Archive for the ‘Doctors Behaving Badly’ Category

To Taper or Not To Taper…

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Below is a comment responding to my last blog post, and my answer to it. I thought this aspect of buprenorphine treatment was so important that it’s worth a blog of its own.

While I wholeheartedly disagree with a decision not to stock any buprenorphine products at a pharmacy, I understand what led to it. The area has a troubling pattern of buprenorphine use to maintain dependence instead of being tapered to actually treat the dependence and help the patient. A pharmacist should be able to refuse prescriptions that are being prescribed and/or used inappropriately without having to fall back on a blanket “we no longer stock it” statement. Ensuring that patients who are being gradually tapered to treat dependence or bring treated for pain have a harder time getting their medication is not an acceptable way to lessen the abuse.

         Posted by janaburson on July 28, 2016 at 8:56 pm  edit

Aha!! You may be on to something. Maybe these pharmacists think, like you do, that buprenorphine should be tapered, instead of being used as a maintenance medication. When it first came out, I think many of us hoped we could taper people off of it quickly. However, more & more studies are showing that the patients who stay on buprenorphine do the best. By best, I mean not dying, no illicit opioid use, can hold down a job, finish school, be a good parent, etc.
People who taper have a high relapse rate. Relapses can be deadly. Our opioid overdose death rate is already too too high. Let’s not make it worse by insisting opioid use disorder be treated like a short-term illness, rather than the chronic disease that it is.
Having said that, patients are different, and taper may be appropriate in selected patients. But it’s not a quick process and it takes time to get the counseling and make life changes.
Would you tell a diabetic, who is not eating right or exercising, that they should taper off metformin, since if they changed their behavior, they would not need medication?

I forget there are still people who think buprenorphine should only be used temporarily, as a detoxification medication. I’m not saying that’s always wrong. A minority of patients may do well with only a taper, but most patients with opioid use disorder do better if they stay on buprenorphine long-term.

Does that mean these patients should never taper off buprenorphine? I’m not willing to say that either. We don’t have enough information from good studies to show us how long is long enough.

We do have studies now that tell us tapering off buprenorphine after a few months of stabilization isn’t going to produce best outcomes for most patients.[1, 2, 3]

We also know active opioid use disorder is associated with a high mortality risk.

Some people do misuse buprenorphine, and shouldn’t be kept on this treatment. Those patients will do better with another form of treatment, perhaps methadone.

Let’s take what we know about opioid use disorder and its treatment with buprenorphine, and apply it to an imaginary disease that has no moral judgment attached. Let’s call our disease “Syndrome X.”

We know Syndrome X causes a great deal of emotional, physical, and spiritual suffering. It can occur in anyone, and has a high mortality rate. It can be effectively treated with a medication that is relatively safe, and does not cause euphoria when used correctly. However, the medication can cause some withdrawal if it’s stopped suddenly.

While on medication, patients with Syndrome X feel normal, unlike how they feel off medication. On medication, these patients are more likely to be in better physical health, mental health, and are more likely to be employed. They are more likely to be productive members of their families and their communities.

The studies of patients with Syndrome X show pronounced reduction of death rates while patients are on medication, as well as lower rates of infectious diseases. We also know from studies that if patients with Syndrome X are tapered off their medication, their death rates increase anywhere from three times to sixteen times compared to if they stayed on their medication.

Who in their right mind would ever recommend tapering the medication? Who would say to their loved one, “You’ve got to get off of that stuff. You just need to be strong.” Or, “Isn’t it time you stop using that crutch?”

It’s only because of the stigma this country has against people with substance use disorders that tapering off a life-saving medication is even an issue. If we were talking about any other chronic illness, there would be a loud clamor for every person to be able to get on and stay on that medication. In fact, doctors not prescribing a medication with as much benefit as buprenorphine has for opioid use disorder would be accused of malpractice.

I don’t push my patients to taper off buprenorphine. If that is their desire, I’ll do everything I can do to help them. I tell them what I’ve seen work in my other patients, work with them on relapse prevention, and encourage them to go slowly, to give their brain time to adjust as their dose comes down.

I’ve had many patients taper successfully, and most of them did this after at least a few years of stability on buprenorphine. When I see new patients, I tell them this isn’t (usually) a quick fix that they can do in a few months and be cured forever. A few lucky patients are able to taper quickly but I think we now have studies showing this isn’t the situation for most people with opioid use disorder.

