Revision of SAMHSA’s 42 CFR Part 2: Better Coordination of Care Balanced with Patient Privacy

The federal law holds providers of services to patients with mental health and substance use disorders to a higher standard of privacy than ordinary medical providers. While other providers must obey HIPPA privacy laws, physicians in our field have always had to meet the more stringent 42 CFR standards.

This year, long-standing rules guarding the confidentiality of patients in treatment for substance use disorders were revised, with the intent of allowing better coordination of care for these patients.

Last week, a group of medical providers who work in North Carolina’s opioid treatment programs met on a teleconference when this issue was discussed. (Pre-COVID we held a conference once a month; now we meet once a week). It was obvious that most of us, including me, didn’t know the exact changes made in the revision. Out of curiosity, I decided to dive deeper into this issue and thought I’d pass it along on my blog.

SAMHSA has a great Fact Sheet that describes all of these changes at this website: https://www.hhs.gov/about/news/2020/07/13/fact-sheet-samhsa-42-cfr-part-2-revised-rule.html

The major changes boil down to a few items. Chief among them is that non-opioid treatment program providers can query a central registry of patients receiving care at opioid treatment programs, in order to prevent double enrollment and (hopefully) prevent adverse drug interactions. In the past, providers who didn’t work at opioid treatment programs didn’t have access to this sensitive information.

On the plus side, advocates of this change say that patients being prescribed methadone or buprenorphine at opioid treatment programs will get better care, because their non-OTP doctors will see which of their patients are receiving methadone or buprenorphine from opioid treatment programs, and won’t prescribe medications which may interact.

On the negative side, we worry patients on methadone or buprenorphine could face discrimination and judgmental attitudes from providers who don’t know any better.

I don’t think this revision will change anything at all. It’s difficult enough getting physicians and other providers to check our state’s prescription monitoring program. I doubt any providers will be savvy enough to know they can get access to our state’s central registry of patients in opioid treatment programs, let alone have the enthusiasm to access this registry.

And speaking of prescription monitoring programs…under the revision, opioid treatment programs are now permitted to report the medications they dispense (nearly always methadone or buprenorphine) to their state’s prescription monitoring program.

Again, proponents of this new rule say it will allow for better coordination of care and will prevent medication interactions. Opponents say, as mentioned for the other change outlined above, that it could lead to discrimination against patients getting treatment for opioid use disorder with medications.

Of course, the wording of the revised CFR 42 says the OTP “may” report prescribing data, not that they “must” report. For now, it’s up to the OTP to decide. At present, I don’t think a system is in place to receive this data anyway. During our latest teleconference here in NC, none of the providers said their OTP was reporting to the state’s PMP.

My opinion – and why have a blog in the first place if I can’t blather about my views – is that this new rule is a mistake. I am opposed to OTPs reporting their dispensing data to the prescription monitoring program.

In my county, patients are sometimes treated differently by medical personnel after they reveal they have opioid use disorder and are in treatment with us. And by differently, I don’t mean they are congratulated on their recovery and offered words of encouragement. Instead, they are told something like, “I hope you aren’t here to ask for any pain medication because I’m not going to prescribe it,” even if they are at a routine office visit for treatment of hypertension.

In some cases, patients are told they can’t be accepted as a new patient because the doctor isn’t comfortable treating them. These providers pretend that the patient’s issues are just so complicated that they don’t have the medical expertise. This is an excuse meant to hide an attitude of judgment and contempt for our patient who have the disease of opioid use disorder, and who are viewed as “difficult” patients.

I don’t think patients know about this recent change to privacy law, and I worry they won’t be happy about it. I hope it won’t deter people from entering treatment at opioid treatment programs. Before these changes become operational, we should tell our OTP patients, so they won’t be caught off guard. Of course, patients receiving buprenorphine products at doctors’ offices (so-called office-based practices) already have their data reported to the state’s prescription monitoring program, so it won’t be any change for them.

This revision also said that natural disasters which disrupt treatment facilities should be considered medical emergencies, allowing for patient information to be disclosed without patient consent. I interpret that to mean that if our facility is swallowed by a giant sink hole (not an unreasonable fear in our little town), we could send patient data to another OTP so that our patients could be dosed, without waiting for individual consent forms to be signed. This would streamline care and be more practical. We could also give patient data to hospital emergency departments or other facilities helping those patients during emergencies.

The revision document takes pains to declare that many things have not changed under this revised rule. For example, the document clearly states that law enforcement is still prohibited from obtaining substance use disorder treatment records without a court order. In other words, random police officers can’t come into the OTP and ask if an individual is a patient. We are still prohibited from releasing this information.

This is how things are at the federal level. At state levels, there are different laws about who can access prescription monitoring programs.

In North Carolina, the law changed in 2018, with the HOPE (Heroin and Opioid Prevention and Enforcement) Act. Prior to this, law enforcement had to have a court order to look at a subject’s data on the prescription monitoring program. After HOPE was passed, law enforcement officers can access PMP data if they have a “reasonable, good-faith belief based on specific facts and circumstances,” to access the data. The law has a few safeguards in place; the officer has to a “certified diversion investigator” before given access to the PMP.

I don’t know how this law slipped past me. I don’t like it. It makes me uneasy. With the previous court-ordered access, at least there was a judge who balanced (thoughtfully, one would hope) patient privacy against legitimate law enforcement goals. Now it appears to be left to the judgment of law enforcement officers who may be predisposed to believe their goal is justified.

