patient who has tapered down to .5mg of buprenorphine per day. I prescribe buprenorphine/naloxone 2/.5mg films for him, and he cuts these into eighths. He takes two eighths per day, for a total of a half milligram per day. I prescribe eight films per month, which is technically a half film too much, but since I can’t prescribe a half a film, I round up.

His pharmacist called me recently, worried he was taking too much because he was asking to fill the prescription two days early.

I asked her to please go ahead and fill the prescription, as I wasn’t worried this patient was taking too much. I am pleased to say I refrained from any sarcastic humor, in the interest of having better relationships with all pharmacists.

I’m trying to be more collegial to all fellow healthcare professionals to reduce my stress and discord.

I’m also going to be taking a short break from blogging but I’ll be back next month.

Update…

I first blogged about David Stojcevski on October 20, 2015, writing about his awful and senseless death from drug withdrawal while incarcerated in a Macomb County, Michigan, jail in 2014. He had been prescribed methadone, clonazepam, and alprazolam but when incarcerated for failure to pay a traffic ticket, he was denied his usual medications.

David died on day seventeen of his thirty-day sentence. When he began to hallucinate from withdrawal, he was sent to a mental health cell where his deterioration was recorded. He ate very little and lost around fifty pounds before his last moments, and he was observed to be having seizures prior to his death.

His autopsy said his death was due to “Acute withdrawal from chronic benzodiazepine, methadone, and opiate medication,” and mentioned seizures and dehydration as contributing factors.

His family posted all 240 hours of his suffering on the internet to protest the terrible treatment of people during incarceration. They sued both the county and Correct Care Solutions, the healthcare agency the county hired to provide medical care for inmates.

The family’s lawsuit took years to wind through the legal system, but they finally agreed to a settlement of $2.45 million dollars, with the county agreeing to pay $1.15 and Wellpath, the company that took over Correct Care Solutions, to pay $1.3 million.

I was pleased the family won their suit. The money won’t bring David back from a senseless and agonizing death, but maybe the dollar amount of the reward will discourage other county jails to ignore drug withdrawal symptoms.

Today I found that CNN has done an investigative piece on the problem of substandard medical care in jails:  https://www.cnn.com/interactive/2019/06/us/jail-health-care-ccs-invs/ Correct Care Solutions was mentioned repeatedly in the piece.

This lengthy article describes widespread lack of essential medical care to people incarcerated at facilities that contracted with Correct Care Solutions. This is the company that merged with another company to form Wellpath in 2018, and it is based in Nashville, TN.

Things are changing and there’s reason for hope, at least in North Carolina.

Our Department of Health and Human Services is trying to get key people in the same room, or at least on the same webinar, to learn from each other. Recently three webinars were presented to jail officials around the state, sponsored by MAHEC (Mountain Area Health Education Center), the NC Department of Health and Human Services, and the Buncombe County Sheriff’s Office.

The first webinar was presented by USDOJ attorneys and a MAHEC Addiction Medicine specialist, Dr. Shuchin Shukla. The attorneys discussed how people with opioid use disorders prescribed medications are protected under the Americans with Disabilities Act (ADA), and the addiction medicine specialist gave an overview of what opioid use disorder is and how medications help patients with this disorder. Repeatedly, the attorneys said they preferred to work with agencies and facilities to avoid ADA claims rather than issue punitive fines.

I was invited to talk on the second webinar, about services available at opioid treatment programs and how they differ from office-based programs. I talked more about methadone specifically, and ways jail personnel and treatment program personnel can work together to continue medications for opioid use disorder.

That webinar went very well, judging from the questions the audience asked at the end. Those questions showed the audience understood how important continued is, and showed they were willing to work for the benefit of inmate patients.

Then the third webinar gave details about how exactly three North Carolina counties are providing medications for opioid use disorder: Buncombe, Pitt, and Durham. They gave data about how many patients are being served and how medications are provided. This webinar was interesting to me about pointed out things I never would have thought about. For example, if patients are transferred to a prison that doesn’t provide medication, what can be done? The presenters talked about how to get buy-in from law enforcement personnel and how to deal with specific problems that arise when treating this population.

One of the presenters talked frankly about how he was skeptical initially, but then saw how medications help inmates with opioid use disorder. He finally decided that the reason he did his job was to help people, and providing treatment helped people, so he is now supportive of these medications.

That last webinar was much more moving that I expected.

This series of webinars is a good beginning and I hope collaboration will continue between the treatment community and law enforcement personnel at all levels. I hope we will soon see medications for opioid use disorder available in all county jails.

I’m grateful to Anna Stein, JD, MPH, for her tireless efforts to improve health care in our state. She works for the NC Division of Public Health, and has helped shape policy in positive directions around opioid use disorder treatment. And her husband Josh is our State Attorney General!

If you are interested, you can view each of the roughly 90- minute webinars here: www.mahec.net/jailmat

Book Review: “The Opioid Epidemic: What Everyone Needs to Know,” by Yngvild Olsen and Joshua Sharfstein

This is The Book. This is the one you need to read for evidence-based information on opioid use disorder, its treatment with medications, and what we can do to address the epidemic.

The prose is lean and easy to understand without talking down to readers. Published by Oxford University Press in 2019, it’s still relatively up to date. It’s a substantial read, at 344 information-packed pages.

I know of one of the authors, Dr. Olsen, from presentations she’s given at national ASAM meetings (American Society of Addiction Medicine). In fact, I just listened to a recorded presentation from spring of 2022 where she was one of the main presenters about how treatment regulations changed both before and after COVID 19. She’s been a leader in the field of Addiction Medicine, holding key positions in both federal and state organizations.

She knows what she’s talking about.

Her co-author, Dr. Sharfstein, is also a standout in the field. He teaches courses at Johns Hopkins’ Bloomberg School of Public Health, giving this book a depth of information not seen in others on the same topic.

The book, written in a question-and-answer format, starts at the first chapter by defining what opioids are and how they work. The authors make clear the difference between addiction and physical dependence, which is so often misunderstood. In that first chapter, the book also answers another common misperception: why using methadone or buprenorphine is not “just replacing one addiction with another.” The authors accomplished this so deftly that I knew the book was a winner.

In the second chapter, they describe how opioids are used for pain, and in the third chapter describe how misuse of opioids can start. Chapter 4 discusses what opioid addiction (opioid use disorder) is.

Chapter 5 covers what opioid overdose is and how it can be treated with naloxone. The authors dispel more myths in the chapter, like the one that says people using opioids will use more if they know naloxone is available to save them.

