Stigma Abounds in Rural North Carolina

 

 

 

 

What Stigma Feels Like

The opioid epidemic has rolled on for more than twenty years now, but misunderstandings and ignorance about best practices regarding treatment of patients still flourishes in medical and dental professionals. Part of my job as an Addiction Medicine treatment professional is the gentle education of other medical providers. Over the past years, I’m more patient than I used to be, knowing that most providers just need information in order to do the best thing for our shared patients. If I’m polite and friendly, our interaction is more likely to go well.

And sometimes, it makes no difference.

This week’s drama unfolded around a patient who was recently diagnosed with cancer. This patient, being treated for opioid use disorder with methadone at 110mg per day, had to see an oral surgeon to have all of her teeth removed before she can undergo cancer chemotherapy. This is because she had extensive decay in all of her teeth which can be sources of infection during chemotherapy.

She saw me a few days after her initial consultation with the oral surgeon to whom her oncologist referred her. She was upset and distressed at what the oral surgeon had said.

She had just found out that all of her teeth, about twenty-one in all, must be removed. And her oral surgeon had told her he wouldn’t be prescribing any pain medication after surgery because she was on methadone.

I listened closely to her and got her permission to call this oral surgeon to talk to him about appropriate pain management for patients with opioid use disorder.

When I called, the surgeon wasn’t there. I was put on hold for four or five minutes, waiting on the surgeon’s assistant. While I was on hold, I listened to their recorded announcements about their practice. The recording told about the educational backgrounds of their two surgeons, then had a pitch about the doctor I wanted to talk with, about how he did missionary work for a certain religion.

Excuse me while I go off on a tangent.

When I heard the bit about missionary work, I felt foreboding. I’ve had past negative experiences with medical professionals who advertise their devotion to a religion as a selling point for themselves or their practices. I notice that sometimes people who profess devotion to a religion seem to be least likely to exhibit the qualities espoused by the leader of their religion: tolerance, patience, love, etc. And I recognize that’s a type of stigma that I hold, which may be unfair to the oral surgeon in question.

I was ruminating on these dark thoughts when the assistant came to the phone. I explained that I was the medical director at the local opioid treatment program, and that the patient being discussed had a diagnosis of opioid use disorder and was being treated with methadone, and that I wanted to discuss the plan for post-operative care with the oral surgeon. The assistant assured me that his doctor’s policy was not to prescribe opioids post-operatively for someone on methadone, because it is a red flag.

“Red flag for what?” I asked.

“That the person is a drug addict & shouldn’t be given any pain medications.”

I took a deep breath and made as effort to keep my tone friendly and cheerful. “Yes, you’re partly correct. As I said, the patient is being treated for opioid use disorder by me. The older term for this medical problem was addiction. She’s being prescribed methadone as treatment for her opioid addiction. It keeps her out of withdrawal and prevents cravings. However, it won’t adequately treat post-surgical pain.”

“In fact, she just had cancer surgery three weeks ago. She was prescribed post-operative oxycodone, 15mg every six hours by the surgeon. We had her mother hold the bottle of opioid pills and dispense as prescribed. This patient did very well and made it through without relapse. We could do something similar after her dental surgery.”

“No,” he said, “We leave it up to the pain clinic to prescribe the pain medication.”

I slapped my forehead and tried to keep an edge out of my voice. “We are not a pain clinic. I don’t prescribe medications for pain. I treat opioid use disorder with methadone and buprenorphine products. I do not prescribe opioids for dental procedures since I’m not an oral surgeon. I don’t know what to expect as far as intensity and duration of pain after extraction of a mouthful of teeth. However, since the surgeon doing the procedure knows how much pain such patients have, he would be the ideal person to prescribe for the post-op pain associated with the procedure that he is doing.”

“Well he’s not going to prescribe anything if the patient is on methadone,” he answered.

“Yes, that’s why I called. I’m trying to educate you about best practices for post-operative care for patients with opioid use disorder who are being prescribed methadone.” I was getting louder and could feel a muscle jumping over my right eye. “What I’m trying to tell you is that this patient’s methadone will not treat post-operative pain. It does keep her out of withdrawal and prevents cravings and helps her function normally, but it won’t treat acute severe pain.”