I remember all the caution that abounded in 2007, when the NC prescription monitoring program first became operational. There was argument about whether the NC PMP could be accessed without patient consent (it could). I was told not to store the printed record of a patient’s PMP report with the rest of the chart, least it inadvertently be forwarded with any request to send records to other providers. The prescription monitoring program was hush-hush private, only for doctors’ eyes, and only to be used to provide better healthcare.

Now, law enforcement doesn’t even need a court order to access it.

I worry law enforcement officers won’t be able to interpret the data they find on the prescription monitoring program. For example, if they look at one of my patients being prescribe buprenorphine/naloxone films, will they look at the “overdose score” that is usually very high for patients on buprenorphine products? Despite warnings from the American Society of Addiction Medicine and other experts, who say it’s not possible to assign an MME (morphine milligram equivalent) to buprenorphine…our prescription monitoring program does just that, thereby implying a patient on sixteen milligrams of buprenorphine is more likely to overdose than a patient on oxycodone and a benzodiazepine. Ridiculous.

I’d like to hear from readers about how you feel about the changes to privacy laws. I don’t think patients, at least in North Carolina, know about the HOPE law that passed in 2018.

Methadone Induction: Be Careful

Graphic illustrating how methadone blood level rises over five days with no dose change

 

 

 

This blog is written with gratitude to Thomas Payte M.D., a leader in the field of Addiction Medicine, who passed away in 2019.  Many years ago, I listened to an ASAM (American Society of Addiction Medicine) lecture by Dr. Payte (on cassette tape, which shows how long ago this was) that changed the way I did methadone induction.

At the time I started working at an opioid treatment program, I felt much empathy for the patients suffering opioid withdrawal when I admitted them to treatment. With the best intentions, I wanted to help them get out of withdrawal as quickly as possible, so I started them at doses higher than I probably should have and increased their doses daily. The other physicians I worked with practiced in a similar way, so I thought that was the way it should be done.

We had patient induction deaths. I learned some things the hard way, but also started going to ASAM conferences and listening to ASAM lectures, which was when I had the good fortune to hear Tom Payte.

Decades later, I can’t be sure exactly what he said, but this is what I remember:

He cautioned that induction deaths were relatively rare but devastating. If we start every patient on 30mg, eventually a patient will die during induction. That shook me up, because not only was I starting patients on 30mg, quite often I was dividing their dose on Day 1 to get a total of 40mg. He said patients inherently metabolize methadone at very different rates, and sooner or later a slow metabolizer would arrive for induction, and rapid increases in dosing during induction would be fatal.

Dr. Payte wasn’t unsympathetic to patient misery in opioid withdrawal. He just reminded me that we must temper compassion with science.

Today, induction guidelines look very different from the way I was practicing back when I started. I have changed my induction practices a great deal over the years as I’ve learned more.

Physicians who work at opioid treatment programs have so much more information available now than when I started in this field. It’s so easy to get colleague input about problems: at a national level, there’s the PCSS system, which stands for Providers Clinical Support System, a system for providing information and even mentors for providers who would like them (https://pcssnow.org/)

At our state level, the North Carolina Governor’s Institute has contracted with me and with Dr. Eric Morse, so that we can be available for questions from providers at any opioid treatment program in the state at any time.

Recently, at an organizational level, our Acadia programs in North Carolina arranged for a monthly phone call for physicians and physician extenders to discuss problems and concerns on a monthly phone call.

ASAM has all sorts of guidelines and position statements (asam.org). SAMHSA has publications to help physicians (https://store.samhsa.gov/)

Because of all this help that’s available, there’s no reason for any provider working at an opioid treatment program in the U.S. to be ignorant of current methadone induction recommendations.

I recently blogged about ASAM’s newly updated guidelines for the treatment of opioid use disorders. In those guidelines, initial dose of methadone, “ranges from 10 to 30mg, with reassessment as clinically indicated (typically in 2 to 4 hours)…” and then goes on to say, “methadone…generally should not be increased every day.” The guidelines recommend methadone be increased no more than 10mg approximately every 5 days.

If you are a provider who is starting every patient at 30mg and then increasing the dose daily, stop it. You are going to have an overdose sooner or later.

And although these guidelines did say that benzodiazepine use should not be a reason to suspend or withhold treatment with methadone or buprenorphine, they did make it clear that use of sedative-hypnotics with these medications increases the risk of serious side effects.

In other words, we shouldn’t deny treatment to patients with a co-occurring benzodiazepine use disorder, but we can’t admit them and carry on like their risk is the same as other patients who aren’t on benzodiazepines. Consider lower methadone starting doses and consider slower rates of induction for these more fragile patients. Consider closer observation and more frequent drug screening

The provider has a lot more work to do when a patient is using benzodiazepines. First, that provider needs to figure out, if possible, how extensive that patient’s use is, and decide the appropriate setting for methadone induction. That may need to be at an inpatient facility.

Second, since benzodiazepine prescribing guidelines recommend these medications not be prescribed for longer than three months, except for end-of-life care, an ongoing prescription must be explained. The prescribers of benzodiazepines must be talked to. In my area, most of the benzodiazepines are prescribed by a handful of practitioners.  When I talk to these prescribers, they say the patient complains of anxiety, indicating they think this justifies ongoing benzodiazepines.