How about this: leave the timing of the taper up to the patient and their doctor.

If you aren’t one of these two people, maybe you don’t get to have an opinion on when or even if a taper should be attempted.

1.Fiellin et al, See comment in PubMed Commons belowJAMA Intern Med. 2014 Dec;174(12):1947-54.

This study concluded “Tapering is less efficacious than ongoing maintenance treatment in patients with prescription opioid dependence who receive buprenorphine therapy in primary care.” The taper arm of the study was started after six weeks of stabilization, with a three week taper. Patients on the taper were offered medication to help withdrawal symptoms and also offered naltrexone treatment. Patients who tapered were significantly more likely to have opioid-positive drug screens compared to the patients who remained on buprenorphine maintanence. Patients on maintenance were significantly more likely to remain in treatment for addiction counseling that the patients were tapered.

2.Marsch et al,  See comment in PubMed Commons belowAddiction. 2016 Aug;111(8):1406-15.

This study of fifty-three young people aged 16 to 23 were enrolled in a double-blind, placebo-conrolled trial. Subjects enrolled in the arm of the study where buprenorphine was tapered over fifty-six days were signigicantly more likely to have opioid-negative drug screens and continued participation in treatment compared to subjects given twenty-eight day tapers

3.Weiss et al, Prescription Opioid Addiction Trial

“Adjunctive Counseling During Brief and Extended Buprenorphine-Naloxone Treatment for Prescription Opioid Dependence: A 2-Phase Randomized Controlled Trial.”  Archives of General Psychiatry 2011.

This study of prescription pain pill users found that taper off buprenorphine after stabilization shows a high relapse rate.

Access to Buprenorphine Will Expand; News About CARA

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Last week, the Department of Health and Human Services (HHS) announced it was raising the limit on the number of patients each doctor can treat for opioid use disorder with buprenorphine, from the present cap of 100 patients to 275 patients. However, each doctor must first meet criteria and complete an application procedure to be approved for this higher limit.

Initially, HHS wanted to increase the limit to 200 but for some reason ended up with 275. It’s still an arbitrary number, and opioid use disorder remains the only disease to have patient enrollment limits legislated for physicians.

HHS still wants physicians to meet extra requirements before they are approved to accept 275 patients, as I blogged about in my May 8, 2016 post:

  • Have professional coverage for after-hours emergencies.
  • Provide case management services
  • Use electronic medical records
  • Must use that practitioner’s state prescription monitoring program
  • Accept third-party insurance
  • Have a plan to address possible diversion of prescribed buprenorphine medication
  • Re-apply for permission to treat up to 275 patients every three years
  • Supply yearly reports about their practice and their buprenorphine patients

For some of the reasons I names in my May 8th blog, at this time I’m not planning to request permission to treat more than 100 patients.

This measure by HHS is a good and positive thing, and will help more desperate people get treatment. Just because I have a few objections to several HSS’s requirements doesn’t mean other doctors will feel the same way. I expect many physicians treating opioid use disorder will undergo the procedure to expand their patient limit.

 

Meanwhile, both the House of Representatives and the Senate passed the Comprehensive Addiction and Recovery Act (CARA) as of last week, and the bill is going before the President for his signature.

This bill, considered weak by some members of the House, contained only a fraction of the requested money to treat addiction. However, other advocates for addiction treatment say even a weak bill is better than none.

CARA’s content addresses the following:

Expand availability of naloxone to law enforcement and first responders, in order to quickly reverse opioid overdoses and prevent deaths. I think our own Project Lazarus helped get this ball rolling many years ago, and I’m so grateful my OTP has had support from them to give our patients naloxone kits!

Expand education and prevention efforts toward teens, parents, and aging people to prevent drug abuse and promote treatment and recovery.

Encourage states to improve their prescription monitoring systems. I hope some of that money will be directed to interoperability, meaning it will be easier to access a neighboring state’s prescription monitoring program. I also hope the Veteran’s administration will start reporting their data about prescribed controlled substances, too.

Prohibit the Department of Education from rejecting financial aid for people who have had past drug offences. I didn’t know people with drug offences on their record were denied governmental financial aid. If we want people to improve themselves and their life situations, why would we deny help for them? So this measure in CARA is great.

Expand resources to identify and treat incarcerated people with substance use disorders using evidence-based treatments.

Great idea, about forty years late.

Expand drug disposal sites to keep leftover meds out of the hands of children.