“Yes but I’m pretty sure the surgeon won’t prescribe anything for pain.”

I thanked him for his time and left my phone number for the surgeon to call me back. This was five days ago and I don’t expect a return call.

This patient is in a bind. She has cancer and can’t start chemotherapy until she heals from getting all her teeth extracted. Time is of the essence. Ordinarily, I’d tell her about the situation and recommend she find another oral surgeon, but she may decide to proceed with this surgeon only to get the whole process moving along.

It’s a real shame that this patient will be forced to suffer pain after her dental extractions. She will get by with Tylenol and ibuprofen, because she will do what she must. I just hate that she’s being treated this way.

Then today. Southern Scripts, an insurance company that one of my long-time patients just switched to, sent my office a prior authorization to fill out before it would OK coverage of buprenorphine/naloxone 8/2mg tabs, 8 mg per day. Among a host of other requirements, they need the patient’s height and weight before they’re willing to authorize payment.

Now that’s a new one. It’s hard for me to imagine what possible height/weight would disqualify a patient for this medication, but what do I know. I’m only the doctor.

Also today, I heard about an exchange one of my patients had with a Walgreens pharmacist. She wanted to fill her Suboxone 8mg film prescription two days early. I had already called ahead and left a message with the pharmacist that it was OK with me, since she had recently tapered from 16mg down to 12mg. She had more problems with that drop than we expected, and so she ran out 2 days early. Since the decrease in dose had been requested by the patient in the first place, and since I didn’t want her to be without medication for two days, I gave permission to fill it early. I did not think this was a big deal.

The patient said that she was third in line at the pharmacy, with six or eight people standing in the area waiting for service, when the pharmacist called out to her, asking why she ran out early. My patient didn’t want to compromise her privacy, so she shook her head, declining to answer. She says the pharmacist began to harangue her in front of all the other people, saying since she wouldn’t tell her why she needed to fill the medication early, she wasn’t going to get it from “her” pharmacy.

The patient left, tearful and humiliated, but not before she demanded the written prescription back from this hateful pharmacist. She took it to another Walgreens in her area and filled it with no problem.

I’m no longer shocked or surprised at the hassles my patients endure. But we are now several decades into this opioid epidemic. I think it’s time we insist on better education and treatment from medical, dental, and paramedical professionals. I’ve been patient and tried hard to approach outdated attitudes as an educational challenge.

Now I occasionally wonder if things will ever change. I find myself having the same conversations with other medical providers that I had fifteen years ago. Are we making any progress against the stigma our patients face? Only time will tell.

20 responses to this post.

  1. Posted by John Hanley on September 2, 2019 at 3:24 pm

    Isn’t loudly harrassing a patient a violation of the HIPPA law. It seems it should be.

    Reply

  2. Posted by Greg on September 2, 2019 at 5:14 pm

    Sadly this is the way it is and will continue to be,some drs,dentists,and pharmacists are just plain ignorant on opioid use disorder,we are gonna be called and labeled drug addicts no matter what or no matter who calls trying to help the patient out,the best thing a patient can do that is on buprenorphine or methadone is to not tell anyone unless absolutely necessary for them to know,people will always look down on us and use this against us no matter what.

    Reply

  3. The oral surgeon has no risk in denying a methadone patient pain meds, but he might feel that there is some risk in giving her pain meds, so his reflex will be no pain meds. Many doctors are more concerned about their own personal and career comfort levels than they are about their patients’ comfort or about learning something new. Unless there is some personal consequence to him for denying pain meds to patients with methadone, he will not care enough to be educated. And yes, the stigma is that patients who are on methadone for OUD or who are poor tend not to elicit the human sympathy that would call for over-riding the reflex response.

