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:

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.

18 responses to this post.

  1. Posted by Majority Ruhl on May 23, 2022 at 2:44 am

    As proud as I am of you for making a concerted effort to remain cordial and objective to the physician that you “spoke” with. It’s also very unsettling. Personally I was hoping that these kinds of doctors were a dying breed. OK OK ok, I was actually hoping they were extinct!! As always the case whenever there’s a patient struggling in your posts- it’s unnerving because my mind’s worried about the opioid withdraw symptoms of the person who endured them!! I always tell people that five minutes in opiate withdraw is four minutes too long!! Especially when a person is on methadone maintenance! If some of these health “professionals” themselves had experienced opioid withdraw personally, I guarantee that they wouldn’t be as concerned with the formalities of medicine as much! Makes me wonder what it was that the facility had expected the patient to actually accomplish during their time trapped inside a building, without necessary medication and while battling withdraw?? Whatever benefits this place could have had for this patient were effectively wasted! You can’t improve your mental health condition as your body slowly begins to enter panic mode without an opiate. I’ve endured opioid withdraw from methadone five times in my life(that’s complete withdraw from methadone, and without taking any other opioid instead for five consecutive days or longer. Anything less than five days is just getting warmed up for the finals!) And three of those God awful occasions were due to being at the mercy of a healthcare provider that simply didn’t feel the need to keep me on my regular dose. By day three I honestly didn’t want to live anymore. I couldn’t eat, sleep or even have a conversation since every two seconds my brain was screaming out for my medicine. It also hurts. I hurt in places that I didn’t even know I had before. What is the medical good of doing this to someone temporarily?? Possibly a long term goal of exiting off methadone completely might be able to eventually reap the benefits of physical torture but for a brief stay at a mental health facility, I’m not seeing the point of with holding the patients methadone. Unless of course the doctor was a sadist or was seeking retribution for something. Then that might be morally acceptable…
    However medically (??) Naw I didn’t attend medical school but I’m going to have to give that doctor two big thumbs down. I couldn’t be more encouraged by your effort to help patients advocate for their right to acceptable care. Most of the addicts I know carry around such guilt that they believe they aren’t entitled to decent care! Opioid addiction is seen as a moral defect and people suffering internalize this stigma. They feel as if they’re being treated poorly because they’re shitty people. No one I know of asks to suffer. Nobody


  2. Posted by Majority Ruhl on May 23, 2022 at 2:58 am

    I almost forgot to ask about discrimination in other forms that are due to the stigma surrounding methadone maintenance. Like child protective services, I know women who are actually told if they would want to remedy their cases then they need to get off of their methadone (?) I know women who have open family court cases only because the social workers and the doctors from outside their clinics have filed against them simply because they are parents, they are on methadone so clearly they must be doing something wrong.! The child welfare system always follows up on all cases regardless of merit. But what happens if a methadone patient suffers an injury, visits the ER and encounters discrimination at the hands of both the doctor and the social worker? Children suffer without their moms. Especially when the only reason a social worker us even called is because the mother is a methadone patient. Clearly she’s up to no good. They can and they do remove children for exactly this reason in my state. Nobody’s looking into it. Sorry didn’t mean to tune into soap box central! Frustrated as usual. Thank you very much for your time


    • Thanks for writing.
      We had this problem in our county some years back. DSS told parents they must taper off methadone before they could get their kids back. First, I wrote letters to the DSS supervisors explaining the risk of death if parents taper off methadone and reminded them this is a medical condition, and for a DSS worker to make medical recommendations was likely outside of their qualifications. Eventually their director met with our director and the situation was resolved. Now, DSS caseworkers tell parents to follow physician recommendations and they aren’t forced off methadone.
      Providers at OTPs need to advocate for their patients in situations like that.


      • Posted by Majority Ruhl on May 24, 2022 at 5:24 pm

        That’s exactly what the problem is around here! Trying to figure out how to engage some of these doctors. Being involved in the problems that their treatment had unfortunately caused should be a priority for the healthcare providers. They can’t expect society to respect what these doctors are saying about opioid addiction and MAT if they don’t understand what the issues are for their patients. Makes me feel better about knowing you stepped up in that department! Good job!! I realize it doesn’t appear to have a connection with patient advocacy however( I assure you that it does)I’ve searched online intensely and I can’t locate an answer to my question! 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 🤔…(also likely most days)!! Thank you

      • great questions! I’m planning a blog to answer what you’ve asked – stay tuned…

      • Now that’s gonna be a terrific idea! So far whenever an “expert” bothers to respond to my questions regarding diagnostic testing for opioid use disorders-I’m told that’s it’s definitely a good question… nothing else!! Tells me I’ve probably asked the right thing a
        bout this.