Just a question I’ve always had…Of all the tons of medication which have been collected at these disposal sites, has anyone ever studied how much controlled substances are collected?

Launch a “medication assisted treatment and intervention demonstration program.”

Not sure exactly what this will look like, but good luck with all of that.

I feel like I’ve beaten my head against the brick wall of prejudice and stigma against MAT in my community for four years. All I have is a headache…and resentment towards the medical community. I’d be very happy if someone else wants to take over for a while.

Launch a program to promote evidence-based treatment of opioid use disorder.

Well, yeah. it needs to happen. Actually it needed to happen about fifteen years ago, but whatever.

Director money towards law enforcement, to get people with substance use disorders help, rather than incarceration. CARA wants law enforcement to be able to work with addiction treatment services.

I indulged a private snicker at that last one. What a change from only a few years ago.

About six years ago, I was trying to educate people about medication-assisted treatment of opioid addiction. I thought I could help educate law enforcement personnel about addiction treatment, since they encounter it so much. I used the internet to find a journal for law enforcement.

I wrote to the editor, offering to write an educational article for their publication about opioid addiction treatment. My hopes weren’t especially high, but I wanted to give it a shot.

I was surprised when the journal’s editor took the time to call me in person. I was so excited!

Then the editor started talking to me like I was a naughty child. He asked what made me think it was appropriate to waste his time with such a query letter. He said I should have known better than to think any of his readers would be interested in the kind of thing I was offering to write, and he was calling to see what kind of person would be so unwise as to think otherwise.

I was stunned. I regret my reaction to him. I was so taken aback that I started apologizing to him, and said I was so sorry for bothering him and wasting his time.

In reality, he behaved like an asshole. If he didn’t want to waste time, he could have passed on the urge to call me to tell me how stupid he thought I was.

I wish I would have stuck up for myself in that conversation. I like to think I would handle it differently today.

Anyway, now, six years later, the government earmarked money to help law enforcement learn about opioid use disorder treatment.

While writing this article, I’ve come to realize I have bitterness towards people in law enforcement, medical fields, judicial, etc…when they denigrated my efforts to educate them about medication-assisted treatment for opioid use disorder.

I don’t want this bitterness. It’s too hard on me. It’s a weight that interferes with my enjoyment of life, and I’m going to release it.

The tide has begun to turn. We have legislation addressing the terrible opioid addiction problem we have, and money earmarked to help the problem. I want to be able to work with people who may have said bad things about medication-assisted treatment of opioid use disorders in the past. I want to work with those people without feeling resentment and without indulging in sarcasm.

Action by the North Carolina Medical Board

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Last month, the North Carolina Medical Board (NCMB) announced they will query our state’s prescription monitoring program and investigate physicians identified as having worrisome prescribing habits. In order to help combat the prescription opioid overdose death crisis, this is part of an action that the NCMB is calling the Safe Opioid Prescribing Initiative.

Announced last month, the initiative will focus on three groups of physicians. This is taken directly from the NCMB’s website:

  1. The prescriber falls within the top one percent of those prescribing 100 milligrams of morphine equivalents (MME) per patient per day.
  2. The prescriber falls within the top one percent of those prescribing 100 MMEs per patient per day in combination with any benzodiazepine and is within the top one percent of all controlled substance prescribers by volume.
  3. The prescriber has had two or more patient deaths in the preceding twelve months due to opioid poisoning. (The initial group of prescribers under investigations were reviewed for the period beginning July 2014 and ending June 2015.)

The NCMB also says letters were issued to the first 72 prescribers (physicians and physician assistants) in April, most of whom were identified under the third criteria. Since nurse practitioners are also allowed to prescribe controlled substances, they will be scrutinized by the North Carolina Board of Nursing.

Responses to this new NCMB initiative have been mostly supportive. In my local newspaper, an editorial applauded the board’s actions, and advocated more such actions, to reverse the crisis of opioid overdose deaths in the state. The Charlotte Observer carried an article that said the NC General Assembly criticized the NCMB for not doing enough to combat prescription opioid overdose deaths

I’m probably not the NCMB’s biggest fan, but I don’t think it’s fair to blame that board for not doing more about the prescription overdose death crisis. The medical board wasn’t even allowed to access the prescription monitoring program’s data until the law changed last year to allow them to do so. Before that, they had no authority to do what the Safe Prescribing initiative outlines. In the past, they could investigate a physician only if they received a complaint about him or her.

