This Should Never Happen

 

I had a frustrating admission to the opioid treatment program last week. The patient wasn’t frustrating; she was delightful. Her experience with the healthcare system was frustrating and disappointing.

This nice lady (details have been changed to protect her privacy) has been going to a local pain management group for several years, with some success. About five months ago, she expressed a desire to taper off her prescribed opioids because she didn’t like worrying about running out of medication. She thought if she worried about withdrawal, it was a sign of opioid use disorder (which she called addiction).

The pain clinic provider listened to her concerns, then switched her to Suboxone in divided doses. It’s not clear if the provider thought the patient had evidence of opioid use disorder, or if he thought switching the patient to suboxone would help manage symptoms of pain, or if he was trying to keep the patient happy.

At any rate, the patient felt well on a relatively low, divided dose of Suboxone. She was able to go about her daily business with relatively less pain for some months.

Then she unexpectedly became pregnant.

That’s when the problems began. The patient says her prescriber got excited about her treatment, and what should be done during her pregnancy. This doctor told her the suboxone could damage her pregnancy and he couldn’t prescribe for her any more. She was also told it was very dangerous to come off Suboxone while pregnant.

As an aside, I need to inform readers that in the past, only the monoproduct buprenorphine was approved for pregnancy. Researchers and physicians worried the combination product, with both buprenorphine and naloxone, could cause withdrawal and side effects. Now, I have information from experts that the combo product is just as safe as the monoproduct. Professionals at the University of North Carolina’s Horizons Program, which treats pregnant women with opioid use disorder, say that the combination product, buprenorphine with naloxone added, can be safely used. This program, which was part of the landmark MOTHER trial back in 2010, has done renowned work for years.

Anyway, after hearing conflicting information from her pain management physician, the patient didn’t know what to do. She was terminated as a patient at this pain medicine practice because she became pregnant, but also told that if she stopped taking Suboxone, it could kill her unborn child. The pain clinic referred her to office-based prescribers of buprenorphine products in a nearby city.

When she called these practices, she was asked questions over the phone about her opioid use disorder. The patient answered honestly, but she was turned down for treatment since she didn’t meet criteria for opioid use disorder.

Not one of her providers or potential providers mentioned going for evaluation at an opioid treatment program. Her obstetrician didn’t give specific instructions for her, instead telling her to taper off her Suboxone if she could.

Thankfully the patient had a friend who knew about our opioid treatment program. This friend thought we could either help this patient or tell her where to go for help.

A day or two after the patient called our opioid treatment program, I did an admission history and physical exam for her. This means I listened to her complete history of opioid use, asked questions for clarification, and did a limited physical exam. When we finished, I told her I didn’t think she met criteria to be diagnosed with opioid use disorder,

How did I come to this conclusion? I asked a series of questions to determine if she met the criteria for opioid use disorder. She had tolerance to and withdrawal from prescribed opioids, but that’s not enough to meet diagnostic criteria. She hadn’t misused her medication by snorting or injecting and hadn’t taken more than prescribed. She didn’t use extra opioids from friends or family and didn’t ever run out early on her medications. She didn’t overuse her medication to the point of intoxication and didn’t use her medications to treat emotional states. She didn’t use alcohol to intensify effects. In short, she wasn’t my average patient.

But what was she supposed to do? Abandoned by her pain management physician, she was in a pickle. Clearly, continued treatment with buprenorphine, either mono or combo product, was the best thing for this patient and her fetus. Since she didn’t seem to have any alternatives, I admitted her to our opioid treatment program. It was the right thing to do.

I took her dose back to the 8mg per day that she’d been on, and I saw her again this past week. She felt fine, with no withdrawal, and we talked more about what to expect while on buprenorphine during pregnancy. I think she will do very well.

After she delivers, she can seek treatment at a pain clinic if that’s what she desires. Right now, she plans to taper off buprenorphine after delivery. That may work well, though tapering with a new baby at home sounds daunting to me. We will help her with whatever she desires.

We aren’t a pain clinic, and the once daily observed dosing isn’t necessary for this patient who has not developed opioid use disorder. It’s a much more intense level of care than she really needs. But we were willing to help her until she can find a better solution, for her well-being and the well-being of her baby.

She was thankful to have a solution and some answers but puzzled as to why other providers didn’t want to help her.

Pregnant ladies taking opioids, with or without opioid use disorder, are hot potatoes, at least in my region. No one wants to take care of them, so they get tossed to one provider after another. This patient’s experience is common.

You would think, now a few decades into this opioid use disorder epidemic, that we would have evidence-based guides to the treatment of these patients. We do, but providers are still reluctant.