Chapter 6 does the heavily lifting of describing what is and is not effective treatment for opioid use disorder. The authors do a great job of describing treatment both in office-based practices and at opioid treatment programs. They cover methadone, buprenorphine, and naltrexone. They even touch on use of kratom and ibogaine as purported treatments with little information to recommend their use.

Chapter 7 covers treatment for pregnant patients. I was so happy to see their discouragement of the use of the phrase “addicted babies” as an outdated and improper term. Chapter 8 discusses use of opioids in teens and recommended treatments for this age group.

Chapter 9 focuses on questions that families of people with opioid use disorder often have. The book encourages the families while still warning them that opioid use disorder is a chronic illness. They discuss the term “enabling” and why allowing a family member to “hit rock bottom” may not be the best thing to do.

Chapter 10 talks about the supports people in recovery need, specifically housing and other essentials. They talk some about peer supports as well, and about 12-step meetings and how in some cases, 12-step meetings can be confusing for people new to recovery on MOUD.

Chapter 11 gives the historical perspective of the opioid epidemic in the U.S., going all the way back to just after the Civil War, and up to the age of fentanyl.

Chapters 12 through 16 are possibly the most helpful sections of this book, describing evidence-based policies that can help us in the areas of prevention, treatment, and harm reduction of opioid use disorder. There’s also a chapter about our failed war on drugs, explaining how we could better use law enforcement to help people enter treatment instead of jail.

I found myself in the “Amen!” corner while reading this book, excited to see evidence-based treatment options discussed so eloquently in a book.

I would recommend this book to any person who wants scientific information about opioid use disorder and its treatment. It’s an appropriate book for public health officials on all levels: federal, state, local, counties, etc.

It is as up to date as possible given its 2019 publication date, and I hope this is the first of many editions of this book. Things change quickly in the arena of opioid use disorder and its treatment, so we should be ready for a second edition soon.

Difficulties Getting Treatment While Pregnant

Ukrainian Art Bought off ETSY by Anastasiia Grygorieva

I read an interesting and depressing article in the Journal of Addiction Medicine (May/June 2022) by Davis et al. It was about access to treatment for pregnant women in states with laws preventing discrimination against them. The study sought to find out if such laws made a difference and assured more access to care than in states without such laws.

As my readers know, using medications for opioid use disorder (MOUD) is the standard of care for people with opioid use disorder, and is particularly recommended for pregnant patients with opioid use disorder. This is because of proven benefits not only to the mom, but also to the infant. Moms on MOUD are less likely to have complications and more likely to have heathy full-term babies.

There’s no evidence that avoiding MOUD during pregnancy decreases the risk of withdrawal in newborns, as some have falsely claimed. This sentence is directed to the backward obstetricians in Tennessee, except apparently, they don’t do much reading, or they’d already know this by now.

Anyway, back to the study. This was a “secret shopper” type of study, where the study’s authors called treatment programs, posing as prospective patients. These simulated patients said either that they were not pregnant or were four months pregnant. They made calls to programs in states that have laws forbidding providers from refusing to treat pregnant patients, and in states without such laws. The study sought to see if treatment is more accessible to pregnant women in states with laws forbidding discrimination.

They called opioid treatment programs and office-based buprenorphine programs in ten states. Four states had laws preventing discrimination due to pregnancy: Kentucky. Missouri, Tennessee, and West Virginia. Study authers also called providers in six other states: Florida, Massachusetts, Michigan, North Carolina, Virginia, and Washington, where there are no such laws.

All callers said they had either Medicaid or private insurance.

In both groups of states, non-pregnant callers were significantly more likely to get appointments than pregnant callers.

 In states with a law mandating treatment access for pregnant patients, the non-pregnant callers got appointments 75% of the time, and pregnant patients only 60% of the time. In states without a law mandating treatment access for pregnant patients, 73% of non-pregnant patients and 62% of pregnant patients were able to get an appointment.

The study was done in 2019, so COVID wasn’t a confounding factor.

Office-based buprenorphine prescribers were significantly more likely to turn down pregnant patients than opioid treatment programs. In fact, at opioid treatment programs, pregnant and non-pregnant patients got appointments at the same rate.

So why don’t laws prohibiting pregnancy discrimination work?

I have some ideas, and so do the authors of this study.

The authors think providers might not know about these laws prohibiting discrimination, or if they do know, have never seen the laws enforced. These providers may not think they will get into any trouble for turning down a pregnant patient.

They also point out that the relevant laws only apply to providers who accept Medicaid for payment. Many OBOT (office-based opioid treatment) programs don’t participate in the Medicaid. I think this is because of low reimbursement rates and administrative hassles.

I also think most providers don’t like to treat pregnant women. They make us nervous. The actual physical treatment is more complicated, and more ethical issues arise. What if we precipitate withdrawal with the first dose of buprenorphine and the patient has a miscarriage?  It takes more time and energy to coordinate with an obstetrician, who may disapprove of buprenorphine use in pregnant women. For example, in Tennessee, buprenorphine providers say many OBs don’t want their pregnant patients on buprenorphine OR methadone. Will that lead to a contentious relationship between the OB and the OBOT physician?

And what if the pregnant woman refuses to go to the OB once she’s started on buprenorphine? Will the buprenorphine prescriber be blamed for a bad outcome if there’s no prenatal care except what she gets in the OBOT office?

I think these thoughts enter the average OBOT provider’s brain when faced with a new pregnant patient.

Things get even more complicated when we consider that some of these states have laws against drug use during pregnancy. In these states, instead of approaching drug use in pregnancy as a public health issue, they view it as a crime.

According to Guttmacher Institute (https://www.guttmacher.org/state-policy/explore/substance-use-during-pregnancy ), at present twenty-four states and the District of Columbia consider drug use during pregnancy to be child abuse, and three consider it grounds for civil commitment. Twenty-five states and D.C. require healthcare professionals to report suspected prenatal drug use.

Lawmakers sometimes say the reasons they pass these laws is to push pregnant women into getting help and getting treatment for their substance use disorders. Except that, as this study shows, it’s harder for pregnant women to get into treatment than non-pregnant, even with laws meant to increase their access.

Opioid use disorder treatment providers might not want to get in a situation where they are mandated to report a pregnant patient who isn’t doing well in treatment.

Imagine you are a woman with a substance use disorder and you just found out you’re pregnant. If you live in a state with laws criminalizing drug use during pregnancy, you might fear your doctor will report you if you seek medical care, assuming the doctor detects your drug use. Would you go to the doctor for prenatal care? Would you try to get treatment assistance? If you tried to get help and were turned down repeatedly, what would you do?