Members of any state medical board have a thankless job. They are asked to make perfect judgments about medical professionals who may present a danger to the public. If they appear to be too lenient, they are criticized by the public for “protecting their own.” (This isn’t accurate anyway, since at least in my state, over one-third of board members aren’t physicians.) If they take strongly punitive stances, they are criticized for overstepping their authority and ruining the livelihoods of the professionals they license.

The professionals on my state’s medical board spend hours evaluating cases, for little or no pay. I think they may be paid nominal reimbursements for travel expenses, but I’m certain it doesn’t come close to making up for the time these people lose from their own businesses and practices.

Contrary to public opinion, state medical boards exist to protect the public, not to advocate for the doctors they license.

The NCMB initiative won’t be easy to implement, either. Just because a physician prescribes a whole lot of opioids doesn’t necessarily mean he’s a bad doctor. For example, a physician working with hospice patients, doing end of life care, should be expected to prescribe large amounts of opioids, and have frequent patient deaths.

Peer review of physicians will be essential. The NCMB will send charts of doctors identified by the three criteria above to be reviewed by other doctors in the same subspecialty. That means, hopefully, that doctors will be judged by other doctors in the same field of medicine.

This is important. This means that good pain management doctors may have to be evaluated and judged by other pain management doctors, through the NCMB. That will no doubt be unnerving, but the outcome should ultimately be positive, if the doctors are taking appropriate precautions.

Only doctors failing to meet accepted standards will have action taken on them by the NCMB, and only those actions will become public.

The NCMB has a big job ahead. They will need to separate the sheep of the doctor world from the goats, and decide appropriate actions to take. I do not envy them this task.

The NCMB has already taken action against many of the pill-mill type doctors, starting over a decade ago. If the board received a complaint, investigated a prescriber, and found him or her to be engaging in worrisome prescribing practices, that practitioner either lost the license to practice medicine, or was prevented from prescribing controlled substances, or was asked to take educational courses in proper opioid (or other controlled substance) prescribing.

I have other concerns about the third criteria of the NCMB’s Safe Prescribing Initiative.

First of all, how will the NCMB know if a prescriber has had two or more patient deaths in the preceding twelve months? I suspect the only cases examined by the NCMB will be those found to be opioid poisoning per the North Carolina Office of the Chief Medical Examiner (NC OCME).

Deciding if a prescribed opioid caused a patient death can be tricky. It depends to a large degree on the tolerance of the decedent, which needs to be determined by patient history. A dose of opioids that would kill one person won’t even make another person drowsy, if they have tolerance.

That factor is particularly important with methadone. My colleagues and I bemoan the fact that when our patients die, it WILL be blamed on methadone, no matter what. One doctor grimly remarked that if one of his methadone patients got shot in the head, the cause of death would still be listed as methadone toxicity. I think he’s exaggerating, but only by a little

The problem is that the North Carolina Office of the Medical Examiner has no standard case definition of what constitutes a methadone overdose death, which inevitably leads to mistakes about cause of death. According to information on their website and what I’ve learned by speaking with them, the decision is made by the blood level of methadone in the deceased.

I’ve felt the sting of being unfairly accused of killing patients. On several occasions, I’ve called the OCME about one of my patients who died while on methadone. I wanted to provide information about the patient’s dosing history before they determined the cause of death. I felt I had important information that could help them…but it did no good.

In one case, my patient had dosed on methadone 130mg for about a year, and then started a slow and steady taper. One year later she was dosing at 60mg per day when she died suddenly and unexpectedly. At autopsy, she had cocaine in her system, and she had a history of heart trouble. I suspected a fatal cardiac arrhythmia caused by cocaine, but the OCME announced the cause of death was: “Methadone toxicity, cocaine toxicity.”

Apparently they based their decision on post-mortem blood levels, known to be inaccurate. After death, the methadone stored in the liver can leak back into the blood vessels, causing elevated readings on which their determination was made, regardless of the history I gave them about her dose.

Five or so years before, another patient of mine died of what I thought was a severe asthma attack. In fact, she called 911 herself, saying she was having an asthma attack. Sadly, by the time EMS arrived, she had stopped breathing and couldn’t be resuscitated. I called the OCME to see what they found at her autopsy. The physician who did the autopsy said he found mucus plugging and bronchial casts, classic findings of status asthmaticus, which is a severe and sustained asthma attack. I was sad about her death, and told him I had treated her for many months for opioid addiction, and that she had dosed daily on methadone 75mg for at least two months.