Doctors get nervous about pregnant women taking drugs, licit or illicit. They fear extra liability comes with the extra person, the fetus. For many physicians, pregnant ladies are someone else’s problem, preferably their obstetricians’.

But obstetricians in this area, with rare exceptions, don’t want to take care of the substance use disorders. Some providers still think people who develop substance use disorders are bad people, or have bad morals, or are weak-willed. They prefer their patients take their drug use somewhere else for treatment.

How could this have been handled better?

I think the pain clinic should have continued to treat this lady with no interruptions in her care. They should have communicated with her obstetrician and coordinated care with the obstetrician. They should have been given the information that it’s now acceptable to continue the patient on Suboxone, and that pregnant patients don’t necessarily need to switch to the buprenorphine monoproduct, although that would have worked fine, too.

If the pain clinic physicians couldn’t manage this patient, they should not have dropped her until/unless they found her a new provider, instead of giving the patients a few phone numbers to call to seek help on her own. It felt to the patient like they were punishing her for becoming pregnant.

This opioid use disorder epidemic started about two decades ago. How long is it going to take for medical providers to learn how to manage or refer patients with opioid use disorder for proper care?

It’s kind of like flying a plane…if you don’t know how to land, maybe you shouldn’t take off in the first place.

Advertisements

11 responses to this post.

  1. Posted by Daniel Strickland on March 11, 2019 at 6:45 pm

    I agree, it should never happen, but as we both know the average medical provider knows little about buprenorphine, either for pain or for MAT.
    As a (former) practicing obstetrician I knew nothing about it. Only when I took the 8 hour DATA 2000 waiver course did the scales fall from mine eyes.
    Personally I believe that every medical provider should at least take the 8 hour course.
    Heck, it’s a good way to get Cat1 CME credit, not to mention actually learn something about OUD .

    Reply

  2. Posted by Alan Wartenberg MD on March 11, 2019 at 8:35 pm

    25 years ago I entitled one of my talks “Don’t put people on medications that you don’t know how to take them off of,” thinking of my English teacher in high school Mrs. Gold and her response to ending a sentence with a preposition. After 9/11 and the reporting on the highjackers who told their flight instructors (apparently without evoking any curiosity) that they weren’t really interested in learning how to land, I changed the title to the same phrase used by Dr. Burson – Don’t take off when you don’t know how to land. I have had many occasions to give this talk, and this poor lady and this terrible story is, I am sure, repeated many times each week, if not daily, in our country.

    Reply

  3. Posted by Sparky on March 12, 2019 at 12:06 am

    Excellent post dr burson,thank you for helping this tossed aside patient and for admitting to your otp,we need more drs like yourself

    Reply

  4. I think all of you doctors need to know more about Dependence, not just Addiction or Opioid disorder, to many doctors put people on opioids. To even think they would turn this Woman away after pregnancy is a crime in itself, many folks are dependent, and that in itself is a problem, try to take yourself off of Subtex, or Suboxone even a small amount brings on severe withdrawal symptoms for users that have been on it for a few weeks, or months. you need to read the comments of people that have been on it. An 8 gram strip is so powerful. I know people that take a 8 gram strip in 20 days, and still can’t get off the stuff. So a taper is almost out of the question.. it can take years, I devised a spreadsheet of use when folks use to use just the 8 gram pills crushed up, it would take 3 years to taper to do a taper that might not provide discomfort to where they could even work. Doctors need to know so much more than just what I read here, it just blows my mind what they think, on the right path, but yet so far behind the curve.

    Reply

  5. Posted by Betsy Ragone on March 12, 2019 at 2:11 am

    Thanks for what you do Jana. So many times, regarding treatment for this disease, patients are left blowing in the wind .. due to fear (litigation), stigma or simply lack of education/knowledge. You bring the whole thing together by listening to the patient.

    Reply

  6. The issue with the fetus is that the statue of limitations STARTS when they turn 18 years old. Try to insure for that !!!– I do agree with all the comments above about physicians not using drugs that cause dependency without knowing how to detox the patients from them — it is just as bad with benzodiazepines.

    Reply

  7. Posted by Terry Ptacek on March 13, 2019 at 5:55 am

    I am curious since you saw her in a methadone clinic, did you use a diagnosis of chronic pain, or opiate tolerence, or ? since opiate use disorder would be inaccurate, but something has to be sent into the insurance company.

    Reply

    • Well, that’s a problem. Since we will have to bill under chronic pain, the OTP probably won’t get paid, even though it’s an appropriate treatment. Thankfully the company I work for has said they will never turn away a pregnant patient for lack of payment. We can’t ask her to pay, since she has Medicaid. That would be illegal. So we will end up treating her for free.

      Reply

Leave a Reply to Daniel Strickland Cancel reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

%d bloggers like this: