Archive for the ‘Doctors Behaving Badly’ Category

Starting Buprenorphine in the Emergency Department

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An interesting study in the April 28th Journal of the American Medical Association (JAMA) looked at three types of intervention for opioid addiction in patients presenting to the Emergency Department for care. It found that patients were more likely to be in addiction treatment and free from illicit opioids when started on buprenorphine in the emergency department, and given a referral to buprenorphine prescriber.

This study, done at an urban teaching hospital in Connecticut, screened patients in their emergency department and uncovered 329 patients with opioid addiction. Some came for help for the opioid addiction (34%) but the others came to the ER for other medical problems.

These patients were randomized to three interventions: one group was given written information about addiction treatment programs in the area. The second group was given this information, plus a brief intervention describing the various ways to treat opioid addiction. Patients in this group were linked with the referral and transportation to addiction treatment was arranged.

The third group had the same intervention as the second group, plus they were prescribed three days of buprenorphine, dosed at 8mg on day 1, and 16mg on days 2 and 3. Patients in this group were provided free office- based buprenorphine treatment for ten weeks, with visits ranging from several times per week to every two weeks, depending on how the patient was doing.

The study’s primary outcome was to compare how many patients in each of the three intervention groups were engaged in addiction treatment thirty days after their emergency department visit.

The results were what you would expect. People in the group that started actual treatment in the emergency department with buprenorphine were significantly more likely to be in addiction treatment thirty days later. In this group, 78% were in treatment. In the group given only treatment referrals, 37% were in treatment at 30 days, and 45% of the people given referral and brief intervention were engaged in treatment at 30 days.

Also, patients in the buprenorphine group reported greater reductions in the number of days of illicit opioid use than did the referral and brief intervention groups. The groups showed no significant difference in behaviors that increase risk for contracting HIV.

These patients were fairly ill, with high rates of co-occurring mental health disorders, with more than half reporting prior psychiatric diagnoses. About a fourth of these patients required acute care for a medical problem other than opioid addiction at their emergency department visit. These patients also had the expected high rates of concurrent other drug and alcohol use. In other words, these patients were about as ill as the average patient with opioid addiction.

However, this study didn’t include patients who were so sick that they required hospitalization, which may have skewed the data somewhat. Because services were free, this likely enhanced retention in treatment, though the authors say that 80% of all patients in the study were insured.
That’s an unusually high percentage, as compared with what I see in my rural area, in a state which did not expand Medicaid access.

The bottom line is that medication-assisted treatment with buprenorphine appears to be an effective way to get opioid-addicted patients into treatment and reduce illicit drug use in these patients. That would seem common sense, but we now have a study to support that assumption.

I love the idea of treatment being started in the emergency department, with close follow-up in an office setting or opioid treatment program. As the authors of this study pointed out, starting treatment for opioid addiction in the emergency department is very similar to how other chronic diseases are treated. For example, patients with new-onset diabetes or high blood pressure are often started on medication to treat the disorder in the emergency department, with a close follow up recommended with a primary care doctor.

Why do we treat the disease of addiction any differently?

My readers know the answer, of course: stigma and lack of education and understanding on the part of health care professionals.

As the authors pointed out in the discussion section of the study, even the referral group got more intervention than the average opioid addict visiting an emergency department in this country.

My patients still report being treated with derision and rudeness by emergency department staff. Not only are their medical problems including addiction not being addressed, they are shamed for being addicted. They are given powerful verbal and non-verbal messages that they are bad people, a pain in the ass to deal with, and unwelcome in the healthcare facility.

You could not invent a better recipe for continued drug addiction and avoidance of future medical care.

This study shows how easily this could be fixed. I would require emergency department doctors to get DATA 2000 certified, and the education of other healthcare professionals too. I don’t know how to initiate this solution but it can’t be done quickly enough.

I’ll say it again: we will know we are treating addiction well when it’s no longer easier to get drugs than treatment.

Pain Clinics Behaving Badly

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I worry about pain clinics. More specifically, I worry about what happens to patients enrolled in opioid treatment programs who transfer to pain clinics.

Weirdly, now there are pain clinics that also claim to treat opioid addiction. I’m not saying that the same doctor couldn’t do a great job of treating both problems, but I worry a great deal when that doctor seems to approach these two distinct medical issues as if they were the same medical issue.

Medication-assisted treatment (MAT) of opioid addiction with methadone or buprenorphine is NOT the equivalent of treating chronic pain. When I call my MAT patients’ other doctors to coordinate their care, quite often these doctors ask me if it would violate the patient’s pain contract with my facility if they were to prescribe opioids for a few weeks. When I tell them I don’t treat pain, but addiction, they are puzzled. I elaborate, and use the opportunity to educate the doctor about opioid addiction and its treatment with methadone and buprenorphine.

To be sure, there’s overlap between the two disorders. Studies estimate that anywhere from a third to a half of opioid addicts also have chronic pain issues. And we know that the treatment of chronic pain (an arbitrary definition is more than three months) with opioids can cause the patient to develop a second medical problem, addiction.

Not all opioid addicts have pain. And not all chronic pain patients develop addiction. Many people who live with chronic pain don’t use opioids. In fact, we don’t have evidence that shows long-term opioids help people with chronic pain all that much, due to the tolerance that builds quickly to short-acting opioids and their anti-pain effect. The human body makes changes to compensate for the presence of opioids, and becomes less sensitive to those opioids. Typically, the dose has to be repeatedly increased to get the same anti-pain effect, a phenomenon known as tolerance. Many of these patients may actually have worsening of their pain, called hyperalgesia, due to the changes the body makes in how pain messages are processed.

Some patients can be treated with opioids long-term (longer than three months) and continue to benefit from them without developing any addiction to them. I don’t usually see these patients, since they are doing well in their treatment at pain clinics. Possibly for genetic reasons, they never develop addiction. By addiction, I mean the obsession with and craving for opioids, and inability to control the use of opioids. They will certainly become opioid dependent, and experience physical withdrawal if opioids are stopped suddenly, but that’s physiologic. The mental obsession, a hallmark of the disease of addiction, is not present.

To illustrate further, let’s look at the new guidelines from the fifth and latest edition of the Diagnostical and Statistical Manual of Mental Disorders, more commonly known as the DSM. In the latest version, eleven criteria are used to decide if the patient has mild, moderate, or severe substance use disorder:
1. Taking the substance in larger amounts or for longer than the you meant to
2. Wanting to cut down or stop using the substance but not managing to
3. Spending a lot of time getting, using, or recovering from use of the substance
4. Cravings and urges to use the substance
5. Not managing to do what you should at work, home or school, because of substance use
6. Continuing to use, even when it causes problems in relationships
7. Giving up important social, occupational or recreational activities because of substance use
8. Using substances again and again, even when it puts the you in danger
9. Continuing to use, even when the you know you have a physical or psychological problem that could have been caused or made worse by the substance
10. Needing more of the substance to get the effect you want (tolerance)
11. Development of withdrawal symptoms, which can be relieved by taking more of the substance.
Only the last two criteria are physical; the rest of the criteria have to do with psychological indicators. In order to diagnose mild substance use disorder the patient has to fulfill two or three of the eleven criteria; if four or five criteria are met, the patient has moderate substance use disorder, and if six or more are met, the patient has severe substance use disorder
Addiction interferes with the patient’s ability to control the use of prescribed opioids. All sorts of bad things can happen, up to and including opioid overdose death, when a person with opioid addiction is given a month’s worth of opioids by a pain clinic.

This is my beef with pain clinic physicians. I’ve seen several examples of them prescribing opioids for a month at a time to chronic pain patients who also have been diagnosed with opioid addiction. These doctors set patients up for failure when they prescribe a month’s worth of heavy-duty opioids like Opana or fentanyl. The patient takes too many pain pills too soon, ends up in withdrawal, and gets kicked out of the pain clinic for misusing the prescription.

Is this unexpected? Is this the patient’s fault? Did the patient bring it on herself because she didn’t follow doctor’s instructions? I say an emphatic NO! Given what we know about addiction, it’s completely predictable, even expected. I’d argue it’s a failure on the physician’s part to understand the nature of addiction.

Maybe the doctor didn’t know the patient had addiction, you may argue. Maybe – but if these patients are transferring from an opioid treatment center, they would have methadone or buprenorphine in their urine drug screen. If either of those drugs were present, wouldn’t it be prudent to ask the patient for permission to call the local opioid treatment program, to see if there are records available? Wouldn’t it be prudent to see if your new patient is STILL an active patient at the local opioid treatment program?