When the death certificate was issued months later, after the toxicology report was available, I was surprised to see the cause of death listed as “methadone toxicity.” I called the medical examiner again and asked why this was listed, and the answer was that it was based on the drug level of methadone in her system.

Thankfully those types of cases are relatively rare.

I worry much more about all the people who die from opioid overdose who are never identified as a coroner’s case. That’s a bigger issue.

Consider the ways in which a deceased person becomes a coroner’s case. Of course, all instances where foul play is suspected require autopsies. Young people with no known medical issues should be investigated. Sometimes, deaths that occur in hospitals or nursing facilities require autopsy, if unexpected. Deaths that occur in police custody always require an autopsy..

In the community, if a person dies unexpectedly, a coroner is called to come to the scene to look for foul play. If there is none, the coroner calls the person’s doctor, to see if there’s an obvious cause of death like cancer or heart disease.

If you are a doctor freely prescribing opioids and/or benzos, what would you say to a coroner? Possibly, you’d say the decedent was ill with various problems and that the death was expected. It could be convenient to describe as “cardiac arrest.” (Technically, all deaths are ultimately due to cardiac arrest, but that doesn’t tell us the cause of death) This would be less upsetting for the family, keep the doctor out of trouble, and save the cost of an autopsy to the state.

Besides, no doctor wants to think the medications he prescribed killed a patient, or even contributed to the person’s death, so that inevitably biases judgment about cause of death by the prescriber.

I wonder how many overdose deaths slip through unnoticed and unexamined. Current data shows a very high incidence of prescription opioid overdose deaths, but I fear it is even higher.

 

Update: Getting CDL on Buprenorphine

Sweet revenge

Since I posted last week about my patient on MAT getting turned down for a commercial driver’s license, some interesting things have developed.

Colleagues gave me suggestions for places where I could refer my patients on medication-assisted treatment to get their commercial driver’s license. As it turns out, several colleagues who work in addiction medicine also work in offices where DOT exams are done. Those doctors suggested I send my patients who need DOT exams to them. I can send a letter of support, describing their progress in recovery, and if everything else checks out, the CDL will be granted. Of course there can be no guarantees, but those offices won’t reject a person for a CDL only because they are being treatment for opioid addiction with medication-assisted treatment.

Problem solved. I thank my fellow physicians who offered that solution!

Additionally, some smart people in NC state government read my post, and contacted me. They suggested that our state’s prescription monitoring program does not permit use of its data for the purpose of denying a person their commercial driver’s license. My patient wasn’t seeing this doctor to get medical treatment, and did not give his permission for his records to be checked. Penalties for misuse of the NC Controlled Substance Reporting System can potentially be $10,000 per offense.

My patient is now deciding if he wants to pursue this issue by filing a complaint with the state. Outwardly, I told him it’s his decision.

Inwardly, I’m thinking, “Oh pleasepleaseplease file a complaint!!”

 

DATA 2000: I’m Not Bitter!

Denial

Recently discussion of expansion of the one hundred patient limit has been in the news. I lost interest in this topic several years ago, when I saw DATA 2000 standards being violated with impunity in my community. Given lack of adherence to DATA 2000 requirements, people who want buprenorphine have no problem getting it.

Is this good or bad? Maybe a bit of both.

At least three physician extenders in my area prescribe buprenorphine for patients with addiction on a regular basis, despite having no “X” number. I don’t know how this happens, but I do know the North Carolina Medical Board investigated this practice, took no action, and these same extenders, still with no “X” number, continue to prescribe buprenorphine for addiction.

Since present DATA 2000 regulations are being ignored, changes in those regulations are moot in my state, or at least in my area.

Do I sound bitter? Yes, I am, or at least I am intermittently. On most days, I’ve got my own patient challenges to deal with, so I don’t have time to worry about other doctors’ practices. But occasionally I do feel some resentment. It’s hard not to fret when other practices get away with things, while I follow regulations.

I also grumble when I’ve got to pick up the pieces for patients expelled from other buprenorphine practices for doing exactly what people with addiction do – take drugs.

I’ve had multiple patients seek admission to our opioid treatment program after they were “fired’ by these other practices. Now, I know I’ll do a better job than they ever did, but it’s a real pain in the ass to try to find out exactly what went wrong. I’ve been hesitant to believe patients’ versions, since they sound incredible, but so far, my patients have told the absolute truth.