That’s not good enough. Benzodiazepines aren’t first-line medications for anxiety disorders. Like opioids did for pain, it appears benzodiazepines make people more anxious when they are used long-term. Benzodiazepines make post-traumatic stress disorder worse, and they complicate ordinary grief reactions. Yet many patients are prescribed benzodiazepines for these reasons.

Third, a plan must be formulated to reduce the risk for the patient. In most cases, this means a reduction in benzodiazepine use by some method. If the patient can control their use of benzos, their prescriber can gradually lower their dose. Most of the time the patient can come off benzodiazepines, or at least get by with much less of these medications. In the meantime, a more appropriate medication for anxiety can be started for better treatment of anxiety.

In many cases, the patient needs trauma-focused therapy to address old issues. Many, perhaps most, of our patients have experienced serious physical, sexual, or emotional trauma in their lives. Appropriate counseling and medication can be just as life-changing for patients as can treatment for their opioid use disorder.

Since alcohol is as big a risk as benzodiazepines, the same cautions during methadone induction need to be taken for patients with alcohol use disorders. Start with lower doses and increase more slowly.

More cautious induction must be considered for medically fragile patients: those with underlying pulmonary disease, lower body weight, those on multiple medications, and the “elderly” over fifty years old. And be sure to ask about opioid use over the preceding week. If a patient was admitted to a detoxification unit, or just got out of jail or a hospital, their opioid tolerance will be lower, and the patient needs a lower methadone starting dose.

If their admission drug screen is negative for opioids, stop for a moment to consider what this means. Does the patient really have opioid use disorder? Has the patient taken an opioid recently that doesn’t show on your drug screen? Or has the patient been unable to use opioids for the last several days? If the latter is true, consider a lower starting dose.

Don’t do cookie-cutter inductions. Carefully evaluate each new patient and gather all the data that you can, including history and physical, old records, the prescription monitoring program, and other treating physicians to help you make the best decisions possible. There will always be that pull…trying to get the patient out of opioid withdrawal so they can stop using dangerous illicit opioids….while trying to provide safe methadone induction.

I’ve written mostly about methadone induction because it’s much trickier than buprenorphine. Methadone is much less forgiving during induction than buprenorphine. With buprenorphine induction, just make sure you don’t start too soon and make your patient sick. At times I wish all my patients could do well on buprenorphine, but that’s not possible. We will never have one medication that works well for everyone. Many patients never feel right on buprenorphine, or it isn’t strong enough to treat their opioid use disorder.

I’m more cautious with methadone induction prescribing now than when I started many years ago. This is from a combination of experience and learning from experts. I strongly recommend the latter form of learning; it’s much less painful.

COVID 19 and the Treatment of Opioid Use Disorder

 

 

 

 

I’m getting cranky. I know I have plenty of company, figuratively speaking of course. Life’s restrictions chafe at my mood, making me grumble more than usual.

I have nothing to grumble about, I know. Every night I thank God that all the people I love are safe and well and don’t have COVID19. I haven’t lost anyone I love and I’m so fortunate to be living out in the country where we don’t deal with the horrors I’ve seen on the evening news.

And yet, being human, I slip from gratitude to petulance when I see all our COVID snack foods are gone. We just re-upped a week ago. Who is eating all these snacks?

Work had annoying moments last week. Even though we were busier, and I had a few admissions to do each day, I still had down time. We’re out of sanitizing wipes, so I couldn’t make the rounds at our OTP, wiping down surfaces. I had to be content with squirting hand sanitizer on my desk, door handles, and other surfaces. But it’s not the same and leaves some surfaces sticky and unpleasant.

We have no N95 masks, so I wore a Breath Buddy mask this week. (The above picture is of me in my Breath Buddy mask.) The Breath Buddy is a respirator dust mask that I bought to wear when I carve chunks of quartz into bowls and other shapes. I’ve gotten used to wearing the hot and bulky thing, but I’m not used to trying to make myself heard while wearing it, and that was a little taxing and annoying. I think it also annoyed some patients who had to strain to hear me.

I saw several patients last week who relapsed on the extra take home medication they received due to the COVID pandemic. These patients didn’t die and likely won’t have any long-term harm, but one patient was especially demoralized by this setback. I felt very bad for her, because she probably wouldn’t have relapsed without the extra take home doses.

But on a positive note, we don’t have any patients who were diagnosed with COVID 19 with certainty, so far. Several were hospitalized with respiratory failure and tested negative for influenza, so they were told to act as if they had COVID 19, but they weren’t tested for it. It’s hard to know what to make of this. We are giving them extra take homes, and dosing them in their cars, depending on their stability.

I feel we have been generous with extra take home doses of methadone and buprenorphine during the COVID 19 situation. But some patients saw me last week to grumble that they should have received more take homes, or that another patient they know got a few more take-home doses than they did, and that it wasn’t fair. This irritated me but I tried to hear them out, then explained that we did a great number of extra take homes very quickly for an emergency situation and that we may have made some mistakes, but that nearly every patient got extra take homes, except for the extremely unstable. I told these patients I would re-assess their take- home status.

I had a great deal of problems with my attempts to do telehealth with my office-based buprenorphine patients this week. Nearly half of the attempts at connection were so poor that we couldn’t communicate, and I had to call them on the phone instead. It didn’t help that our power went out at our house, so we were running on our generator, which may have affected my internet connection.

