“You know what? Let’s just switch every patient over to methadone and be done with buprenorphine!” I said angrily during case staffing last week.
This all started several weeks ago, when an angry patient was leaving my office. I don’t recall why he was unhappy with me, but on his way out of my office, he was venting about how he was being treated harshly, compared to patients doing much worse things. He said many patients leave our facility after dosing with buprenorphine with much of the medication packed between their teeth and lips. He said some people sold it, and some injected it, and that we were too stupid to see it.
I didn’t think much about it, but later that day at case staffing, we discussed asking patients to show us the area between teeth and lips, just to see if diversion in this manner was occurring.
I need to explain why we don’t want patients to leave with buprenorphine still in their mouths. Because we are administering this medication at an opioid treatment program, we must abide by different rules than an office-based buprenorphine practice. While physicians in office-based practices can prescribe as many days’ supply of medication as they see fit, different rules apply to opioid treatment programs.
In my state, buprenorphine patients still have to meet time in treatment requirements, same as methadone patients, before they can get any take home doses. Fortunately, our State Opioid Treatment Authority (SOTA) leaders are intelligent and reasonable people, and allow us to ask for take home exceptions early, at the four to six-week mark, for patients on buprenorphine who are doing well and have a couple of drug screens showing only the prescribed medications. This is because buprenorphine is so much safer than methadone.
But when patients first start, or if they’re still using other illicit drugs, or if their lives are unstable in some other way, they must do daily observed dosing with us.
Observed dosing means that they stay on premises while the medication is consumed. With methadone, it’s a quick swallow, and the patient says goodbye, and it’s done. With sublingual buprenorphine, our patients sit in a designated and monitored area until their medication is fully dissolved. We’ve had some patients walk out of the building with buprenorphine still in their mouths, and inject that buprenorphine. Because of that, we ask the patients to show a nurse under their tongue that the med has dissolved before they leave our facility.
But this idea that some patients may be packed medication between their teeth and lip was new. The nurses picked one day to ask all patients to show them their whole mouth – all around teeth, under tongue, after dissolving.
They discovered a handful of patients who had packed medication into a cheek, clearly with the intent of taking that buprenorphine outside the premises.
What did they intend to do with it? I don’t know. Maybe they planned to give part of their dose to a loved one. Maybe they planned to take it later, or maybe they planned to inject it. Maybe they sell the buprenorphine. I have no idea, but I have clear evidence that the patient isn’t taking the medication I’m prescribing.
I have an obligation to prevent diversion of medication I prescribe into the black market. If I know a patient is engaging in behavior that’s suspicious for diversion, I can’t in good conscience continue to prescribe that medication.
We could enter a discussion about how diverted buprenorphine is really a harm reduction method, by providing a safer opioid to the people in the community with opioid use disorders. But opioid treatment programs, called “methadone clinics” in the past, have long histories of stigma. Law enforcement types and regulatory inspectors do not want to hear about harm reduction. Some of these people barely tolerate our existence as it is. I support harm reduction, but I must deal with the world as it is now.
Diversion from an opioid treatment program can get that facility shut down.
When the nurse called me with a list of names of people engaged in diversion of buprenorphine, I had to tell her I will not prescribe any further buprenorphine for those patients. They must either switch to methadone or seek treatment elsewhere.
About half chose to leave and the other half chose to start methadone.
We felt like we had to start checking patients’ entire mouths every day, and found more patients who were diverting their medication. All in all, about ten patients were found to be attempting to divert.
I did not react well. I was furious.
Before you write a comment to me saying how unruly behavior is often a symptom of the disease of opioid use disorder, and that I shouldn’t take such things personally, and that the majority of patients were dosing correctly and that’s what I should concentrate on…yes, I know all of that.
But I had to go through a process to get there, and maybe writing about it is my way of dealing with these feelings.
I get particularly upset when a patient does something that threatens my view of myself as an effective helper. When it starts to look like I’m making it easier for some patients to inject themselves with buprenorphine, I feel anger initially, but underneath that emotion is a whole lot of fear.
I fear I’m not really making any differences in the lives of these people, and that they all look at treatment as a joke. I’m afraid I’ve been deluding myself that medication-assisted treatment helps patients. I wonder if I should go back to primary care practice, where nothing I ever said or did seemed to make a bit of difference in the lives of people with chronic illnesses. I fear that the MAT detractors are right, and that I’ll end my days by regretting the action and advocacy I’ve taken over the past decades.
I feel disillusionment.
As you can see, my strong negative emotions sometimes trigger a runaway train in my mind. Thankfully, as I age and mature, the train slows much faster than it used to.
I’m better now. Thankfully, I can go back to the information that lead me to this field in the first place…the decades of scientific information that show beyond a reasonable doubt that while individual patients may fail to improve with MAT, overall it saves lives. Then I can look at the smiling faces of patients who have completely changed their lives while in treatment.
When I get to the point I can look at reality uncolored by emotion, I see the vast majority of patients at the opioid treatment program are doing very well. Nearly all have improved in some way, some more than others, of course. Some of them do have rocky starts, but can do well if we address the issues and get them to stay in treatment.
Early into the New Year, I’ve re-learned a lesson about disillusionment, fear, and the process of working through all of that to a more reasonable view.
I suspect many people in the helping professions deal with this process over and over. It can be challenging, but such jobs are rewarding as well.