Sometimes opioid-addicted people must take opioids for acute pain disorders, but there are ways to minimize risk, like having a dependable non-addict hold the pill bottle, only prescribing a few days at a time, and doing pill counts. Since acute pain is a short-term problem, it doesn’t carry the same risk as month after month of opioid prescribing.

I do have specific advice for the pain clinics of the world, particularly in my part of the world:
1. Get old records. If the patient is transferring from my opioid addiction treatment program to your office-based opioid treatment program, we have essential information that can help you give the best and safest treatment. More likely, you’ll get information that will keep you from harming the patient.
For example, if you want to start the patient on buprenorphine, it would be essential to know the date of the last dose of methadone, and the amount. Otherwise, you could put your new patient into precipitated withdrawal, and unpleasant experience all around.
As another example, if you’re treating a pain patient with fentanyl, you may have second thoughts – hopefully – if we have old records describing the patient’s past near-fatal overdose from fentanyl.
2. Don’t be an asshole when I call you to get information about a patient who transferred from my program to yours, then back to mine after having a relapse back to active addiction. It’s not my fault, and certainly not the patient’s fault. You should have known that a person with opioid addiction, doing well on methadone maintenance, would decompensate when you switched her to fentanyl patches and a hundred and twenty oxycodone for breakthrough pain.
I’m not trying to rub it in your face, but I am trying to educate you, in the nicest way possible, that you made a mistake. I’m hoping if I can explain to you why the patient’s decompensation was predictable, you won’t continue making the same mistake. I’m also making sure you won’t keep prescribing opioids for this particular patient.
3. Don’t let your physician assistant prescribe buprenorphine for “pain” but then also list opioid addiction on the patient’s problem list. It’s disingenuous. We all know that under DATA 2000, physician assistants and nurse practitioners can’t prescribe buprenorphine for addiction. You say it’s for pain, so that a physician extender can see this patient, but then have to tell the patient’s insurance it IS for addiction to get them to pay for it. Besides being bad medical practice, isn’t that insurance fraud?
4. When the family member of one of your patients tells you that patient is misusing her medications, please check it out. Yes, sometimes people do call prescribers trying to interrupt a patient’s treatment for malicious reasons. We have the same problem at our opioid treatment program. However, we do all we can to check on patient safety. If the third party says your patient is injecting your prescribed medication, it’s easy to call the patient into the office to look for track marks. (You do know what those look like, right?)

Doctors at pain clinics could say I’m just mad because they sometimes “steal” our patients. While I’m not happy when patients leave our treatment program, no one can “steal” patients because no one owns patients.

The biggest part of my disgruntlement all centers on the four behaviors I’ve described above. If new pain clinics/addiction treatment programs were accepting our patients who were doing well, and were appropriate for an office-based addiction treatment program…I’d be fine with that. If it worked out for the patient, and saved them time and money with no increased risk of relapse, great. I love to see patients doing well.

But I don’t think all pain clinics give good care, and I’m disturbed when patients suffer set-backs due to mismanagement.

A 1980’s Flashback

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Brownish-purple bumps covered the face and torso of the patient lying in the hospital bed, and I watched as tears puddled just above a particularly prominent nodule. Then I looked at his partner, a fit young man, who had turned his face and body away from the patient. With his head propped against the wall, I could see his shoulders shaking with sobs. With a detached and distant part of my brain, I wondered if he was crying for his sick partner, or if he was crying because he had a vision of what likely lay ahead for him as well.

I didn’t know what to say. I had just informed the patient, my patient for only three days, that he tested positive for HIV. The nodules all over his body were Kaposi’s sarcoma. I knew he already suspected all of this, but now we knew for sure. Not for the first time, I thought about how ill-equipped I was at dealing with the aftermath of giving bad news. I yearned for a nurse or social worker who could come spout words of comfort to this young man and his partner.

But there were no words of comfort. In 1988, I was in my second year of my Internal Medicine residency, and the only anti-retroviral we had was AZT, zidovudine. The virus mutates quickly, so resistance developed to our only treatment. We could treat opportunistic infections as they emerged, and even give antibiotic prophylaxis to stave off some of the infections like pneumocystis, but every patient I treated progressed towards physical debilitation and death.

Patients in the late 1980’s often came to medical attention as a result of one of the many devastating infectious diseases seen with immunosuppression. If they were poor or had no established physician, they were assigned to the Staff Medicine services and we residents took care of them, under the supervision of our attending physicians. New AIDS cases were diagnosed every week by the resident physicians at Charlotte Memorial Hospital and accounted for a full fourth of our patient case load.

At morning report, where we discussed our new admissions , Cryptococci meningitis, pneumocystis carinii pneumonia, toxoplasmosis, and other opportunistic infectious diseases seen only in patients with severely compromised immune systems were as common as uncontrolled diabetes mellitus and COPD exacerbations. At morning report, it was… ho-hum… just another case of progressive multifocal leukoencephalopathy.

But then in the early 1990’s, scientists developed HAART, an abbreviation for highly-active anti-retroviral therapy. Suddenly HIV became more of a chronic disease. Though it still causes significant illness and suffering, it’s no longer the inevitable death sentence it was in the 1980’s.

My current patient had the worst case of Kaposi’s sarcoma that I had ever seen, and I’d already seen more cases in two years as a resident physician than prior generations of doctors saw in a lifetime.

My generation of physicians trained at an unusual time in history. We saw strange and exotic diseases from immunosuppressed HIV patients that hopefully no generation will see in the future, and half of those new cases were diagnosed in IV drug addicts, mostly addicted to opioids.

How is it, then, that IV opioid addicts were not given appropriate treatment?

I still plead ignorance. I didn’t know any better. I took my cue from my teachers and mentors, who communicated verbally and nonverbally that addicts weren’t sick, but “bad” people, even weak people who would not stop doing something that put them at risk for dying from AIDS, a dreadful disease caused by HIV.

I still marvel at the mismanagement of my drug-addicted patients back then. About half of the new HIV diagnoses were made in IV drug abusers, yet I don’t recall ever hearing of needle exchange programs or methadone maintenance, though there was a methadone maintenance program in Charlotte at that time.

We should have been calling to arrange intakes at that methadone maintenance program before our opioid-addicted patients even left the hospital. If they didn’t have HIV, getting them into medication-assisted treatment could have been life-saving from several points of view. Not only would they be less likely to overdose and die, but they would be three times less likely to contract HIV.

I lament all of those wasted opportunities and every patient who didn’t get the care she should have had.

Now, let’s at learn from the past, and not repeat mistakes in this generation.

At present, we’re quibbling about increasing access to medication-assisted, office-based treatment with buprenorphine, out of fear these patients won’t get appropriate counseling. Even AATOD wants to wait until precautions can be put in place to assure office-based programs will provide good counseling, which is an essential part of treatment.

It’s a legitimate concern, but perhaps not the most pressing issue of the opioid addiction epidemic when people are dying from overdoses and being put at risk for Hep C and HIV.

It’s a little like worrying about how badly your house needs painting while part of it is on fire.

Office-based Opioid Addiction Treatment: Raising the One-hundred Patient Limit

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The hearts of addiction medicine doctors nationwide are aflutter at rumors that the limit on office-based buprenorphine patients may be raised or lifted. As it is now, the DATA 2000 law says each doctor who prescribes buprenorphine from an office setting for the treatment of opioid addiction can have no more than one hundred patients at any one time.

DATA 2000 was a big deal. Until it passed, it was illegal for any doctor to prescribe any opioid to treat opioid addiction, unless they worked at a specially licensed opioid treatment program. In other words, doctors in an office setting had to refer opioid-addicted patients to opioid treatment centers for medication-assisted treatment. And the only medication available was methadone.

Then DATA 2000 allowed Schedule 3 opioids to be prescribed from physicians’ offices for the purpose of treating opioid addiction, as long as these medications were FDA-approved for this purpose. Thus far, buprenorphine is the only medication that meets the DATA 2000 requirements.

But the law had other limitations. For example, each physician had to get a special DEA number to prescribe buprenorphine. And as above, no physician could have any more than one hundred patients on buprenorphine at any one time.

My office gets multiple calls each week from people seeking treatment for opioid addiction in an office setting. These callers say they’ve already been to the websites that list doctors. (http://buprenorphine.samhsa.gov and http://suboxone.com . They’ve made multiple calls and discovered these doctors aren’t taking new patients because they’re already at their one hundred patient limit. This is happening all over the country; patients want treatment but can’t get it. For many such people, opioid treatment centers are geographically impractical, so that’s not an option either.