All in all, I am doing better than I’m feeling, as I suspect most of us are. I even baked my own COVID snacks. I love to bake scones, but was a little tired of them, so I made the dough as usual but added the only fruit-based thing I could find: a leftover can of cranberry sauce from Thanksgiving. Unfortunately, they came out of the oven looking like something from a crime scene. Fortunately, they tasted great.

We will make due with what we have, until more normal times return.

More Phun with Pharmacies

It seems to come in waves. Weeks will go by without any pharmacy troubles, and then all at once several crazy or annoying things happen at once.

 

First, I got a message from a patient asking why he received fewer films than I usually prescribe. This patient is a star. He’s been in recovery over ten years and prefers to stay on buprenorphine/naloxone films to treat pain from a chronic medical issue, rather than taper off the medication. I’ve had the pleasure of treating him for over ten years, and he’s never had unexpected drug screen results. He always keeps his appointments and is flourishing in his life.

I thought the issue was likely due to his insurance, but knew I’d have to talk to his pharmacy to figure it out. So, I called, and a pleasant pharmacist tried her best to be helpful. I’d written for one and a quarter films per day and wanted #40 dispensed.

Technically, the pharmacist explained, I should have prescribed 37.5 films, but of course that’s not possible, so insurance would only pay for 38 films per month.

“OK,” I said, “But why did you only give him 35 films, instead of 38, then?”

There was a moment of silence until she said, “Huh. Well, that’s a good question. I don’t know.”

“Who would know?” I asked, foolishly.

“I don’t know.” Maybe the head pharmacist?”

“Can you ask, if you don’t mind? I’m kind of curious.”

She said she would, and that she would call me back with an answer. It’s been a week and I’m not expecting a call back. It’s really a minor thing, and maybe not worth anyone’s time, except…WHY?????

Today, I was enraged at the experience of another patient. He’s been in recovery for around twelve years and has been doing very well for the past six years with no illicit drug use. He has a family and just started his own business employing several other people. He’s doing well and made much progress in recovery.

He got a tooth pulled recently, a procedure that was more complicated than usual. His dentist gave him a prescription for ten hydrocodone pills for pain, and he tried to fill it at his usual Walgreen’s, where he fills his buprenorphine/naloxone tablets, prescribed by me.

He said the pharmacist said no. She told him that people being prescribed buprenorphine/naloxone can’t fill prescriptions for opioids. She didn’t offer to call the dentist, or to call me, to see if it was medically appropriate to fill the prescription, which it was. She just said no.

I saw red.

“What did you do? Did you call the dentist? Did you talk to her boss?”

“Nah, I didn’t want to make her angry and I wasn’t in that much pain. I just took a whole lot of ibuprofen along with Tylenol and got by.”

“If that happens again, please call me. I’d be glad to set this pharmacist straight. In fact, what’s her name? I’ll call her now.” I was fired up and ready for a fight.

He couldn’t remember her name and seemed a little reluctant.

I get it. He must deal with that pharmacist to fill his medication and didn’t want to make waves. I didn’t call, but told him if he ever had a similar experience, let me know, and I’d call and explain that being on buprenorphine products doesn’t mean a patient can never be treated for pain.

Then tonight was one of the funniest and most bizarre things I’ve heard from a pharmacy.

It started when my fiancé (and therapist to my patients) told me he had a message from a patient, saying that my E-prescription couldn’t be processed because it needed to be in a different format.

Well that’s odd, I thought. The format is determined by the electronic prescribing platform, and is fairly standard. Alas, I’ve had to learn two different e-prescribing software programs.

Again, I was going to have to speak to the pharmacist directly.

Initially I spoke with a nice gentleman who tried hard to help me. I asked him what the problem was, and he told me my DEA number had to be in a “Nadine” format.

“Wait, what? What are you talking about?”

“You need to put in your N-A-D-E-A-N number.”

“Do you mean my DEA X number?”

“No, it’s the NADEAN number.”

“You’re going to have to explain that to me. I don’t understand.”

“Ms. Burson, I’ll get the pharmacist to help you.”

“OK,” I said.

I had my phone on speaker, and I thought he had put me on hold. I sighed and asked my fiancé, “Did he just call me Ms. Burson?”

I wasn’t on hold.

“I’m sorry, I should have said Dr Burson. It’s just habit,” he said.

I felt a little ashamed about complaining. It’s not a big thing. I went to med school in the 1980’s, so I’ve had many colleagues, nurses, patients, AND pharmacists call me “Ms.” instead of “Doctor” over the years. But then again, it is 2020, so maybe it’s time to realize that females are doctors, too.

Anyway, another nice pharmacist came on the phone and explained that the DEA must be formatted in a specific way. All CVS pharmacies had been given instructions not to fill buprenorphine products unless they were formatted thus:

NADEAN:X and the rest of the DEA number.

I had not used this format – instead, I typed “Use DEA X1234567.” (not my actual DEA number, of course),

I said I did put the DEA X number on the prescription. I asked her if she saw it. She said yes, she did, but the NADEAN stands for Narcotic Addiction DEA Number and if it wasn’t submitted in that format, it couldn’t be filled.