Recently I admitted several patients after they were dismissed from the other practice for misuse of their opioids. These patients had been prescribed buprenorphine by the physician extenders, and were apparently doing well. Then on one visit, the nurse practitioner or physician assistant asked the patient about pain, and after being told some pain did remain, these patients were taken off buprenorphine and prescribed powerful opioids instead.

Even the patients thought this action was odd. These patients said they knew they would relapse, but due to their disease of addiction, were unable to refuse this jackpot of opioids when offered.

Events unfolded in a predictable manner. The patients went back into active addiction, and injected the oxymorphone they were prescribed. They ran out early, and when a pill count was demanded, they of course failed. Dismissed for being a bad patient, the confused patients came to the opioid treatment program where I’m left to try to figure out what the hell has gone on.

Thankfully, the people I’ve seen survived their relapses, and were able to re-stabilize on either buprenorphine or methadone. But I wonder how many other people have had worse outcomes.

Perhaps if buprenorphine prescribers had better education about addiction, such relapses could be avoided. That’s one big downside of ignoring DATA 2000 requirements.

Doctors with Addiction

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Physicians and other medical professionals have higher rates of addiction than the general population, but they respond better to addiction treatment. That’s the conclusion of Dr. Daniel Angres, seen on the front page of the most current issue of Internal Medicine News, Vol. 49, No. 3, February 15, 2016.

I get a copy of the Internal Medicine News every few weeks, and I always skim the articles. This week, front page coverage about addiction in physicians caught my eye.

This Dr. Angres said physicians who are appropriately treated for addiction have a five-year sobriety rate of around 80%. This is, of course, much higher than seen in non-physicians.

This news isn’t that new. Similar data has been described in early studies. [1-6]

I read this present article with interest, wondering if I would see new data, but the article appears to be a summary from a doctor with decades of experience treating physicians.

Studies of data collected on physicians with addiction show they’re more likely to misuse alcohol than any other drugs, but opioids are a close second, and then sedatives. Physicians are less likely than the general population to use street drugs. Presumably this is because they have access to prescription medication and are less likely to seek drugs from the street.

Long work hours, high stress, and poor self-care are thought to fuel much of physician drug use, but this idea is based more in theory than fact. As with the general population, mental health disorders are more frequent in physicians with addiction than in non-addicted physicians. Interestingly, one study showed that tobacco use, more than any other data collected from addicted physicians, was most strongly correlated with the presence of addictive disease. [8]

In one large study of physicians diagnosed with addictive disease who were under contract with the North Carolina Physicians Health Program, 85% of the physicians were male, and the average age at diagnosis was 44years old. Around two-thirds were married. Over half were mandated to undergo treatment by an agency such as hospital, medical board, malpractice insurer, or other less formal requests from spouses and practice partners.

Combining all available studies of addicted doctors, it appears psychiatrists and anesthesiologists were over-represented, meaning there were proportionately more of these specialists than one would expect from the number of these specialists. Both pathologists and pediatricians were under-represented.

Female physicians, same as females in the general population, have a telescoping of addictive disease. They tend to develop more severe addiction earlier than males. By the time female doctors enter treatment, they tend to have more severe addiction. They are also more likely to misuse sedatives than male doctors. and are more likely to have mood disorders with suicidal ideations. Female physicians tend to have harsher sanctions from medical boards than their male counterparts. [4]

Most states have physician health programs (PHPs), which are kind of like employee assistance for doctors, only with much more power. States have their PHPs set up in different ways, but usually the PHPs are separate from the medical boards. PHPs are set up to evaluate physicians for the presence of addictive disease, refer for appropriate treatment, and monitor recovery for a period of years. They are set up to be non-punitive, but if physicians relapse or don’t follow PHP recommendations, those doctors usually get reported to medical boards, where sanctions including loss of medical license are imposed.

PHPs may not do physician evaluations, but instead refer afflicted doctors to a treatment center for this evaluation. Many times, physicians are sent to specialty treatment programs who say they have special programs for physicians. Physicians tend to spend much longer in treatment than other people with the same addictive illness. It’s not at all unusual for a physician to be recommended to undergo inpatient treatment for three to six months.

PHP monitoring contracts usually extend for five years. This monitoring usually includes frequent random urine drug screens, aftercare treatment, and participation at 12-step meetings. In North Carolina, physicians are commanded to attend at least three 12-step meetings per week for their five- year monitoring contract.