    Reply

  4. Posted by Andrew Angelos on September 2, 2019 at 6:28 pm

    I hardly want to waste the time to compose myself. Why don’t you consult with other doctors, and prescribe the pain meds needed from the get go. Instead you try to push your ideals on medical professionals who disagree with your point of view. I can certainly say that the addiction specialists are better suited to estimate dosing standards because those doctors know what doses of methadone and bupe those patients are on. We are not constitutionally guaranteed the right to a pain free life. I have been on bupe for years it blocks pain petty well, and methadone works even better. Not to mention that most of the effects of oxy and Fentanyl are blocked unless the person stops bupe or methadone. For patients sake someone back down. I can’t do it he’s an addict, well I cant do it I’m not an oral Surgeon. The real reason no one wants to prescribe to addicted patients in treatment who are having augury is because they die more often and the doctor could be found negligent. You worry about the pain your patient while being the only one able to solve the problem.

    Reply

    • FYI – I am not permitted to prescribe anything except the methadone and buprenorphine at my OTP. And these are hardly my “ideals”….they are accepted protocols/best practices for management of acute pain in patients on bupe/methadone.

      Reply

      • Posted by JNH on September 8, 2019 at 3:37 am

        I’m going through this exact experience now, minus the cancer, and I take Bup, 12 years, never relapsed. I’m 32, and part of the reason for delaying treatment is this exact reason! I plan to start my mouth reconstruction this fall and I dread it for this reason! My bup dr like you, isn’t allowed to write pain meds anymore.

        Oral surgeons want 50–108,000$ For implants and I’m willing to pay it (50,000) to fix my mouth, but once you tell them you take bup- they act as if you’re a criminal and won’t even call me back. It’s sad. Like you, I thought surgeons would be more educated by now. One dr asked me if it was meth mouth, which crushed my soul bc I’ve legit never done any illegal drugs, and that was why I was at his office, to get it fixed and stop that wrongful assumption, and one told me the bup causes dry mouth which caused the tooth decay.

        The truth: I was told at age 13, then again at 16 years old….when I had my 2nd set of porcelain veneers put on, that’d lose my teeth at a very young age mainly due to genetics, gum disease, grinding, and 120,000$ worth of failed dental work.

        We have a very long ways to go in dental field becoming educated.

        I agree and understand you’re speaking the truth! I’m living it!

      • Posted by Andrew Angelos on September 8, 2019 at 3:17 pm

        The special license to prescribe bupe is additional to a physicians license is it not? It is hard for me to believe that you are completely unable to prescribe these medications. If this is the case the laws make no sense. Who better to treat the pain of addicts than the otp doctors. The License to prescribe it what 10 hours of training. Why not push for another extension of the x license which will allow people like you to prescribe. Instead you push back on the broken system that made all these addicts in the first place. I am sorry but this seems more like your trying to punish the system, but the punishment is payed by your patients. If doctors stood up for patients, in the best interest of their patients, it is hard for me to believe that there would be much consequence. It make me sick when someone is truly in need and all you doctors can do is play the blame game, but your both to blame. Policy should not be the first thing on doctors mind. Patient care should come first.

      • You misunderstand. This was a patient I was seeing at the opioid treatment program, not my office-based practice. It’s not a law, just the that the organization I work for doesn’t want physicians to prescribe controlled substances aside from medications to treat opioid use disorder.

    • Posted by Simon on September 4, 2019 at 1:28 am

      This is a pretty short sighted response. If we regularly threw our hands in the air and said “it’s all too hard” then nothing would improve. Doctors need to learn, and in my experience they are often very reticent to do so.

      Specialists prescribe within their area, but generally not others. For example, I take a very safe blood pressure medication and have for 10 years. My psychiatrist won’t script it for me as it’s not his area. It’d be perfectly safe for him to do so, and there’s unlikely to be repercussions, but he has a professional boundary. He’s not treating me for hypertension.

      Dr Burson is not performing oral surgery and should therefore not be prescribing post op pain relief. She can advise the prescribing doctor, but it’d be inappropriate for her to prescribe (and she can’t as per her comment).