I thanked her for her time, and told her I knew she was only the messenger, and said I would cancel the prescription I had just electronically submitted and re-issue another with their preferred format of “NADEAN:X1234567”

I’ve seen plenty of inefficient and even counterproductive things in my career in Addiction Medicine, but this is probably the funniest and most ridiculous bit of red tape I’ve seen in a long time. It was so silly I didn’t even get angry. I was giggling to myself, thinking was a great blog post it would make.

Obviously, someone was over-interpreting a corporate message that was trying to say that the X DEA number needs to be on every electronic prescription. But it is being literally interpreted, at least at this CVS, that NADEAN:Xnumber has to be in that format. Prescribers beware: if you are sending a prescription to a CVS, use this format or your patient will be unable to fill their prescription, even if you have your DEA X number on it.

Continuum of Care for Opioid Use Disorder

 

 

 

 

 

 

“Continuum of care is a concept involving an integrated system of care that guides and tracks patient over time through a comprehensive array of health services spanning all levels of intensity of care.” (Evashwick, 1989)

Continuum of care isn’t a new concept. It’s a pattern of care that we use to treat patients with all sorts of chronic medical illnesses. For mild forms of a chronic illness, primary care providers manage patients’ illnesses. For more severe forms of the same illness, patients are referred to specialists, with more experience and training in that area of medicine. Ideally these shared patients flow back and forth between specialists and primary care providers as needed based on the severity of illness as it may fluctuate over time.

We ought to apply this same concept for the management of opioid use disorder. It’s a chronic illness which can have exacerbations and remissions over time, just like diabetes and asthma.

I try to follow this concept at the opioid treatment program where I work. Patients new to treatment often are ill, not only from the drug use, but also from neglected physical and mental health issues. They need more intense care. An opioid treatment program offers more structure and supervision than an office-based practice, so it’s a level of care that’s appropriate for such patients.

At the opioid treatment program, we can do daily observed dosing, to make sure patients take the dose I prescribe. We assess the adequacy of the dose by asking about withdrawal symptoms and observing withdrawal physical signs. We can monitor for side effects. We can do frequent drug screens, to provide information about the proper level of counseling needed. Counseling, both group and individual, are built into the system at opioid treatment programs.

At the other end of the spectrum, stable patients with years of recovery in medication-assisted treatment need less care. We still need to monitor for relapses, but they usually don’t need as much counseling, and no longer require observed dosing. They need the freedom that office-based practices provide.

Stable patients on methadone get more take home doses, but opioid treatment programs are their only option for treatment setting. Stable patients on methadone can’t get their treatment in primary care settings. It’s illegal for office-based physicians to prescribe methadone for the purpose of treating opioid use disorder. Primary care doctors can prescribe methadone to treat pain, but not if the patient also has opioid use disorder.

It’s different for patients on buprenorphine (Suboxone, Subutex, Zubsolv, Bunavail). Since 2000, it’s been legal to prescribe this medication from office-based settings for patients with opioid use disorder.

But that doesn’t mean this is the right setting for all patients with opioid use disorder.

I have an advantage, since I see patients in both settings, both opioid treatment program and an office-based practice. I have the luxury of being able to treat new patients in the opioid treatment program, and after they stabilize, talk to them about transitioning to the office-based practice. If a patient encounters a rough patch, I can ask them to return to the opioid treatment program for more intense treatment until they again stabilize.

I can use the same concept as used with other chronic medical illnesses.

Sometimes a new patient can safely be treated in an office-based program. This all depends on individual patient circumstances. One patient may have a fantastic support system at home, while another may have to put up with active drug use in his home. Obviously, the latter patient needs more support from treatment staff.

Sometimes patients on buprenorphine aren’t appropriate for office-based treatment, even after months of treatment.

Unfortunately, most patients with opioid use disorder aren’t placed in a treatment setting based on their needs. Most patients end up in whatever facility they enter for the duration of their treatment, which may not be the best thing for the patients.

It’s rare for an office-based practice to refer their patients who are struggling to opioid treatment programs. Many office-based providers, enthusiastic about treating patients with opioid use disorder, still regard opioid treatment programs with great suspicion. It’s partly due to lack of knowledge about OTPs. It’s also partly due to that old bugaboo that blocks so much of appropriate treatment for people with substance abuse disorders: stigma. Some providers believe all sorts of outlandish things about what takes place at opioid treatment programs.

It’s painful to admit, but some providers’ opinions are formed based on the actions of poorly run opioid treatment programs. Some opioid treatment programs provide little more than daily dosing of medication. In our business, those programs are referred to derisively as “juice bars,” meaning patients get a daily dose of methadone, which looks like red juice, and little more.

These programs taint the reputation of good opioid treatment programs which offer an array of services all meant to help the patient. This is a real shame.

So, what about me? Do I refer stable buprenorphine patients at our opioid treatment program to other office-based buprenorphine practices? Well…not so often.

I know plenty of excellent office-based buprenorphine providers across the state who are diligent and painstaking about the care they deliver. And I know some providers in my area who don’t meet that standard. I’m hesitant to refer to them.

For example, one nearby provider charts extensive patient visits. These notes include everything from history of present illness, complete review of systems, and complete physical exam for each visit. Yet I was troubled about how similar each visit was, and suspected there was a whole lot of “cut and paste” going on, and that the charted care wasn’t actually being delivered.