On the other hand, PHPs frequently serve as advocates for physicians doing well in recovery. They can help these doctors with their malpractice insurers, hospitals, and other insurance companies.

While PHPs exist to help addicted physicians get the help they need, medical boards exist to protect the public from impaired physicians. Medical board actions are public records, which means safety-sensitive workers like doctors and nurses are not necessarily protected by the same privacy laws as other citizens.

As the article by Dr. Angres states, physicians have excellent recovery rates compared to other groups of people recovering from addiction. Doctors with addiction who get involved with a PHP have abstinence rates of 80% at five years.

We know there are some factors that predict a poorer outcome: injection of opioids as main drug of use, co-occurring psychiatric diagnoses, and continued use of nicotine. [7]

Lower rates of relapse in these recovering physicians are seen with lack of psychiatric co-occurring illness, longer time spent in professional treatment, participation in 12-step recovery, smoking cessation, and longer monitoring contracts (five years as opposed to three years). [7]

The article by Agres does mention the use of one medication to treat opioid-addicted physicians: naltrexone, which is an opioid blocker. This long article did not contain any mention of buprenorphine or methadone, except this vague sentence: “…medication-assisted treatment may be necessary for heroin addiction.”

I know most PHPs and medical boards won’t permit a doctor on methadone or buprenorphine to practice medicine, but it is very difficult to get these agencies to go on record one way or the other with their official position.

North Carolina’s Board of Nursing is a refreshing exception. The NC BON decided several years ago to allow nurses on buprenorphine and methadone to be licensed to work, though they do require significant input and advocacy from each recovering nurse’s treating physician. I recall they had decided to collect data from opioid-addicted nurses and compare outcomes of nurses in abstinence-only programs with nurses treated with buprenorphine and methadone. I don’t know if that study is ongoing, but it could contain some intriguing data.

Most medical boards and PHPs take the position that MAT impairs licensed professionals, but there’s scant data to support such a statement. In fact, available studies show pretty much the opposite. Some addiction medicine specialists – like me – feel denying evidence-based, potentially life-saving treatments to patients who work in safety-sensitive jobs is unethical, without established evidence showing harm from these treatments.

But then PHPs counter by saying that with success rates of 80% at five years, why consider MAT with methadone or buprenorphine, since it’s obviously not needed. Furthermore, many addiction treatment specialists say that if the treatment available to doctors were available to every opioid addict, MAT would be needed in relatively few people.

That may be true. None of the opioid-addicted patients I see can access three months of quality inpatient treatment, followed by aftercare for one year, and five years of monitoring with serious consequences for relapse. Even the ones with insurance may be able to go to inpatient treatment for several weeks, even one month if they are lucky. Maybe if all people could get the gold standard of opioid addiction treatment, we wouldn’t need to use MAT as much. I still believe some patients would require MAT. But right now, that’s not a realistic option for any of my patients.

I see both sides of the issue. And I also wonder what has happened to the 20% of medical professionals who had the gold-standard of treatment, and still relapsed. Did anyone talk to them about methadone and buprenorphine, if their main drug was opioids? Given the strongly 12-step oriented mindset of many PHPs, I suspect they weren’t told about this option.

  1. Dupont et al, “Setting the standard for recovery: Physicians’ Health Programs,” Journal of Substance Abuse Treatment, 2009, Vol. 36(2)159-171.
  2. Ganley et al, “Outcome Study of Substance Impaired Physicians and Physician Assistants Under Contract with North Carolina Physicians Health Program for the Period 1995-2000,” Journal of Addictive Diseases, Vol. 24(1) 2005, pp1-12.
  3. Paul Earley MD, FASAM, “Physician Health Programs and Addiction among Physicians,” Principles of Addiction Medicine, Fifth edition, 2014, WoltersKluwer pp602-621.
  1. Penelope Zeigler: PCSS-O – archived webinar 5/15: “Treating Substance Use Disorders in Health Professionals”
  2. Berge, K. H., Seppala, M. D., & Schipper, A. M. (2009). Chemical Dependency and the Physician. Mayo Clinic Proceedings, 84(7), 625–631.6.
  3. Boyd et al, “Ethical and managerial Considerations Regarding State Physician Health Programs,” Journal of Addiction Medicine, 2012, Vol. 6(4)243-2468.
  4. Stuyt et al, “Tobacco Use by Physicians in a Physician Health Program, Implications for Treatment and Monitoring,” American Journal on Addictions, 2009; Vol 18(2)103-108.