With abortion becoming far more difficult to obtain in many states, I suspect most pregnant women in these states will try to carry on as best they can during the pregnancy, without prenatal care, and hope for the best at delivery.

Medically, this is the worst option.

The maternal mortality rate in the U.S. is 17 deaths per 100,000 live births, which isn’t as good as all other high-income countries, but at least we have fewer maternal deaths than Turkey, Chile, and Mexico. This dismal data isn’t due to drug use alone, but to lack of available health care, among other factors. [1]

Infant mortality rates in the U.S. aren’t anything to brag about either, with most recent data showing we have 5 deaths per 1000 live births. That’s far worse that countries like Norway, Japan, and Singapore, but on par with countries such as Uruguay, Serbia, and the Slovak Republic. Even the Russian Federation and Cuba had better infant mortality rates than the U.S. did in 2020. [2]

Maybe it’s time we re-thought our healthcare system and our drug laws for pregnant women. And maybe if laws are passed to improve access for pregnant women, they should be implemented with the kind of support that makes providers eager to treat them.

  1. https://www.commonwealthfund.org/publications/issue-briefs/2020/nov/maternal-mortality-maternity-care-us-compared-10-countries
  2. https://data.worldbank.org/indicator/SP.DYN.IMRT.IN?most_recent_value_desc=false

Patient Impairment

Ukrainian art from ETSY: Alex Gru

Patients on MOUD (medications for opioid use disorder) need to dose daily for stability unless they are on depot-release forms of such medications such as Sublocade. We encourage patients to dose daily around the same time whether it’s from a take home dose or at our facility. Patients taking consistent and sufficient doses have reduced rates of overdose death, improved mental and physical health, and better employment.

However, sometimes it’s not safe to dose a patient. This can be due to a medical crisis that must be resolved, or due to impairment from sedative medication. It’s relatively rare for patients to arrive at their opioid treatment program with impairment, but it does happen, and physicians and providers need to be prepared for how to handle these events.

Sedatives like benzodiazepine (Xanax, Valium, Klonopin, and the like), alcohol, and other sedatives do not mix well with opioids. Both opioids and sedatives affect the part of the brain that tells us to breathe when we are asleep. People can die from single large doses of opioids, and they can also die if they mix sedatives and opioids. They go to sleep, stop breathing, and die from lack of oxygen to the brain, heart, and other important organs. This can happen quickly, as with a potent dose of fentanyl, or it can take much longer, perhaps hours, with longer-acting sedatives and opioids.

Before the patient gets to the unconscious stage, there’s often a period of impairment, when the patient doesn’t act or sound like their usual alert selves.

Impairment is defined, for these purposes, as a decline in mental function over baseline. Instead of being alert, the patient may be drowsy or inattentive. Instead of having clear speech with appropriate content, the patient may have slurred words, rambling or incoherent speech. There may be loss of control of motor function, leading to unsteady gait, stumbling, or even falling.

Impairment happens on a continuum; at one end a patient can be so impaired that he’s unconscious and needs to be revived with Narcan and CPR. At the other extreme, impairment might be so light that clinicians can’t detect it.

Part of our job at an OTP is to evaluate risks and benefits. If a patient is impaired, the risk of dosing her that day might outweigh the usual benefit of that dose.

Impairment must be evaluated by medical personnel. While receptionists, security guards or counselors can alert medical staff about a potential problem, the medical evaluation must be done by medical personnel.

This evaluation is done by the physicians or physician extenders unless there are none on site. In that case, an RN can gather data and evaluate for impairment. He or she can decide about the safety of dosing or may call the program physician for help with the decision. In our state of North Carolina, the Board of Nursing has said while RNs can work independently, LPNs cannot. LPNs can collect data but then must consult an RN, physician extender or physician to decide about the safety of dosing.

At our opioid treatment program, we take the patient to a private area. We don’t want to embarrass any patient in front of other people. I walk with my patient to my office, observing gait and balance. I try to be friendly and compassionate, realizing that the patient may be feeling fragile.

Once in my office I ask them how they are feeling, and about recent drug use or new medications. I listen to the content of what they tell me and to the delivery of their information. I listen for slurred speech or softening of consonants, speech content, and flow of conversation.

It’s helpful to get vital signs: temperature, blood pressure, heart rate, and respiratory rate. I add a pulse oximetry reading too. If these readings are abnormal, it can indicate a physical health problem as a cause of impairment. This can be serious and requires immediate medical investigation, usually at the local emergency department.

After talking to the patient, I turn to my computer and take my time typing data. While I do this, I watch the patient too. If she nods or falls asleep during conversational lulls, it’s probably not safe to dose her.

We have several tests we can ask the patient to do to test for motor impairment from sedatives. There’s the tandem gait test, which is what policemen do when they ask motorists to walk in a straight line. There’s the finger to nose test where the patient extends both arms, closes their eyes and brings the index finger to touch their nose.

My favorite is to ask my patient to stand on one foot for thirty seconds. It’s easy to do and I do it with them, so they won’t feel so put on the spot. Most people wobble a little but can keep their balance without touching down with the free foot or reaching for furniture.

We can also look for nystagmus of the eyes. This simple test, often misinterpreted by non-medical people, involves asking the patient to look to their extreme left or right. Then the examiner watches for slight bouncing of the eyes back and forth as the subject tries to keep their eyes in the extreme lateral position. Normal people can have one or two beats of nystagmus, but patients who have taken sedatives such as alcohol or benzodiazepines will have continued movement of their eyes.

Medical providers must remember that some medical crises can look like impairment from sedatives. A few months ago, a patient checked for impairment had a blood pressure of around 70/40 with an irregular heart rate into the 150’s, obviously in atrial fibrillation. We called the ambulance to take him to the hospital and he ultimately recovered.

Patients who are deemed to be impaired by medical providers often say they didn’t get any sleep the night before. This may be true, but lack of sleep shouldn’t cause slurred speech or problems with balance, unless they’ve been without sleep for days, in which case they probably need to go home and sleep before they get their next dose anyway.

It’s difficult for me to tell a patient they can’t be dosed that day. I know it will upset them and make them angry. I just keep trying to tell them that I’m refusing to dose them due to safety concerns, and that I’d rather they be angry with me but still alive.

Medical providers should expect a great deal of anger and should not take it personally.

We also try to get a urine sample for drug testing, thought that test won’t tell us if the patient is impaired. A urine drug screen only tells us if a given drug has been used in the recent past. Patients can be impaired with a negative drug and can be alert and fine to dose with a drug screen positive for multiple things.