Recently a patient transferred from this practice back to me, at the opioid treatment program, for purely financial reasons. We requested a copy of her charts, as we do for all patients who have been seeing other practitioners. This is good medical practice, even if it hasn’t been all that helpful with this particular provider in the past.

I was reading the records, and was confused. I read in the exam section of her last visit, “Abdomen consistent with eight month pregnancy.”

How had I missed this, I thought. I’m no obstetrician, but even I should pick up an advanced pregnancy on exam.

I slid my eyes back to the patient, sitting on a chair near the corner of my desk. Her abdomen looked flat.

“Um, so…are you pregnant?”

“No! Why?”

“Well you don’t look pregnant,” I added, not wishing to offend her. “It’s just that this last note says you’re eight months pregnant.”

She sighed and rolled her eyes. “The baby is seventeen months old. I guess they just never changed it in my chart.”

I looked back at each note. Sure enough, the exams for each date all read, “Abdomen consistent with eight month pregnancy.” For many months. Clearly, this was cut and paste charting. It’s not quality care, and may be illegal if the provider charged for services not delivered.

This confirmed my worst suspicions about the level of care provided at that practice, so I don’t think I will be referring patients to them.

In this country, we do have obstacles to providing a continuum of care for patients with opioid use disorders. We have some office-based practices that aren’t well-run and have little oversight. We have substandard opioid treatment programs providing little more than medication dosing, and we have undeserved stigma against opioid treatment programs that have been providing quality care for many years.

In fact, opioid use disorder may have the least organized continuum of care of all chronic diseases.

What’s the answer? Better communication and better education among medical providers.

I’m doing my part.

I go to many conferences, to learn the latest data and standards in my field. I also meet other providers at these conferences, even though by nature I’m a bit of a recluse. I’ve given talks, both to community groups and at medical meetings, to do my part to pass on what I know. I don’t enjoy public speaking, but find that once I get involved in my topic, I lose my fears.

All providers of care for people with opioid use disorders need to do this – we must meet each other, talk to each other, and learn from each other.

Here are a few wonderful opportunities to interact and learn:

ASAM conferences: the American Society of Addiction Medicine holds several conferences per year at the national level, and these are excellent for learning and meeting the leaders in the field. You can read more at their web site: www.asam.org

 

In my state of North Carolina, you can get some valuable information from the Governor’s Institute, at https://governorsinstitute.org/ and also their blog: http://www.sa4docs.org/

You can attend webinars, get clinical tools, and obtain mentoring from the Providers’ Clinical Support System MAT, at https://pcssmat.org/

If you are a provider in North Carolina and want CME hours while you teleconference with peers and mentors, you can participate in the UNC ECHO project. You can read more about that here: https://uncnews.unc.edu/2017/02/15/unc-chapel-hill-initiative-will-combat-opioid-use-disorders-overdose-deaths/

Write to me if you want to participate and I can forward you to the people that can make that happen.

Journal Errors

 

 

Each morning before getting ready for work, I try to read at least part of a medical journal. Usually I read tediously boring things about diabetes, hypertension, and the like. However, recently, with the overall increased focus on opioid use disorder, I’ve noted more articles about this issue.

Sometimes, the authors don’t get it exactly right. I suppose to some doctors, treatment of opioid use disorders is as boring and confusing as I find diabetes treatment to be. But then, I don’t write about diabetes. I do think if you are writing for a medical journal, you ought to take care to be accurate.

Last week I read Internal Medicine News. This is not a pre-eminent journal. It does not have the reputation of the New England Journal of Medicine, or the Journal of the American Medical Association. In fact, it is what we commonly call a “throw-away” journal. It’s really more of a newspaper, a summary of other medical journals, that a publisher of original studies. For that reason, it’s a more informal publication.

While I understand all of that, I was chagrined when I read a short article titled “Interdisciplinary approach to opioid withdrawal can aid successful long-term recovery.” In this article, the author names three medications that can be used to “wean patients off opioids:” naloxone, buprenorphine, and acamprosate.

Huh? Surely that’s got to be an error. Maybe the editor cut out some text essential to accurate understanding. You know I love to write letters to tell people when they are wrong, so I emailed the following letter to the journal’s editor:

Dear Sirs:

I read some information on page 18 of the November 1, 2016, issue of the Internal Medicine News that I feel needs to be clarified. Likely due to space limitations, Dr. Lorenzo Norris M.D. may have given the wrong impression about medications used to treat patients with opioid use disorder.

Dr. Norris mentions naloxone, buprenorphine, and acamprosate as medications that can be used to “wean a patient from opioids.”

In fact, naloxone is an opioid antagonist, and though it can be life-saving in the face of an opioid overdose, it should not be used to wean patients from opioids. As an antagonist with a high affinity for the mu opioid receptor, it would precipitate immediate and severe opioid withdrawal. Therefore, naloxone is not recommended to wean a patient. However, the related opioid antagonist naltrexone can be used after a patient is through acute opioid withdrawal, to help prevent a relapse to opioid use. It can be used in either daily oral formulation or the depot monthly intramuscular injection.

Acamprosate, while approved for use in patients after undergoing alcohol withdrawal, has no indication for use in patients with opioid use disorder.

The third drug, buprenorphine, can be used to wean a patient off opioids, but multiple studies have shown extremely high relapse rates when it is used in this manner. Buprenorphine gives much better results (lower incidence of opioid-positive urine drug screens, lower risk of use of illicit opioids, reduced risk of death) – when used as a maintenance medication.

