Advice for New Prescribers

 

 

 

The medical care providers of this nation are being encouraged get training necessary to prescribe buprenorphine products (brand names Suboxone, Zubsolv, Bunavail, Sublocade, and the generics) for the treatment of opioid use disorder in their patients. We need more good prescribers, because even after twenty years into this opioid situation, only about twenty percent of patients who need treatment can get it.

I’ve written on this topic a few times in the past, but this blog entry will contain some advice directed to new prescribers of buprenorphine products. Hopefully it will help them have good experiences prescribing medication-assisted treatment.

Here are some ideas that work for me at my office:

Treat the patient with opioid use disorder with the same attitude and compassion that you would for any other patient with a potentially fatal chronic illness. If you can’t do that, then don’t treat patients with substance use disorders. Patients detect negative attitudes such as distain and dislike even when those attitudes are communicated non-verbally. For whatever reason, if you can’t put judgment aside, then work on your own issues before you attempt to treat suffering people trying to get well.

Patients will resent a physician with a bad attitude. That will contaminate the relationship with predictable results.

For example, I talked to one physician who had his waiver to prescribe buprenorphine from an office setting. I asked him why he wasn’t using his waiver to treat patients, since there were so many in our community that needed help.

He told me the visits with the first two patients went poorly. He said both these patients threatened his life and the lives of his family members. After that, he decided not to risk treating anyone with opioid use disorder.

I was shocked. I’ve never, in the thirteen years I’ve been prescribing from an office practice, had any patient threaten my life, though I’ve made some angry at me. I had to wonder what kind of bedside manner this doctor had, for his first two patients to want to kill him. That sounds like I’m blaming the doctor, and maybe I am, but his experience was so contrary to my own that I had to wonder what was going on. I suspect his patients didn’t feel respected by him.

I’ve had one patient threaten me with bodily harm, but that was at an opioid treatment program in Gastonia, NC, more than a decade ago. The patient was an avowed KKK member, tall and large, with tattoos of hate groups on his muscular arms. I might have been worried, except at the time he threatened me, he was so impaired on benzos that I could have pushed him over with a finger. I’d just told him he couldn’t dose with methadone that day, due to impairment. The next week, he greeted when we passed in the hall. I assume he had been in a blackout from his benzodiazepine ingestion the week before and didn’t remember our previous interaction.

Be clear with your patients about your expectations. At the first visit, I sit with the patient and go over a patient agreement form. I adapted it from a SAMHSA website where you can find helpful forms, tools, and ideas.

https://pcssnow.org/resources/clinical-tools/

https://www.samhsa.gov/medication-assisted-treatment/training-resources/publications

In that agreement, I outline my expectations. I have paragraphs indicating that disruptive or violent behavior won’t be tolerated and are grounds for immediate dismissal from my practice. In thirteen years, I’ve never had one patient become rowdy or disruptive. Having said that, I do realize other prescribers have had different experiences.

I ask patients to keep and be on time for appointments, and if they don’t show up and don’t call, they will be charged for the missed visit. I tell patients I won’t call in prescriptions if they miss a visit. Having said that, I’m also flexible enough to know that things do come up – cars break down, traffic jams occur, etc. In the winter, travel can be treacherous, so that’s another factor to be dealt with. All I ask is that the patients communicate problems early so we can find a reasonable solution.

Patients who miss appointments, don’t call, and won’t answer our calls to find out what’s going on will have problems at my practice. It may or may not be their fault, but if it doesn’t work out they will need to find a new provider.

My agreement also says I won’t “fire” a patient before I talk to them face-to-face. Patients tell me they’ve been dismissed by a practice by letter, for some issue or another. I think that’s cowardly, and disrespectful to the patient. If there’s a reason I feel I can no longer to continue treatment as we are, I owe it to the patient to tell them exactly what the problem is. Sometimes we can find solutions short of termination and sometimes we can’t. At least the patient will know I respect them enough to talk to them, and they will know the basis of my decision. They will also get a referral to a new provider, or at least a recommendation.

Be careful with patient selection and try to match the patient with the best level of care.

Not every patient will do well in an office-based setting. For example, if a patient has been using buprenorphine products illicitly by insufflation or injection, that patient probably is best treated in an opioid treatment program, where observed dosing is done.

Most patients need to be on the combination products buprenorphine/naloxone. Adverse reactions do occur with the monoproduct, but they are rare, and drug diversion is not. If a new patient needs the monoproduct, I refer them to an opioid treatment program where they can be properly observed.

If that patient has been treated in another office-based setting with medical records that support their progress and compliance on the monoproduct, my recommendation would be different. Many factors influence my treatment decisions, so I need all the information I can get to make the best decisions.