Alcohol breath testing is the only drug where levels correlate with blood levels. Depending on the alcohol breath test, we can determine if the patient is under the influence of alcohol or not. The legal limit is .08, but patients on MOUD may be impaired at a much lower alcohol level, due to alcohol/drug interaction. We don’t dose patients if alcohol is detected.

After determining a patient to be too impaired to dose, I ask for help from the patient’s counselor. We must find a way to get them home without allowing the patient to drive. In big cities, public transportation takes care of this, but in our rural community, everyone drives everywhere because there is no public transportation. This can be difficult.

Also, we want to get permission to call a friend or family member to stay with our patient to watch them. We want to educate this person to call 911 if the patient becomes unresponsive and can’t be wakened, and make sure they know how to use Narcan, while waiting for EMS.

Anytime a patient can’t be dosed due to impairment, the physician must meet with the patient the next day, or as soon as possible. Impairment might be a warning that the patient has so little control over drug use that an inpatient treatment setting is indicated, at least temporarily.

Above all, it’s important to encourage the patient and let them know we care about what happens to them. We remind them part of our job is to make treatment as safe as possible. More than that needs to wait until the patient is clear and not impaired.

As I said in the beginning of this blog, impairment events are rare. Most of our patients never have such an episode. But when we do have a patient with impairment, we must be ready to intervene with compassion and good judgment about what is in the patient’s best interest.

Book Review: “Bad Medicine: Catching New York’s Deadliest Pill Pusher,” by Charlotte Bismuth

The author wrote about her investigation and prosecution of Dr. Stan Li, a pain management physician who was ultimately convicted of two counts of manslaughter in the second degree and related offenses.

The author was an Assistant District Attorney with the Special Narcotics Unit when she started this case. She worked for four years accumulating data to show a jury that this doctor was motivated by greed and not by concern for his patients. She proved he prescribed dangerously high doses of opioids, many times along with prescriptions for sedatives, causing harm to patients.

He was convicted and then sentenced to ten years in prison. He was incarcerated in but died in early 2020 at age 68 from COVID which he contracted while in prison.

It is a story that needed telling. It’s not an unusual story at this point, with many similar books about pill-pushing doctors, but this one was written by the prosecuting attorney, giving more insight into how the government viewed their case and how they presented their case in court.

I have mixed feelings about this book.

I didn’t care for the way the author told her story.

For some reason, starting ten or so years ago, it became cool and hip to tell a story out of order. Telling the beginning first, then the middle, then the end suddenly became old-fashioned in the publishing industry. This book told the story upside down and sideways, and this annoys me mightily. The author went from “Day 1023 before the trial,” to “Day 45 after the trial,” and it’s confusing.

I’d advise the author to ignore what the hipster publicists think is cool and just tell the damn story.

Also, the author included details of her personal problems scattered among the disjointed narrative of the trial. I didn’t care for that, feeling that if she wants to include those kinds of things, call it a memoir instead of a narrative nonfiction. I wanted to read about the prosecutor’s thoughts and feelings about the physician and the case, not about the prosecutor’s Botox decisions. However, some people do like such details in a book, so I might hold a minority opinion.

I also felt a little sorry for Dr. Li. He came of age when the so-called “experts,” bought and paid for by pharmaceutical companies, told doctors there was little risk of causing addiction in patients with pain. He must have bought into that farce whole-heartedly, though his later actions suggested he did realize he was running little more than a pill mill. What those paid experts said back in the early 2000’s always did appear to fly in the face of common sense, but they were well-funded by the pharmaceutical companies. And none of those experts went to jail.

I didn’t expect the author to say much about treatment, since that wasn’t the theme of the book (but neither was Botox and we got to read about that). At any rate, there was perhaps one mention of medications to treat opioid use disorder.

The inner thoughts of this prosecutor were well-expressed. She appeared relatively naïve about physicians and their prescribing practices, and it seemed to take her some time to understand the difference between a good pain management practice and a pill mill. I could have saved her time: it’s all about the amount of time the physician spends with the patient.

A pill mill doctor will spend only a few minutes with each patient because he’s seeing fifty to a hundred patients per day. Pain management providers see patients for ten to twenty minutes at a minimum, seeing around twenty to thirty patients per day.

I was dismayed at the slow pace of work of this prosecutor. The dangerous doctor came onto the ADA’s radar about three years after he started his practice. It took her four years to investigate, meaning he did most of his work while the prosecutor trudged along getting evidence.

I know real life doesn’t move as fast as on “Law and Order.” But taking four years to investigate a doctor she thought was so dangerous? Seems like she would speed her investigation to keep patient harm to a minimum.

But it’s a good book, other than the annoyance of being disjointed.

Mortality in Opioid Treatment Programs

By Ukrainian artist Maksym Kisilov

I came across an excellent article about mortality in Norwegian opioid treatment programs. [1]

Unlike the U.S., Norwegians have an organized healthcare system, making it easier to do studies on groups of citizens. The researchers who wrote the article wanted to study mortality among patients enrolled in their Norwegian Opioid Treatment Programs, so they looked at data from the Norwegian Cause of Death Registry and the Norwegian Patient Registry and studied those patients.

We already know that people who use illicit opioids have  up to fifteen times the risk of premature death as compared with the general population, and we know from multiple studies that MOUD reduces mortality for these people. Studies like this one help us find common causes of death for patients in treatment which may help us provide interventions to improve the quality and length of life for patients on MOUD (medications for opioid use disorder).

In this study, out of the 7622 patients enrolled in treatment, 38% were dosing on methadone and 59% on buprenorphine, either as monoproduct or in combination with naloxone. The article doesn’t mention what the other 3% were taking but I suspect it was naltrexone.

The researchers looked all patients who died in a two-year period from early 2014 until the end of 2015. To be included in the study, these patients had to have died no more than 5 days after their last dose of medication. Two-hundred patients died during that time, which gave a rate of 1.4% per year, out of all patients enrolled in treatment.

That’s a little higher than what has been found in other studies. A recent systematic review with meta-analysis of all-cause mortality in patients enrolled in opioid treatment programs showed a rate of .93 people out of 100 over a one-year period. [2]

Again, I want to emphasize this rate is between two to eight times lower than patients with opioid use disorder who aren’t on MOUD.

Causes of death in the Norwegian study fell into broad categories: somatic disease accounted for 45% of the deaths; drug-induced deaths made up 42% of the deaths, and 12% were categorized as violent deaths, leaving 1% as uncategorized. The mean age of death was 49 years old, and 74% of the decedents were male. Autopsies were done on 63% of the decedents, a relatively large percentage.

Somatic deaths were due mostly to cancer, cardiovascular deaths, pulmonary illnesses, and liver diseases. A full 30% of cancer deaths were due to lung cancer. Bacterial infections accounted for 15% of the somatic deaths.