Giving Dr. Norris the benefit of the doubt, I’m sure he would have elaborated on buprenorphine for maintenance treatment of opioid use disorder, had space permitted. However, this is such an important concept that I feel it deserves elaboration.

Thank you for your coverage of this critical issue.

Sincerely,

Jana Burson M.D.

Maybe I’m being too picky. Maybe the editor will think I’m being a know-it-all smarty pants. After all, at least this publication is trying to cover opioid use disorder treatment, which is a wonderful thing.

I don’t know. If we give out information, let’s make sure it is correct, given the depth of misunderstanding that already abounds in the field of Addiction Medicine.

I’ll let you know if I get any reply.

Diagnostic Overshadowing

 

 

I was trying to get through a pile of non-Addiction Medicine journals when I came across an article titled “The Ethics of Behavioral Health Information Technology: Frequent Flyer Icons and Implicit Bias,” in the October 18^th, 2016, issue of the Journal of the American Medical Association.

 

According to the authors, Michelle Joy M.D. et al, at least one electronic medical record (EMR) system provides a way to display an icon shaped like an airplane, as a way to inform treating physicians that the patient is a “frequent flyer.” This term has long been used to describe patients who repeatedly come to emergency departments or other providers on a regular basis.

This term has been used for decades. I’ve used it myself in the past. It’s a short-hand phrase that usually means, “This patient is a pain in the ass because he/she keeps coming back for inappropriate reasons.” More elegantly and succinctly, the authors of this article say the term frequent flier is short-hand for “problem patient.”

This article points out the ethical harms of stigmatizing patients in this manner, and presents the term “diagnostic overshadowing.” This means a physician’s attitude towards a patient can be skewed by the idea that the patient is seeking care for inappropriate reasons. The article goes on to cite studies showing patients with mental health conditions are less likely to get appropriate medical care compared to patients without mental health issues, likely due to this diagnostic overshadowing.

I see this every week in my patients with opioid use disorder. Even my patients who are in recovery and doing well say they are treated differently when they go to our local hospital emergency departments, or even to their primary care doctors. After they reveal they’re on buprenorphine or methadone to treat opioid use disorder, they detect changes in the attitudes of their care providers.

Often, the patient will say, “I know I’ve tried to score drugs from him before, but this time I didn’t get a chance to say anything before the doctor accused me of being a drug seeker.” The doctor, reading the past records, jumped to the conclusions that this person is only in the emergency department to get pain pills. The doctor shuts down further communication because of his diagnostic overshadowing. The patient doesn’t get a chance to receive appropriate care. Maybe just as bad, that patient is given the message that they don’t deserve respect, due to their diagnosis of opioid use disorder.

If this happens to patients years after they’ve been in recovery, just think about what happens to people in active opioid use disorder. They are pre-judged as drug seekers, and the emergency department doctors sometimes decide, before gathering information, that the addicted person has no valid medical problems. The doctor starts with an assumption that the patient is a bad person, rather than a sick person.

This attitude leads to medical disasters. Patients with current intravenous drug use are more likely, not less likely, to have serious medical problems.

I’ve seen two patients who had serious infectious medical emergencies that were missed by local emergency room doctors. Both patients were seen multiple times at two local hospital emergency departments. Both said they were treated with distain by personnel. One was seen a total of four times before she went, on her own, to the emergency department of a nearby teaching hospital, where she was immediately diagnosed, and taken for emergency surgery.

I believe these two patients encountered doctors who experienced the diagnostic overshadowing described in the JAMA article, because they had opioid use disorders. Their doctors assumed they only wanted pain pill prescriptions and weren’t all that sick.

What do we do about diagnostic overshadowing?

We must educate physicians more completely about addiction and mental health disorders. I’ve written in previous blog posts about the lack of training, at least in the past, for physicians about substance use disorders. Specific training in medication-assisted treatment of opioid use disorders wasn’t taught at all. This is slowly changing, and medical schools now teach students about these vital medical problems. This will help younger physicians, who are getting their training now.

What about older doctors, already in practice? I think all of us working in substance use disorder and mental health disorder fields have an obligation to educate our peers. I know I held significant bias against methadone before I knew anything about it. One doctor friend encouraged me to read and learn. When I did, I found piles of information supporting this evidence-based treatment.

Now I try to pass along what I’ve learned. Sometimes I’m successful, sometimes not. I’ve talked to doctors in my community, with a wide range of results. Some physicians have become allies, supportive of the patients we share. Others have not been willing to listen or learn about MAT. One doctor told me if I prescribe MAT for one of his patients, he will dismiss that patient from their practice.

The only difference between this doctor and me was in our willingness to learn. Had I not agreed to read some of the tons of studies showing that methadone helps patients with opioid use disorder, I’d still be opposed to methadone, as he continues to be. It’s a reminder to remain teachable.

It’s easy to become frustrated with my colleagues. For example, I can’t remember even one patient being referred to our opioid treatment program by the local hospital’s emergency department physicians. I have not been successful at educating these doctors.

Up until this last month, we didn’t get referrals from our local substance abuse and mental health treatment provider for the county. One patient specifically asked them to refer her to a methadone clinic, and was told, “We don’t do that.” Fortunately, she had friends who told her where to find our treatment center.