Since addiction is a devastating and potentially fatal disease, government officials feel pressure to do something to help our nation’s opioid addiction problem. Lifting the one- hundred patient limit has been suggested as one option to improve the situation. This would seem to be the best, easiest, and quickest way to get more people into treatment. At least, most Addiction Medicine doctors like me think it makes sense.

Not everyone agrees.

Opposition has come from some unexpected sources. I went to an opioid addiction treatment conference in a neighboring state lately and heard the president of AATOD (American Association for the Treatment of Opioid Dependence), Mark Parrino, MPA, speak against lifting the limit.

First let me say I admire Mr. Parrino immensely. He has been and continues to be a huge advocate for this field. He’s done more good in the field of opioid addiction treatment than most people I can think of, and has been doing this good work long before I ever even entered the field.

But that doesn’t mean I agree with him on everything.

When he spoke at the conference, he said he was opposed to expanded buprenorphine treatment in the office-based setting because patients don’t get the counseling that they need, so it really isn’t medication-assisted treatment, it’s just medication assistance. He says opioid treatment programs provide on-site counseling, drug testing, and other services that can help patients, and that most office-based programs don’t offer such comprehensive services. He also said diversion of buprenorphine from office-based practices is a huge problem, and that much of the black market use is actually abuse of the medication. He raised the uncomfortable issue of price gouging by some unscrupulous buprenorphine doctors who charge large fees and deliver little care.

You can read a statement on the AATOD website that fully describes their opposition – or at least call for caution – regarding raising the one hundred patient office based treatment limit:
http://www.aatod.org/policies/policy-statements/increasing-access-to-medication-to-treat-opioid-addiction-increasing-access-for-the-treatment-of-opioid-addiction-with-medications/

I don’t completely disagree with the points Mr. Parrino made at the conference, but I do think the same arguments can be made against OTPs if one were inclined to do so.

What about opioid treatment programs that pay lip service to the counseling needs of the patients? What about OTPs that hire people to be counselors with little or no experience in the counseling field? Just as Mr. Parrino can point to the worst examples of office-based buprenorphine treatment, I can point to OTPs who aren’t doing a great job. How can an OTP counselor provide Motivational Interviewing as a therapeutic technique if that counselor has never even heard of MI? Yet I’ve seen these problems at opioid treatment programs.

Don’t paint all office-based practices with the same brush. Many of us want to provide good treatment with adequate counseling. For example, my office has a therapist who is a Licensed Professional Counselor with a Master’s in Addiction Counseling. He does a great job, and as an added bonus has great legs. (He’s my fiancé, before you assume I’m sexually harassing him at the workplace).

Alternatively, if the patient prefers to do only 12-step meetings, I’m OK with that, so long as they provide me with a list of meetings they’ve attended each month. Or if they’re already working with a therapist, it’s OK with me if they want to continue, as long as they agree to allow me to speak with their therapist about issues directly relating to the treatment of their addiction.

Diversion of buprenorphine to the black market is a big problem. Not all office-based buprenorphine doctors are as careful as we should be. We will never be able to get rid of all diversion of any controlled substance that we prescribe, but all buprenorphine doctors should be doing drug screens and have diversion controls in place to limit the problem.

Not as much methadone is diverted, but only because of the very strict regulations on methadone take- home doses at the OTP. Many patients – and OTP personnel – feel present regulations on methadone take- home doses are overly strict and limit flexibility of treatment for patients who are doing well. Is the answer then to regulate take -home doses of buprenorphine as closely as methadone?

What about the predatory doctors who prescribe buprenorphine just for a quick buck, sensing they can charge exorbitant fees from desperate opioid addicts? I can’t say anything in their favor. They embarrass me. As with many things in life, the actions of a few give the rest of us a bad reputation. But I do think these doctors are in the minority.

And don’t believe everything you are told about office-based practices; I’m sometimes told by patients that I’m in it “for the money” though I charge the same for an office visit for a buprenorphine patient as I would for any other medical ailment. Some patients feel like their treatment should be free, but the U.S system of medical care is not usually free for any disease.

In short, though I recognize there’s some truth in many of Mr. Parrino’s statements, I still think most buprenorphine doctors try very hard to do things right so that they provide good care for opioid addicts who can’t or won’t go to an opioid treatment program. Expanding access by raising the one-hundred patient limit will allow more people to get addiction treatment.

Opioids and Benzodiazepines Prescribed More Frequently in the South

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Last month, the CDC released information comparing rates of opioid and benzodiazepine prescriptions by state and by region. It did not surprise me to learn the South had the highest rates of benzodiazepine and opioid prescribing of the entire nation.