This leads me to my next recommendation: get old records. Make the effort to get records from a previous practice. Sometimes patients, to curry favor with a new prescriber, will tell tales about how awful their last prescriber was. That may be true…or there may be more to the story, so get records to get a better idea of what happened at the last practice.

Don’t falsify your own records. It’s unethical and probably illegal to bill for services you document but don’t provide. To get higher insurance reimbursements, physicians sometimes chart long review of systems and/or physical exams than were performed. This is called “up-billing.” I suspect up-billing when I see records with four pages of single-spaced type for each visit, but then notice the same four pages for each monthly visit, with no changes.

I blogged before about a patient whose records recorded an exam saying “consistent with eight-month pregnancy” for every monthly visit for over a year. Yeah…kind of suspicious…using that cut-and-paste feature, I think.

If you do telemedicine, make sure you have some sort of medical personnel on site with the patient to look for physical finding you may miss with telecommunications. I just admitted a patient to our opioid treatment program who had been on Suboxone for six months from a provider he only saw online. This patient was injecting his medication, but his prescriber couldn’t see it. His most prominent tracks were on the side of his neck, which could be hidden with a high collar. Obviously, this could have ended in disaster had the patient not realized he needed a higher level of care.

Be careful about lab schemes. If a laboratory diagnostic service is charging patients $500 for one drug screen, it’s probably a scam. In past years, these organization popped up like mushrooms in manure, saying they could do extensive lab testing for all patients, but only charge those with insurance. Uninsured would get free testing.

As it turns out, some of those companies charged outrageous fees to the insurance companies, including Medicaid and Medicare, for expensive and unnecessary testing, in get-rich-quick schemes. Here’s a link to an article that explains how this works:

https://www.healthcarefinancenews.com/news/report-urine-based-drug-tests-helping-some-doctors-soak-profits

Good providers don’t want to sully their name by associating with shady laboratory service providers. Physicians can do good point-of-care testing on site for $10 or less. Sometimes patients need more extensive testing, and this can be decided on a case-by-case basis rather than testing every patient for dozens of drugs that aren’t commonly used in the community where you practice.

Be aware of what drugs are trending in your area and make sure they are included in your drug testing protocol. In the past, heroin was rare in rural areas, but that’s changed. As I’ve discussed on this blog, heroin frequently contains fentanyl, a much more powerful opioid that’s responsible for many overdose deaths.

Ask your new patients what drugs are being used in your community. They can be great sources of information, as can local addiction medicine educational conferences, and your local law enforcement officials.

Make friends with the medical director at your local opioid treatment program. Most physician medical directors at opioid treatment programs are happy to work collaboratively with office-based providers. We share patients all the time and need to do what’s best for the patient. We don’t need to look at each other as competitors, because there are more than enough patients for everyone, unfortunately. Let’s work together to get people into treatment, and to match the patient with the right level of care.

It can be a relief for an office-based provider to know they have a facility willing to deliver a higher level of care when necessary. Sometimes the patient may need inpatient treatment, but at other times it might be an opioid treatment program, where the patient may come daily for dosing and oversight.

Again, some patients, in an effort to curry favor with a new prescriber, may talk disparagingly about another treatment facility, so don’t take a patient’s word that an opioid treatment program does an awful job.

Decades ago in my previous life as a primary care physician, I learned that the new patient who tells me how wonderful I am compared to their last terrible doctor will soon be saying the same thing to another new doctor, about how terrible I am. I know there are terrible doctors, but there are also some patients that can’t be pleased no matter how good the physician.

Finally, get involved with organizations that can help you. You don’t need to re-invent the wheel; as I mentioned above, help is available from several sources.

Go to the SAMHSA website mentioned above and you will find helpful resources. Or you can go to the American Society of Addiction Medicine website for information: https://www.asam.org/  You may decide to go to one of their excellent conferences.

Go to the Providers’ Clinical Support System (PCSS) website and search their educational offerings at https://pcssnow.org/ They have archived webinars, mentoring programs, and other great things available.

If you work in North Carolina, there is the UNC ECHO program, which offers live teleconferences three days per week on issues surrounding medication-assisted treatment of patients in the office setting. You can hear cases presented and listen to input from experts and other prescribers, while getting free (yes I said free) CME hours. Once involved, you can present your own difficult cases to get help with difficult patient situations. You can go to their website at: https://echo.unc.edu/ or leave me a comment with your email and I can connect you to the organization.

It can be difficult to persuade new prescribers that treating patients with opioid use disorder is rewarding and fun. I became a physician because I wanted to help people, sappy as that sounds. I didn’t feel the sense of satisfaction during the decade I worked in primary care, for whatever reason, that I now feel working in the field of Addiction Medicine.

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4 responses to this post.