Our program manager, nurse manager, and I met with the treatment program’s supervisors, who said they had no idea their facility was trying to prevent patients from accessing opioid treatment programs. They promised to fix the situation.

Thankfully, something changed, and we just got our first few referrals from this program over the last two weeks. I see this as a tremendous success of advocacy, though it took our program manager quite some time to get through to their management.

In a blog earlier this year, I described how the local detox center wants to provide Intensive Outpatient Program for our patients on methadone and buprenorphine. That’s a collaboration I didn’t think would ever happen, yet in a few weeks I hear their program will be ready for our patients.

So things do change, but not quickly. All of us advocating for MAT need to be patient, yet persistent. Maybe then we can eliminate diagnostic overshadowing for our patient populations.

Black Box Warning

 

 

Last month the FDA (Food and Drug Administration) announced their decision to require black box warnings on opioid and benzodiazepine prescribing information. This warning will state that co-prescribing these two classes of medications increases the risks to patients of death, coma, sleepiness, and respiratory depression. The FDA also said they would require medication guides for patients, describing these risks.

Black box warnings are the strongest warnings issued by the FDA. These warnings are literally placed in a bold black box at the top of the prescribing, where the information is most noticeable.

I applaud the FDA’s action. I think FDA’s statement will make physicians and other providers think twice before blithely writing a benzodiazepine prescription for a patient already prescribed opioids. A black box means, “Take this seriously!”

Ten years ago, co-prescribing of opioids and benzodiazepines was commonplace for primary care physicians in my area. Earlier this year, our state medical board announced they would investigate the top prescribers of opioids and benzodiazepines together. Since then, I have noticed some prescribers appear to be backing away from the routine prescribing of benzodiazepines..

Most opioid treatment centers have policies in place to address benzodiazepine use, both licit and illicit. There are still a few OTPs who approve benzodiazepines to be prescribed for methadone or buprenorphine patients, but I think they are in the minority. Most opioid treatment program physicians feel that besides the dangers of sedation and overdose, there are few medical indications for long-term (more than three months) benzodiazepine prescriptions, and much better long-term treatments for anxiety disorders.

An article In the April 16^th, 2016 issue of the American Journal of Public Health underlined how important it is to evaluate benzodiazepine prescribing in the U.S., particularly when prescribed along with opioids. [1]

The authors begin the article by stating that benzodiazepines were found to be involved in nearly a third of opioid overdose deaths in 2013. The authors wished to investigate nation trends in benzodiazepine prescribing and in fatal overdoses involving benzodiazepines.

The authors found the percentage of U.S. adults filling benzodiazepine prescriptions increased significantly over past years. They also found that among people who filled benzodiazepine prescriptions, the amount, defined as lorazepam equivalent doses, also increased significantly. Simultaneously, overdose deaths rates involving benzodiazepines rose nearly four-fold, though deaths appear to have plateaued since 2010.

Another study, this time in Canada, evaluated the risk of death in polysubstance users. In a prospective cohort study of IV drug users, done from 1996 through 2013, benzodiazepine use was more strongly associated with death than any other substance of abuse. [2

Many patients ask why they can’t take benzodiazepines while on methadone or buprenorphine. I tell them I’m mainly worried about the increased risk for overdose death, but I also tell them benzodiazepines are over-prescribed. Prescribing information suggests benzodiazepines are most beneficial when prescribed for no more than three or four weeks. Long-term prescribing of benzodiazepines is generally discouraged, due to serious side effects seen even in patients with no substance use disorders.

Benzodiazepines are associated with increased risk of auto accidents, increased risk of completed suicide, worsening of mood disorders like depression, increased risk of drug-induced dementia, and increased risk of daytime fatigue. Benzodiazepines are also associated with increased risk of cancer, falls, and pneumonia.

Although an association of benzodiazepines with these conditions doesn’t necessarily mean benzodiazepines cause these conditions, it’s a good reason to be conservative when prescribing benzodiazepines and other sedatives, pending further studies.

Sedative medications including benzos can make undiagnosed sleep apnea worse, even to the point of causing death. Obesity increases the risk of sleep apnea, and with more adults becoming obese, the risks of benzodiazepines in such patients may be overlooked.

As for my patients, many of whom are prescribed methadone or buprenorphine, the risk of drug interaction and overdose with the hypnotics usually outweighs all of the benefits, and I recommend that patients do not mix these two types of medications.

1. Bachhuber et. al., “Increasing Benzodiazepine Prescription and Overdose Mortality in the Unites States, 1996-2013,” American Journal of Public Health, April 16, 2016.
2. Walton et. al., “The Impact of Benzodiazepine Use on Mortality Among Polysubstance Users in Vancouver, Canada,” Public Health Rep., 2016 May-June;13(3)491-9.

Doctors with Addiction

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.

4. Penelope Zeigler: PCSS-O – archived webinar 5/15: “Treating Substance Use Disorders in Health Professionals”
5. Berge, K. H., Seppala, M. D., & Schipper, A. M. (2009). Chemical Dependency and the Physician. Mayo Clinic Proceedings, 84(7), 625–631.6.
6. Boyd et al, “Ethical and managerial Considerations Regarding State Physician Health Programs,” Journal of Addiction Medicine, 2012, Vol. 6(4)243-2468.
7. 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

 

 

 

 

 
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