U.S. citizens already receive twice the number of pain pills per capita than our Canadian neighbors. But in addition to that difference, there’s a 2.7-fold difference between the state with the lowest opioid prescribing rate per capita (Hawaii) and the states with the highest rate per capita (Tennessee and Alabama tied for first place). [1]

The same held true for benzodiazepines, with even more difference in prescribing rates. In Hawaii, doctors prescribed benzodiazepines 19.3 times for every 100 people. But in Tennessee, doctors prescribed benzodiazepines 61.4 times for every 100 people. That’s over a three-fold difference between these states.

Alabama, Tennessee, and West Virginia were the top three prescribers for both opioid and benzodiazepines. We already know that higher prescribing rates are associated with higher overdose deaths rates from these medications. Incredibly, these three states were more than two standard deviations away from mean prescribing rates for the entire country.

Even more disturbing, Tennessee doctors prescribed oxymorphone (Opana) at an amount 22 times that of doctors in Minnesota.

That’s just bizarre. It could also explain why so many of the patients I admit to OTPs in the mountains of North Carolina mention Opana as their drug of choice.

The CDC authors of this report admit it’s unlikely there’s much difference in rates of disorders needing treatment with opioids or benzodiazepines. My interpretation of this statement is that it’s an indirect way of saying doctors in the South are overprescribing opioids and benzodiazepines. The authors allude to the problem of overprescribing in the South, mentioning that the South also has higher rates of prescribing for antibiotics, stimulants in children, and medications known to be high risk for the elderly.

How did my state of North Carolina compare to the rest of the nation? Our data isn’t as embarrassing as that for Tennessee, but there’s certainly room for improvement. In NC, doctors prescribed around 97 opioid prescriptions per 100 people, and 45 benzo prescriptions per 100 people.

Benzodiazepine co-addiction complicates induction onto methadone and buprenorphine done by opioid treatment programs for the treatment of opioid addiction, and this co-addiction also predicts poorer treatment outcomes. [2, 3]

This supports what I’ve long suspected: the treatment of opioid addicts with MAT is different in the South than in the West. My colleagues in California, inferring from the CDC’s report, don’t have to deal with benzodiazepine co-addiction as often as I do in the mountains of North Carolina. That co-occurring addiction changes the clinical picture, and makes induction onto methadone particularly more risky.

This is not the South’s finest hour. We must do more to educate doctors about appropriate prescribing, starting in medical school and continuing throughout the physicians’ professional careers. If doctors don’t start this change, someone else will surely do it for us.

1. http://www.cdc.gov/vitalsigns/opioid-prescribing/index.html
2. Brands et al, 2008, Journal of Addictive Disease
3. Eiroa-orosa et al, 2010, Drug and Alcohol Dependence

Drug Arrest for Doctor

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Last week, news outlets in my area were all aflutter about a physician in a small town who was arrested for prescription medication fraud. It was alleged that he prescribed opioid pain pills to seven of his wife’s friends and acquaintances, none of whom were his patients, so that they could pick up the pills and deliver them to the doctor and his wife.

I’m not giving the name of the doctor, his wife, or the other people arrested, though you can get those if you click on the link below. I figure all of them are getting enough bad press without me piling on too. Besides, this bizarre situation has addiction written all over it. [1]

The SBI investigated this case for four months and finally arrested the eight involved people last week.

The doctor’s wife was a teacher, and she was accused of convincing coworkers at her school to become involved in the illegal activity. These people were teachers, teacher’s assistants, or administrative aides at the school. The illegal prescriptions were filled from late 2012 until early 2014, and totaled around 200 prescriptions and 25,000 doses of hydrocodone. According to the news reports, some of the people filling the prescriptions were using some of the pills, and delivering some back to the doctor and his wife. Others say they thought they were helping people get access to pain pills by using their names.

If this news report turns out to be true, I have a hard time believing the doctor and his wife would take such a risk unless one or both are addicted to opioids. No one is immune to addiction, as we know. And I doubt the people filling the prescriptions would participate in this mess unless they were getting something out of it, too. Claiming to have filled phony prescriptions just to help someone out…I call bullshit on that. These people could also be pill abusers or addicts, or maybe were getting paid to pick up the pills, but I can’t imagine anyone would do this highly illegal thing without some sort of remuneration.