Homicides, suicides and auto accidents accounted for most of the violent deaths, with half due to suicides.

Among the drug-induced deaths, none occurred during induction, though induction has been found to be the most dangerous time in other studies. More patients (55%) of the decedents died while taking methadone than buprenorphine. In fact, the mortality rate was double in methadone patients compared to buprenorphine patients. The average dose of methadone for those patients who died was 90mg, and for buprenorphine was 16mg.

 In Norway, MOUD is started by either specialists or general practitioners, and 68% of the decedents had their medication prescribed by general practitioners.

Nearly 30% of the patients who died from drug-induced deaths had a non-fatal overdose within the past five years, and 43% had filled at least one sedative prescription in the year before death. The median duration of treatment among these deceased patients was eight years.

Out of the 84 drug-induced deaths, methadone was reported as the main cause of death in 37%. Heroin was blamed in 20%, and buprenorphine was reported as the main intoxicant in around 18%.

 In the discussion section of this study, the authors say both age and lifestyle factors influence the causes of somatic disease seen in these patients.

Norway has one of the oldest opioid treatment patients in Europe, with a mean age of forty-five. With aging treatment programs come aging patients, which may account for the large number of deaths from somatic diseases. Nearly all countries face this situation, including the U.S. Also, nearly all patients with opioid use disorder smoke cigarettes, and this contributes to cancer risk, COPD, and cardiovascular diseases.

And why were there significantly more deaths among the methadone patients than among the buprenorphine patients? Again, the study’s authors wonder if increasing age and co-occurring medical disorders make methadone more dangerous. They wondered if patients taking more medications for these medical disorders might cause QT prolongation in these methadone patients.

So how does this data help providers of treatment in U.S. opioid treatment programs?

After reading this study, I’ve decided to spend more time talking to my patients about smoking cessation. I need to encourage those who wish to quit smoking and we need to put that as a goal in their treatment plans. We need to consider some stop-smoking groups at our OTP, and perhaps find funding for smoking cessation medications.

Smoking causes or worsens cardiovascular diseases like strokes and heart attacks and causes most cases of COPD (Chronic obstructive pulmonary disease). We know it causes or contributes to many kinds of cancers.

If we want our patients, who have survived opioid use disorder and found recovery from it, to lead longer and happier lives, we must address nicotine use disorder. It’s another drug and just as deadly as opioids, though it kills more slowly and thus less dramatically.

Our patients must be connected to quality primary care. In the OTP where I work, owned by a nationwide corporation, providers are permitted to prescribe only the methadone, buprenorphine products, and naltrexone used to treat opioid use disorder. This means all primary care management of chronic health conditions is done outside of our OTP, and we must refer patients for care.

This is a rural area, and we don’t have enough primary care providers. Our patients often get turned down by these providers. I suspect it’s because of stigma in some cases, against people with substance use disorders. Also, most of our patients don’t have any health insurance. I’d estimate that around half our patients have no way to pay for medical care. There is a free clinic in town that’s open one day per month, but the amount of care provided is limited. There are FQHCs (Federally Qualified Heath Centers) in neighboring towns, but transportation is difficult.

I don’t know how to fix this in our broken healthcare system. It’s frustrating.

I was unpleasantly surprised that so many of the Norwegian patients died from overdose deaths. From the data, a large percentage filled a sedative in the year prior to death, underlining – once again – how dangerous these medications are when mixed with methadone or buprenorphine.

A depressing number of the overdoses were attributed to methadone alone. However, I wonder if Norway has the same issue we have in some states: there’s no standard case definition of what constitutes methadone overdose death. In North Carolina, it appears that if methadone is found in the decedent, it will be named as the cause of death.

The large number of suicides by patients in the violent deaths group was surprising and makes me wonder if we are doing all we should be doing at the OTP to screen for patients with serious mental health issues. We do have the local mental health clinic where we refer our patients, and their quality of care has improved in the past years. Perhaps we can start screening for depression more often, for example, by using the PHQ9 form that patients can complete.

According to the data in this Norwegian study, aging patients on multiple medications could benefit from being followed more closely than I’ve been doing. All patients must see me once per year at a minimum for a yearly assessment, but I’d like to see older patients on methadone every three months. I’ll be looking for potential medication interactions and adequacy of their dose.

 I’ll particularly be asking patients about gabapentin. I’m convinced this medication has been at least partially responsible for some episodes of impairment and overdose among patients, and it is prescribed way too freely by providers in my county.

In fact, in my more paranoid moments I think I’m the only person in the county who isn’t prescribed gabapentin.  I think there may be traffic checkpoints at the county lines: “Ma’am we’re just making sure you have a prescription for gabapentin. No? Ok, then we must issue you a prescription for it. Here’s your script for gabapentin 1800mg three times per day.”

Once a patient tells us he’s just been prescribed gabapentin for the ever-present “nerve pain,” I call the provider and explain the dangers of mixing gabapentin with methadone. Even if that provider reduces or stops the medication there’s always another provider eager to take over prescribing. Since it isn’t reported on our state’s prescription monitoring program, I don’t know who is getting a prescription unless the patient tells us. On at least two occasions, providers prescribed both pregabalin and gabapentin for the same patient. One provider said she didn’t realize she was prescribing both and the other was intentionally prescribing both medications because the patient asked for both. And yes, both patients had swollen legs.

This interesting article gave data that I can discuss with our clinic leaders with the goal of improving care and along with it, the quality and length of life of our patients.

  1. Bech et al., “Mortality and causes of death among patients with opioid use disorder receiving opioid agonist treatment: a national register study,” BMC Health Services Research 2019 Jul 2;19(1):440. Doi: 10.1186/s12913-019-4282-z. PMID: 31266495; PMCID: PMC6604272.  
  2. Ma et al., “Effects of medication-assisted treatment on mortality among opioid users: a systematic review and meta-analysis,” 2018, Molecular Psychiatry,

Indiana: Discrimination Against Nurses on MOUD

Ukrainian art – Julia Datta

Many medical boards and nursing boards don’t allow their licensees to practice if they are prescribed MOUD (medications for opioid use disorder). It’s something that hasn’t been talked about much. Most of the boards preferred to keep quiet about these decisions, trying to avoid publicity and lawsuits from healthcare professionals who were denied licenses to practice their profession.

As I’ve talked about in other blog posts, things are changing. The Department of Justice has investigated discrimination against people with opioid use disorder who are treated with medications such as methadone or buprenorphine.

In March of this year, the Department of Justice (DOJ) finished investigating Indiana’s state board of nursing, because they have refused to allow nurses on either buprenorphine or methadone to participate in their Nursing Assistance Program.