 

 

After the Overdose

aaaaaaaaaaaaaaaaaaaaaaaaaaapic

 

 

 

 

 
I just read an astounding and completely believable study in a recent issue of the Annals of Internal Medicine. [1]

This study, done by Dr. Larochelle and associates at Boston University Medical Center, did a retrospective study of prescription opioid overdoses. They looked at patients who were being prescribed opioids long-term for non-cancer pain who had a non-fatal overdose. The study lasted from May 2000 until December 2012, and included over twenty-eight hundred patients. All of these patients had commercial insurance, and were between 18 to 65 years old.

This study found that after having a non-fatal overdose, 91% of these patients resumed getting prescription opioids, and that 70% got them from the same doctor.

The lead author said he was shocked to find so many survivors continue to be prescribed opioids after having an overdose from these very opioids. He had hoped after a near-fatal experience, prescribers would do something different to address pain, in order to prevent future overdose.(https://hereandnow.wbur.org/2016/01/13/opioid-prescriptions-after-overdosing)

From other studies, we know that the best predictor of a future overdose is a past overdose, which is why I ask every patient entering the opioid treatment program (OTP) if he has ever had an overdose.

The author of this study postulated that with our fragmented healthcare system, the prescribers may not have known the patient had an overdose. Not knowing about any problems, the doctor continued to prescribe opioids.

I have no problem envisioning how this happens.

Not long ago, one of my opioid treatment program (OTP) patients missed two days of dosing. Per our protocol, her counselor called her on the first day she missed dosing. The patient told her counselor that she had been admitted to the hospital for trouble breathing, and was being treated for asthma.

Also per out protocol, we request hospital records for every patient of ours who gets admitted to the hospital, and our patient gave permission for this.

When I got the records four days later, imagine my surprise when I read that she had respiratory failure due to an overdose. Her drug screen at the hospital was positive for methadone and also benzodiazepines, and indeed she was now positive for benzos at the OTP too. This information lead to a drastic change in this patient’s treatment plan.

If we had not called to see where our patient was, she could have returned in several days and not told us about her hospital admission.

Our local hospital did not call our OTP to tell us our patient was hospitalized with an overdose. Indeed, they didn’t call to tell us she was in the hospital. To my patient’s credit, she did tell them she was a patient of ours, since it was recorded in her hospital record.

When our patients are admitted to the hospital for medical reasons, the admitting doctors continue to prescribe the usual dose of methadone, and I am happy about that, but they don’t call us to confirm the dose. They take the patient’s word for what the dose has been, instead of making a quick phone call. I worry that someday, one of our patients, in a misguided effort to feel an opioid effect, will tell his hospital doctor he’s been dosing at a higher dose than he actually is, and catastrophe could ensue.

In contrast, the big teaching hospital an hour away, which is where our patients go when they are really sick, routinely calls to confirm each patient’s dose.

The Larochelle study seems to indicate there’s a lack of communication in other medical communities as well. Emergency department physicians may administer Narcan and revive a patient, but no one thinks to take the next essential step: call that patient’s prescriber about the drug overdose.

We can’t assume the patient, now revived from a near-death experience, will tell her doctor about what happened. If that patient has an addiction, she might keep quiet about prescription mishaps, fearing her supply of opioids may be cut off.

Family members might tell the prescribers, and that’s very helpful, but often patients are told the doctor can’t release any information. That is true, but the family can certainly give information to the doctor.

I know hospitals and emergency departments are busy. Healthcare professionals are all busy. We are being asked to do more and more in less and less time. But this is a communication issue, and it need not be a physician- to- physician communication. A nurse or even a social worker from the hospital could call or fax valuable information quickly. Privacy laws can be blamed for some lack of communication, but there are exceptions in life-threatening situations.

And please, let’s make medical records readable. Even when I finally get local emergency department records about one of my patients, I have a hard time deciphering them. I’ll admit to being a bit of a Luddite when it comes to electronic medical records, but partly because most electronic records are not all that helpful.

For example, on our local emergency department records, I quickly can find the results for Ebola screening (it’s on the first page, at the top), but often I am left scratching my head about what the doctor’s final diagnosis and treatment plan was for the patient.

We’ve got to fix this communication problem. It’s great when an overdose is treated and prevented. But let’s do just a little more, and communicate to the prescriber of the overdose medications.

It is life and death.

  1. Ann Intern Med. 2016;164(1):1-9. doi:10.7326/M15-0038
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