This was a big news story because people were shocked that this drug ring (allegedly) involved a doctor and schoolteachers. But as we know, addiction is an equal opportunity destroyer. For too long, society has imagined that drug addicts are people lying in the gutter with a needle hanging out of their arm. In reality, opioid addicts today look like our next door neighbors.

I reacted to the story with sadness, and with curiosity. I was sad because I think it’s highly likely all the people who were arrested suffer from addiction, and are in need of treatment. But maybe they’ll get lucky, and will be mandated to treatment instead of jail.

I was curious because I wonder why the doctor prescribed only hydrocodone. Why not advance to a more powerful opioid, if you are going to break the law anyway? If you know what you are doing is illegal, why not splurge, and prescribe Dilaudid, or OxyContin? Or maybe he’s smart, thinking that higher powered opioids would call more attention to the scheme. But surely he knew this could not remain secret, with seven other people involved.

This story may illustrate, again, that we don’t do our best thinking in the midst of addiction.

1. http://www.wtvm.com/story/25968161/dr-orrin-walker-abby-walker-rss-bostian-elementary-drug-scheme

My Occupational Pet Peeves

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I feel like venting. It’s my blog, so I can if I want to. These things annoyed the stuffing out of me this week:

 Opioid treatment programs who list themselves as capable of dosing patients with both methadone and buprenorphine, but when the counselor calls to set up guest dosing for her bupe patient, they don’t really use buprenorphine.

That’s false advertising. Why do you waste everyone’s time by advertising something you don’t provide?

 Pharmacies who list prescriptions for patients in the North Carolina Controlled Substance Reporting System (my state’s prescription monitoring program) BEFORE the patient picks up the prescription.
I called the patient in to see me, and she denied filling the prescription listed on the NC CSRS. I called the pharmacy, and the patient is right. This pharmacy chain enters data as being filled before it’s picked up by the patient because they can’t do it any other way with their computer system.

If this database is worth doing, isn’t it worth getting it right?

 Patients being prescribed controlled substances by the VA (Veterans Administration) in my state don’t have their medication listed on our prescription monitoring site.
This is a patient safety issue. Why won’t the VA protect their patients?

 I call the doctor for one of my opioid treatment programs to discuss how best to coordinate his care. After spending five minutes on hold on the phone, a nurse comes on the line and says “Doctor is in with a patient right now. He can call you when he’s done.”
What the flip does Doctor think I’ll be doing when he calls me back? Sitting with my feet on the desk, playing free cell on my computer, waiting breathlessly for his phone call? No, I’ll be talking with my next patient.

This is doctor one-upmanship. When Doctor does call me, I’ll interrupt the patient I’m with, come to the phone, and it will be Doctor’s receptionist who says, “Hold for Doctor, please,” and I’ll have to wait a few more minutes if I’m lucky.

 New patients who don’t keep their appointments with me.
I don’t have many office- based Suboxone openings, what with the 100 patient limit. I can’t take every new patient who calls, so if you call at the right time and do get an appointment, please keep it, or at least call to let me know you won’t be there. There are other people I could see during the hour I set aside for you. And if you don’t keep that first appointment or call to cancel it, don’t call for another. I can’t afford to have you in my practice. Sounds harsh? Yes, maybe so, but I have financial realities to meet.

 Insurance denials of coverage for buprenorphine products (Suboxone, Subutex, Zubsolv, etc.)
Coventry (that’s right, I’m calling you out, you lame excuse for an insurance program) recently denied coverage for Suboxone films because my patient was found to have received a prescription for tramadol from a dentist.

First of all, my patient told the dentist not to prescribe any opioids because he was in recovery from addiction and had to be careful. My patient took the prescription his dentist gave him, on which was written both tramadol and an anti-inflammatory medication. He called my office and asked if he could take the anti-inflammatory. He didn’t ask about the tramadol because he didn’t intend to take it.

When we found his insurance company refused to pay for his monthly Suboxone prescription because he had filled a tramadol prescription, he told me he still had the tramadol at home, if it made a difference. I said yes, and asked him to bring it in, which he did. I did a pill count. All the pills were there, and I watched him discard those pills, and wrote a letter to his insurance company, appealing their decision to stop paying for his Suboxone.

That was last week. I haven’t heard back. For now, my patient is paying out of pocket for his medication, which as readers know, is not cheap.

Ah, I feel much better now….

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