The medical boards tasked with protecting the public from problematic physicians usually gives the chore of monitoring doctors with mental health and substance use disorders up to an independent organization, usually called Physician Health Programs. Some nursing boards do this monitoring themselves, through some type of nursing assistance program. These programs monitor licensees with substance use disorders through mandating treatment programs, doing random drug screening, and other methods. The licensees who do well in their recovery receive advocacy from the assistance programs and regain their nursing licenses and go back into their professions.

Indiana’s nursing board would not allow nurses on buprenorphine or methadone to participate in their nursing assistance program, leaving these patients with no method to get their licenses re-instated. The treatment providers that the Indiana nursing board contracted with were all abstinence-based, and patients on MOUD couldn’t participate.

The DOJ says this violates those nurses’ civil rights.

Their full report can be read here:  https://www.justice.gov/crt/case-document/file/1492726/download

Released in March of this year, the DOJ decision says, in part, that their conclusions of law are:

“The Nursing Board’s prohibition on ISNAP participants’ use of OUD medication in ISNAP (Indian State Nursing Assistance Program) penalized Complainant for her disability and was not justified by any individualized medical assessment.”

Because the DOJ found that the Indiana Nursing Board violated title II of the ADA, they recommended they immediately do the following items:

“1. Adopt or revise written policies to eliminate the ban on ISNAP participants using medication to treat OUD and to explicitly state that the Nursing Board, and its contracted vendors, may not discriminate against, exclude from participation, or deny the benefits of its services, programs, or activities—including ISNAP—to qualified individuals with disabilities because they have OUD.

 2. Appropriately train and educate all Nursing Board staff and the staff of ISNAP vendors about OUD and the nondiscrimination requirements of Title II of the ADA.

3. Pay compensatory damages to the Complainant and other aggrieved individuals for injuries caused by the Nursing Board’s actions described in this letter.

4. Provide the United States with written status reports delineating all steps taken to comply with these requirements, including the date(s) on which each step was taken, and, where applicable, information sufficient to demonstrate compliance.”

I thought this decision was appropriate, and I applaud the DOJ for finding against the abstinence-only version of treatment offered by the Indiana Board of Nursing.

I had the pleasure of working on the North Carolina Board of Nursing’s Advisory Committee from 2010 until 2013. This committee met twice per year and served to advise the NCBON about various aspects of the Board’s job. Considerable time was spent discussing how board Licensees were doing in the recovery programs that were set up under the Board and how that program was administered.

I’m pleased to say that North Carolina was ahead of the times. As far back as 2008, I remember managing the care of nurses who were my patients, on either methadone or buprenorphine products. The Board allowed them to work and participate in the recovery programs, with only a few added precautions.

The Board required periodic updates be sent from the physician prescribing the methadone or buprenorphine. They wanted information about updates in the treatment plan. They also asked for a standard form to be filled out and faxed back to the NCBON after each visit, stating how the patient was doing in treatment. That was simple enough, and I was happy to advocate for my patients with the NCBON.

I saw some of those patients only for a few years, but others I still see today, after over a decade on MOUD. Those patients have done well in their lives and their recovery, rising to the top of their field. They are the kind of nurses that you’d be relieved to have taking care of a loved one.

The NC BON wasn’t enlightened because of me; they already had progressive attitudes before I served on their advisory committee. It was the work of other doctors and personnel who served before I came on the scene. Whatever the reason, I was pleased and surprised with approach towards MOUD.

Around 2013, the Advisory Committee for the Board of Nursing asked me to do an hour-long presentation on opioid use disorder and its treatment with medications. In 2012, there was an article published [1] that claimed medical professionals shouldn’t be considered for buprenorphine therapy, and naturally they were concerned about this report.  In my presentation to the committee, I included my critique of that article. I felt the author was biased and misrepresented the data found in some of the studies she cited.   I was happy to do this, and it seemed well-received. I was grateful the leaders of the Board of Nursing wanted as much information as possible.

Then in 2019, I experienced the highlight of my medical career. I was asked by the North Carolina Medical Board to come and talk to the full board about the same topic: opioid use disorder and its treatment with medication, and how it compares to the usual abstinence-based treatments that physicians usually receive.

What made it the highlight of my career? For one thing, I had some…how shall we call it…experience with the medical board. They saw me at my lowest point – when my own recovery was new and shaky.

During my own substance use disorder, I’d decided the cause of my substance use was my job. Anyone with my job would use drugs, I reasoned, so if I just quit work, I could stop using the drugs and alcohol that I knew were causing me problems. I quit my job and was dismayed when I still couldn’t control my substance use. Convinced I wouldn’t ever want to practice medicine again, I inactivated my license.

It was an impulsive and foolish decision which I later regretted. But people under the influence don’t always make great decisions.

It wasn’t long into recovery before I saw that my addiction was about more than my job. To be sure, there were certain pressures at work that hadn’t helped any, but there were multiple factors. To re-activate my license, I had to complete a form that asked if I had ever had any issues with substance abuse. I answered honestly, and said I was working with the North Carolina’s Physicians Health Program. According to Board regulations, I had to meet with the board to be granted a Consent Order to get an active license and return to work.

I met with the Board three or four times, and it was always scary as hell. These people had the power to revoke my medical license permanently, although they really had no reason to do so.

Because I was doing well in my recovery, the board members who met with me were pleasant and encouraging. They congratulated me on my recovery and granted a consent order with some restrictions on my license for the first year or so. It wasn’t long before I got a full unrestricted license back.

As nice as they were, I was still overwhelmed with shame and felt like a bad doctor & a bad person. As easy as it is for me – now – to tell patients now that they are a sick person trying to get better and not a bad person trying to be good, it didn’t feel that way to me in early recovery. I still felt much guilt for “allowing” addiction to happen to me.

Then for the medical board to ask me to come back twenty years later, to speak to the board as an expert was overwhelming.

But it was a tough assignment. Physicians in abstinence-based recovery do very well, with 80% abstinence rate at five years. But that’s for all physicians, using a variety of substances. As we know, recovery from opioid use disorder doesn’t always look the same as recovery from other substances. Among physicians in these studies, alcohol was the most used substance, but opioids were in second place.

In my talk, I acknowledged the data showing physicians recover at better rates than the general population with abstinence-based treatments, which may change the decisional balance about using MOUD, particularly if the patient was strongly motivated to have abstinence-based recovery. But I also said medications were the gold standard treatment for opioid use disorder, there was no firm evidence that patients on stable doses are unable to function as physicians, or physician assistants. (The NC Board of Nursing oversees Nurse Practitioners). Patients who want to use MOUD should be allowed to practice in their professions if there are no other safety concerns. If there were specific concerns, the physician could have neuropsychiatric testing for reaction time, dexterity, etc.