  3. Posted by Holly Terrell on May 23, 2022 at 10:12 am

    It absolutely does need to stop. Oct17th I’ll celebrate 5yrs in recovery (Methadone maintenance) I worked dang hard to get where I am today. Recently I went to my clinic to turn in my expired Narcan and get another one,well we were out,so being the responsible patient I am I went to a local pharmacy and told them what I wanted had the expired box in hand. They went from friendly to nasty and so did I! By the time I was done the people in line were cheering but it wasn’t about all that. That pharmacy didn’t have a problem filling all the scripts that I got addicted too but ur gonna get nasty after I’m in treatment on MAT and I’m trying to be responsible and carry the Narcan don’t think so and they got educated real quick! It’s sad that we’re constantly having to advocate for ourselves like that. Maybe one day we won’t have to quite so hard


    • Thank you!!!! I wish I could have seen that.
      It’s hard to understand why they were nasty to someone seeking to obtain a life-saving medication.
      More education of pharmacists is needed.


      • I agree with you Dr. Burson. Your awesome! I can only wish there was more people like you in this world. Thank you for sharing!

  4. Posted by Marjorie Sales on May 23, 2022 at 11:36 am

    Thank you, thank you, and thank you again for this post. I am a Nurse Practitioner who sees a large number of patients for Buprenorphine/naloxone maintenance. I have been frustrated beyond measure with the discriminatory practices of ED providers, primary care providers, specialty providers, surgeons (some of the worst offenders), pharmacists, and the list goes on. I will bookmark the DOJ website, and unfortunately I see myself using it all too frequently. But it brings a sense of hope to know that maybe, just maybe “a change is gonna come…”


  5. For patients taking suboxone, by patient reports some pharmacists routinely make snide comments, make it difficult to get Rx filled completely requiring multiple returns to the store, etc. Education is sorely needed in many areas.


    • Your exactly right on this. In the past I’ve witnessed this many time’s. It’s just makes no sense to me. The ones that are guilty of this do need to get educated . I feel they should just do their job, fill meds and treat that patient as they treat someone picking up blood pressure meds🤷‍♀️


  6. Posted by Stephen beck on May 23, 2022 at 8:04 pm

    As a physician treating many patients with suboxone I have only one thing to say: unf’ing believable. Ignorance and ineptitude never ceases to amaze me. MAT is as close to a miracle as you’re going to get in medicine. Basic opiate addiction guidelines should be mandatory for psychiatrists at last. Thanks for the justice department


  7. Posted by Majority Ruhl on May 28, 2022 at 3:36 am

    Ok I’ll bite, what do you mean “the justice system”? I got the distinct impression that methadone maintenance patients, clients, addicts folks etc weren’t allowed to even entertain the notion of JUSTICE. No wonder methadone gets a bad rap! It’s well known that whenever a person hears the “M” word, they automatically assume that whomever is associated is a criminal, a junkie and most certainly guilty of something or other. Besides DOJ, ACLU.. they are not interested in assisting individuals only the majority. Where do they believe they can find future indicators of the group’s problems if not with the individuals? Justice really is blind.


  8. Ok ok ok one last point I swear!(what are the odds)? I was hoping that I’d never again see the word “client” when referencing methadone maintenance or medicated assisted treatment. It’s unlikely that I’d ever capture the attention of the facilities that allow this particular term to repeatedly pop up on orientation day! Once again I have to say that I’m disappointed in the professionals that claim to care but choose to knowingly refer to patients in this manner. Let’s face it when most people hear the word “client” at best they imagine an attorney scenerio. At worse they envision a prostitute or escort. And truthfully dealers will occasionally use it whenever they gossip about the people buying from them! Regardless, it’s a term reserved for the consumer. Not the most appropriate way to refer to a person who’s sick and seeks out medical treatment. In fact I had to double check and make sure I was entitled to the same adequate care as any other Patient due to the fact located within my orientation paperwork was the word “client” repeatedly and no where did I see the word patient! Not sure if this would help eliminate stigma associated with addiction and treatment but have to assume it couldn’t hurt.


    • Thank you, well said! When someone has an illness, “patient” should be the standard term. I also hate “consumer,” “customer,” and “service recipient.”


      • Posted by Majority Ruhl on June 10, 2022 at 5:32 pm

        Wow gotta admit that’s a first! “Service recipient”

        I had to pause and jot that one down!!

        Now I’m pretty sure that a human being that’s sick and requires medical attention, isn’t merely just hoping to be a recipient of anything! The goal is to heal, right? Or I suppose at a minimum treat a condition. Cars are technically the recipients of repairs. I’ll go out on a limb and even concede that someone starving who applies for food stamps might consider themselves a recipient of welfare. But never in my life have I told someone, “yesterday I was the service recipient during a doctors appointment. Feel much better now!”

        Seriously (??)
        And I thought I encountered poor ideology.

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