  1. Hey i couldnt figure out how to contact you i am already on a split of 83/103 due to nausea and passing out on my hour plus ride home while driving and withdrawling from afternoon until next day as well as peak/trough results. Now wi is denying split doses that cant proof more recent half life peak and troughs. While on this dose my peak trough was 938/1428. Since im on a split how is it determined if i still need it?

    Reply

  2. Posted by Diana on January 26, 2019 at 11:55 am

    A question from a not-new but nevertheless :

    For a variety of reasons, I assumed the methadone tx for a pt with HIV, chronic pain and a hx of OUD. For many years, she has been stable on methadone 40mg q6h. The high dose was partially due to her tolerance, but also due to the fact that she was on Atripla and efavirenz (EFV) induces methadone metabolism.
    I’ve tried several times to modernize her ART, but needing to re-tweak her methadone was always too great a barrier.
    Now, her HIV has become resistant to efavirenz (due to a new K103N mutation). On the one hand, this is a great opportunity to upgrade her to a more potent and tolerable HIV regimen. On the other hand, IDK what to do about her methadone! Her new meds (dolutegravir + TAF/FTC) will not have any significant pharmacokinetic interactions with methadone.

    In some of the studies I’ve seen, pts starting EFV needed to increase their methadone an average of ~50% – but inter-individual variation was wide, and I haven’t found any studies going in the opposite direction.

    I wouldn’t feel comfortable just cutting her by 50%. 20mg q6h might still be too much (and with accumulation, could lead to unintentional OD). Or 20mg q6h might be too little, and leave her in pain and w/d that puts her at risk of relapse (with all of the life-threatening risks that accompany addiction, including fatal OD).

    For a patient without OUD, I’d prob start at 10 q8h and increase by 5 or 10 q5-10d. Since that’s almost certain to be a lowball (better safe than sorry!), I’d give a generous amount of an IR agonist for prn coverage of any pain/withdrawal until the right dose is achieved. But b/c of her hx of OUD, she doesn’t feel that she can manage IR agonists without engaging in addictive behaviors. She’s come a long way and has the self-awareness to know that an unmonitored bottle of IR hydromorphone or oxycodone would be a recipe for disaster.

    There’s no easy way to pinpoint the correct dose w/o trial and error. The safest way (start low, go slow) will likely cause withdrawal sxs and pain that put her at high risk of relapse. Since the ID clinic she attends is only open 1 day/week, I can’t monitor her in-person more frequently than that.

    What can I do? I thought that the ideal solution would be to admit her to an inpatient setting where she could be closely monitored, but the hospital I called said “we don’t do that” and referred me to an OTP. Is a temporary switch to an OTP appropriate here? I would have no problem continuing to prescribe the methadone if their MDs were willing to hold it, dispense it, monitor her QD. and determine dosage adjustments.

    Worth mentioning that part of the reason I assumed her methadone was b/c her clinic couldn’t accomodate split dosing. At the time, she was metabolizing very rapidly, but it’s not clear whether she’ll continue to rapidly metabolize once the EFV is out of her system (which will be slow, its t1/2 is about 50hours). Even if her methadone metabolism normalizes, she will probably still need split dosing for analgesic coverage.

    As a stop-gap measure (while I figure this out), I’ve added dolutegravir to her Atripla. Thus, she’s taking what should be a full and effective ART regimen (b/c leaving her on Atripla alone would risk her developing resistance to the other two drugs in the combo, but stopping the EFV would risk a methadone OD). But that’s just a stop-gap. Even if it were appropriate to continue the EFV indefinitely (which it isn’t!), her insurance isn’t going to keep paying for it.

    Sorry for the lengthy question, but I’m unsure how to proceed.
    Any advice would be greatly appreciated.

    This is a great blog!

    Reply

    • Wow. This situation is beyond my expertise. I’d consider contacting some of the experts at: https://pcssnow.org/
      Also, Dr. Ed Salsitz at Beth Israel probably is the most knowledgeable physician about methadone and prescribing it from an office-based setting. I don’t have contact information but you could find it on the internet and maybe get a message to him.
      If this patient has opioid use disorder, are you sure she is taking the methadone exactly as you are prescribing? Do you have blood levels drawn while the patient did observed daily dosing? Is it even legal for you to prescribe methadone for OUD from an office setting? I understand this patient has chronic pain, but sometimes the opioid use disorder prevents patients from taking methadone as prescribed, without a period of time of stability.
      I tend to err on the side of safety. Would you have to cut her 50% in one fell swoop? What about a more gradual reduction in preparation for medication change?
      please let me know what you find out.

      Reply

  3. Posted by Diana on January 26, 2019 at 11:56 am

    That should’ve said “a not-new but nevertheless confounded prescriber.”

    Reply

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