I was asked bluntly if I thought the Medical Board could legitimately deny MOUD to one of its licensees seeking recovery. I told them with the data about the increased risk of death for patients denied medication, I didn’t think they could, or should. I said especially if a licensee had a relapse onto opioids after an episode of abstinence-based treatment, methadone or buprenorphine should be presented as an option to the patient, to prevent death.

I said some things that the board probably didn’t want to hear, but I spoke the truth as I knew it, which was what they asked me for.

I was gratified with their response. I think I was one of three speakers, and my understanding was that after my bit, I’d leave, and the next speaker would start. However, the full board called for a break and board members came up to me and thanked me for talking. I was embarrassed by how happy I felt.

At that time, I didn’t know that the law would have considered it a violation of the ADA to deny physicians access to medications for opioid use disorder.

Today, the DOJ appears to have made the decision for all the state licensing boards that to deny licensees the ability to practice is discrimination that can bring legal attention and action onto the boards.

 I think it’s the right decision. In this age of shortages of healthcare personnel, a more flexible approach will allow more recovering people to be able to practice in their profession. It may also reduce deaths from opioid use disorder in this population, as it does for people in general.

  1. Hamza et al., “Buprenorphine Maintenance Therapy in Opioid-addicted Health Care Professionals Returning to Clinical Practice: A Hidden Controversy,” Mayo Clinic Proceedings, 2012 March 87(3): pp. 260-267.

Answering Questions

Ukranian art by Anna Shevel

“Addiction is considered a behavioral mental health disorder, correct?? So what types of diagnostic testing are useful when determining the level of care for someone who’s seeking treatment for an opiate use disorder? Or is the notion of attempting scientific evidence to verify or properly assess patients like these just not practical? surely there’s even one test that a physician should perform besides a standard urine screening (??) Urine test can only verify the presence of an opiate, on one particular day, one occasion, right? In theory I could visit the dentist, take a prescription pain killer one time and then be equally qualified for any MAT program that’s relying on only a urine test! Or maybe I’m just confused… Thank you”

I decided to answer my reader’s question in the form of a whole blog, given the complexities of what the poster is asking.

This is really a two-part question; the first part involves how doctors diagnose opioid use disorder, and the second is how they decide the appropriate level of care.

Let’s take the first question. We use the DSM 5 criteria to confirm a diagnosis of opioid use disorder, and the criteria also help describe the opioid use disorder as mild, moderate, or severe:

My reader is correct: one positive urine drug screen for opioids isn’t diagnostic for opioid use disorder. We need patient histories to confirm the diagnosis. As you can see, all but one (physical withdrawal) of the eleven items are based on patient history, which is why providers who use medications to treat opioid use disorder usually ask new patients to come to arrive in withdrawal. But even when that’s not possible, there are workarounds.

Upon meeting a new patient, I ask her to tell me her story: how she started use, how the use changed over time, what happened in her life. I settle into my chair and listen carefully, trying my best not to interrupt.

I’m listening for common themes, keeping in mind the diagnostic criteria. I’ve talked to thousands of patients over the past twenty-one years, and the histories are similar but not identical. If the patient has an unusual history, I’ll ask questions for clarifications. Some patients are vague with poor memories and other patients recite a straightforward history that I could type word for word. Most are somewhere in between.

Though patient history is a big part of making the diagnosis of opioid use disorder, it’s only one piece of the diagnostic pie, though it is a large piece. We have other factors.

For example, we do point of care (immediate results) drug screens on admission. These results should match the patient’s history and show the opioids the patient has used most recently. If that screen is negative for opioids, we need to know why. Perhaps our test is limited, or it’s been too many days since last use. If the drug screen doesn’t match the history, we need to take a closer look.

We look at prior treatment or lack of it. If I already know the patient from a previous admission, the diagnosis has already been made. We only need to make sure the patient is still appropriate for treatment at our level of care.

I’ll ask for old records. If the patient has had prior treatment elsewhere, I want to see those records, for information not only about diagnosis, but also how the patient did in treatment. It’s nice to get that information before starting treatment but that’s not always possible. Usually, we can get this data within the first 24-48 hours.

I check our state’s prescription monitoring program to look for prior opioid prescriptions and prior buprenorphine product prescriptions. Again, findings should match patient history. If the patient gives a long history of opioid prescriptions from pain clinics, I should be able to see them on our PMP. If I can’t, I need to ask which state the patient filled them in, and when. I might need to double check the patient’s birthdate or spelling of name. Now with so many people using heroin/fentanyl, most patients have limited data on the PMP, which is a big change from five years ago.

I do a physical exam. We ask patients to come for intake in at lease mild withdrawal if possible, so that I can see signs of opioid withdrawal. I look at the size of the pupils, watering of eyes and nose, goosebumps, tremor, and at the blood pressure and heart rate. I look for needle marks on the skin if the patient gave a history of intravenous use. I look for muscle jerks and overall appearance.

While it’s true that other things can cause physical signs that mimic some opioid withdrawal signs (benzodiazepine withdrawal, stimulant intoxication), it’s another way to confirm the patient’s history.

Occasionally I ask for collaterals, with patient permission. Collaterals are family or friends who can confirm the patient history. They aren’t available for every patient but can be helpful. At our opioid treatment program, we often have patients come for admission because they have relatives in treatment with us, and collateral information is easily obtained. Sometimes family will come with the patient and can be a source of information if the patient permits.

But what my reader was really asking was this: What keeps a patient from lying to the physician to meet criteria to start methadone or buprenorphine?

Of course patients can lie. But why would they? Unless they have opioid use disorder, starting medications like methadone and buprenorphine would cause a new problem for them – physical dependency on opioids. If they lied, saying they already had this problem, they would create a new problem for themselves.

And at the end of my evaluation, when I’m reviewing the consent form for treatment, I make sure the patient understands that if they start buprenorphine or methadone, they will be physically dependent on the medication.

I tell patients that the medication – mostly methadone – can cause some euphoria in some patients, but it wears off. Anyone starting treatment with methadone only to feel euphoria is making a huge mistake that they will regret.

The most common reason the patients that I see don’t qualify for admission to the opioid treatment program is that they aren’t using opioids. About once a month or so, a patient who wants to stop using methamphetamine will come for admission. For some reason, they believe buprenorphine or methadone will help them stop using methamphetamines. I tell them I’m glad they came for treatment, and we can help them access the right kind of treatment. But starting methadone or buprenorphine isn’t the right thing to do, since they aren’t already using opioids. In fact, there are no evidence-based FDA approved medications to help with methamphetamine use disorders. We’ve had plenty of medications show initial promise, like naltrexone, bupropion, mirtazapine, and others, but none (as of today) have enough evidence to use with confidence they will help.