      Even if she could, how bad does it look for a doctor to give out pain meds with the left hand, and addiction treatment with the right. If this was commonplace I’m sure some industrious doctor would find an easy way to generate new customers for his/her addiction treatment business 😉

      Reply

      • Posted by Andrew Angelos on September 8, 2019 at 11:19 pm

        To me it looks like the most informed professional is caring for their patient, in the most informed and professional manner possible. To the best of my knowledge the surgeon treats what they cut, not the entire body. Addiction, however, relates to the mind and body, and is triggered in most addicts by pain. Any addiction doctor could defend themselves by prescribing to a patient who has been refused meds by a lesser qualified medical professional. However, doctors who just throw prescriptions around willie nilly would have to worry. This is the line that needs to be crossed to wake people up. If I was a medical professional of good ethics and morals I would be willing to take the heat for the patients whom I took care of. Let’s be real. A script for surgery lasts a few days. It’s not ongoing. I think the real issue is that addicts can’t really be trusted; This gets me back to what I said before. We are not guaranteed freedom from pain, so stop getting mad at the other doctor who is really doing the same thing you are, which is distancing themselves from complications by adopting certain policies. Addiction medicine specialists should be aware of the complications and welcome them.

  5. Posted by Bowza on September 2, 2019 at 6:52 pm

    This is exactly why I would never tell anyone your on methadone, there is no reason to other than enjoying being treated poorly .drug addiction will never be accepted as a medical problem by most people, I work as a first responder and see it first hand , as soon as someone says I take methadone they are treated differently and talked about after . I always tell my patients to keep it to themselves next time because humans are judgmental , i think it’s a civil rights issue , if science says there is no negative evidence to someone taking a prescription medication and a doctor treats you differently they they should be sued for malpractice and discrimination.more people are realizing medication is the answer but only because someone they love has died or needs help and until more of the right people are affected by opiate addiction nothing will get better . But until then don’t stay strong and quiet 🤫

    Reply

    • Posted by JNH on September 8, 2019 at 3:41 am

      I have to tell this information to my surgeons because I have to be put to sleep with general and I’m scared not to disclose that I take subutex. But you’re right- I’ve been advised more than once to not tell them. That needs to change!

      Reply

  6. Posted by Lee S on September 2, 2019 at 8:04 pm

    On more than one occasion, I’ve had Doctors tell me, when I was hospitalized, that I wouldn’t need anything for pain because “your methadone dose will take care of your pain” which we know is not correct. Now, I don’t tell them. After many years on methadone, more than 30 years, I find it hard to believe that even in today’s society, methadone patients are still treated as less than. Thank you for your posts, they are always so informative.

    Reply

  7. i have a ” Dear Doctor” letter i write to educate other physicians and NPs., DDSs and PA’s about MAT and Pain and MAT and mental health — it links to several websites — i give the patients a copy that they can take to heir provider or to the ER with them. i got it from someone else in addiction medicine long ago and it is useful – shall i post a copy here ?

    Reply

  8. Reblogged this on My Sharing Blog.

    Reply

  9. Posted by Simon on September 4, 2019 at 1:12 am

    Sorry to hear about your patient. I think that oral surgeon is bordering on malpractice. I can tell you right now that many people in her situation would likely source their own illicit pain relief, which is much, much worse than being supervised by a Doctor (to state the obvious). 1 tooth? Paracetamol/ibuprofen. 10+ teeth? Hell no.

    As a Suboxone patient, this is one of my fears – needing pain relief. It hasn’t come up yet, so I’ve got no idea how it’ll go. I have trust in the medical system here (Australia) and my ability to negotiate, but maybe that trust is misplaced. I’m sure I’ll find out one day.

    To touch on your comment about religion…I hold the same view. I often find the more religious people are, the less kind, accepting and tolerant they are. It’s a real head scratcher. Maybe 2000 year old books don’t hold all the answers 🙂

    Reply

  10. Posted by Lisa Wheeler on September 8, 2019 at 5:55 pm

    Patient A needs to report oral surgeon to Board. You know me…I’m happy to badger him until he talks to you if you want.

    Patient B needs to report pharmacist to Board as well as make a HIPAA complaint to Walgreens and feds.

    Unfortunately I have seen numerous pharmacists violate HIPAA over things from HTN meds to psych meds to OUD meds.

    Not sure what they teach in pharmacy school on privacy, but my experience leads me to believe not much.

    Reply

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