Once we determine our patient has the diagnosis of opioid use disorder, we need to select the appropriate level of care. This is easier. We use the American Society of Addiction Medicine Criteria:

  • Acute Intoxication and/or Withdrawal Potential.
  • Biomedical Conditions and Complications.
  • Emotional, Behavioral or Cognitive Conditions and Complications.
  • Readiness to Change.
  • Relapse, Continued Use or Continued Problem Potential.
  • Recovery and Living Environment.

In most cases, if the patient has no urgent medical or mental health issues, outpatient treatment with methadone or buprenorphine (or rarely, naltrexone) and counseling will be the appropriate level of care.

There are some exceptions. Federal regulations say patients can’t start on methadone without at least one year of physical dependence.  And if the patient has only mild opioid use disorder using the DSM criteria, patients might be better served with non-medication treatment, though that’s debated by experts.

It’s rare for me to see a patient with less than a year of opioid use and I rarely see a patient with mild opioid use disorder. I can still admit them to the opioid treatment program if I submit a request for an exception to the rules to our state’s SOTA and the federal government too, and the few times I’ve needed to do this, it was quickly approved by both agencies.

I hope this answers my reader’s questions. We do have diagnostic criteria, and we do have placement criteria that we follow for best results.

The Age of Advocacy

Ukranian Art, by Ana Plusk

The medical providers who work at opioid treatment programs in North Carolina have a weekly teleconference to discuss various things: difficult cases, best practices, and advances in treatment for opioid use disorder. We learn from each other.

Lately we’ve been talking more about advocacy efforts.

Especially with the opioid settlement money getting ready to flow out of the state’s financial faucet, we need to remind people that MOUD is the gold- standard, first line treatment for opioid use disorder. We also need to advocate for our patients when they encounter discrimination and are denied their legitimate medication.

Leading this effort is the person who chairs our weekly online meetings: Eric Morse, M.D.

Dr. Morse, owner of a number of opioid treatment programs across the middle of North Carolina,  started sending complaint reports to the Department of Justice when patients are denied their medication while incarcerated or admitted to other facilities.

He told us he sent a complaint about one patient seeking admission to a well-known abstinence-based inpatient rehabilitation facility. This patient was on MOUD but was told he couldn’t take the medication while at the facility. He made another complaint about a patient who was denied the ability to continue MOUD while incarcerated.

The DOJ let him know they decided not to pursue further investigation. That’s disappointing, but not surprising.

Another provider reminded our group that it’s much better to try to educate these facilities and their medical providers rather than make reports to authorities. However, in both above situations, Dr. Morse had exhausted all efforts to contact and educate the medical directors of both facilities prior to sending any complaints.

We now have a website to submit complaints about violations of patients’ rights directly to the Department of Justice: https://civilrights.justice.gov/report/

Anyone can report a violation of a person’s rights experienced at healthcare facilities, jails or prisons, places of employment, schools or educational programs, voting rights, or public facilities. You can print the form, fill it out and mail it in, or you can submit online. The patient can submit the complaint, and so can anyone who witnessed the violation. It can be submitted anonymously, but no reply about outcome could be sent in that case.

This month I’ve been more vocal to our patients who were denied their civil rights. I printed a stack of the complaint forms and have them on my desk. I’ve handed out several to patients who were denied their usual dose of methadone or buprenorphine when incarcerated at our county jail. Maybe one or two complaints won’t matter, but I’m hoping that after fifty or a hundred are submitted, the DOJ may look closer.

I’ve also kept in mind the advice to try to work with other physicians before complaining about them.

In this following example, I changed details to protect the identity of my patient.

A few weeks ago, one of our patients was involuntarily committed to a psychiatric facility in a nearby town. He called his counselor at the opioid treatment program and said the admitting psychiatrist told him that the facility “wasn’t a methadone clinic” and that he would not be getting his usual daily dose of methadone while he was at this facility. My patient was understandably worried he would go into opioid withdrawal. He gave the counselor his psychiatric doctor’s name and asked that I call to advocate for him.

I was happy to do this.

I didn’t have a signed release of information giving me permission to talk to this doctor, but I felt this was an exception to this rule. Medical professionals can communicate without a signed release if there’s a medical emergency. I would call involuntary commitment to a psychiatric hospital an emergency, of course.

When I finally got her psychiatrist of the phone, he was not pleasant.

I introduced myself and thanked him for returning my call, trying to be as polite and friendly and collegial as possible, but my efforts didn’t work. He kept saying, “I can’t talk to you about this patient because I don’t have a release.” I pointed out that under emergency circumstances I felt we could talk even without a release, but he disagreed.

I told him that I appreciated how he felt about this situation, and that he felt he couldn’t talk to me, but perhaps I could give him useful information. I told him the patient’s usual dose of methadone, and said best practice was to continue this dose for the duration of hospitalization. He said that while he couldn’t talk about this patient, in general he didn’t dose patients if he felt they didn’t need it. I then said that the only circumstance I could think of where it would be appropriate to hold the dose would be if the patient was sedated and he was worried about overdose. He then said, “You’ve hit the nail on the head,” over and over.

I can’t say he was lying because I couldn’t see this patient for myself. But I did know he had called his counselor within the hour and sounded very alert and very angry.

This physician was short with me and talked over me to some degree. For a man who said he couldn’t talk to me he interrupted a lot. And, as I pointed out, he could have gotten permission from the patient to talk to me, but he wouldn’t.

What I gleaned from our interaction – and I may be wrong, and prone to overreacting – was that he didn’t think much of me or of our opioid treatment program who were putting people on methadone when they didn’t need it. I felt undertones of hostility and distain from his manner.

After the patient was allowed to leave, 72 hours later, he signed a release so we could get his hospital records. It was thin and short on information. It contained only his discharge diagnoses and not much else. The patient wasn’t on any new medications and there was no admission history and physical, no doctor’s note, and no mention of methadone anywhere in this record. There was no documentation of the conversation with me, and no reason why he allowed this patient to go into opioid withdrawal for three days.

I gave my patient a form to report this to the Department of Justice, as I feel my patient was treated inappropriately and was discriminated against by this doctor who refused to dose my patient as usual while he was being held in a psychiatric hospital against his will.

I will send a complaint report this as well, and I’ll let you know if I get any follow up.

This needs to end.