Archive for the ‘Doctors Behaving Badly’ Category

Patients with Substance Use Histories Denied Primary Care

Shocked and Appalled

 

 

 

 

 

One of my long-time and very stable patients saw me a few weeks ago for her yearly history and physical. That’s a minimum requirement for the patients I treat with methadone or buprenorphine at the opioid treatment program. For patients in treatment for many months, I no longer need to see them frequently for positive drug screens, dose adjustments, and other things, so we make sure to set aside time each year for me to catch up on how they are doing.

This isn’t only good medical care, but it’s fun for me. I love talking to patients and hearing the ways in which their lives have improved. It’s fun for them to discuss how they are accomplishing their life goals.

This day, after asking about the adequacy of her dose, her mood, her sleeping habits and biggest sources of stress, I asked about her overall health. To start with, I asked the name of her primary care physician. She told me she couldn’t get one, because of her history of opioid use.

I asked for further details: she called a local practice about becoming established as a patient, and part of their screening was to ask if she’d ever been prescribed opioids. She said yes, but that problem was in the past, and she didn’t need opioids now. She was then told that the practice wasn’t accepting any patients with a history of opioid use.

Merely opioid use, mind you – not opioid use disorder.

This wasn’t because of her insurance status, as she is covered by the largest private insurance carrier in the state, Blue Cross/Blue Shield of NC.

She said her feelings were hurt, and she started crying as soon as she got off the phone. She said, “They made me feel like a piece of shit.” She even teared up in my office as we were talking two weeks later.

This does not sit right with me.

I gave her the website of the North Carolina Medical Board and gave her the web address and phone number of where and how to file a complaint against that practice. I told her that denying entry to primary care for a patient because of past opioid use was immoral, if not illegal. I’m not a lawyer, but I figured if she let the medical board know, they could figure this out.

She hadn’t even told them she was on methadone. I know it’s a violation of the American with Disabilities Act, the ADA, to discriminate against someone with opioid use disorder who is in recovery on medication-assisted therapy. But I didn’t think that was the case for her, since she didn’t have time to tell them she was on methadone. By her description, their decision was based only on her history of receiving opioid prescriptions in the past.

I doubt there was any misunderstanding on her part, since she’s not the first patient we’ve had who reported similar situations. Also, local practices tell our patients on methadone or buprenorphine that they don’t have the “expertise” to care for them if they are taking methadone or buprenorphine from me.

This is ridiculous, since primary care physicians care for patients with specialty medications all the time. Cardiac patients on complicated heart medications still get primary care. HIV patients on powerful anti-viral medications still get primary care. Patients with opioid use disorder are no different.

But to be denied primary care merely because opioids have been prescribed in the past…it’s a step beyond the usual discrimination I see.

Of course, if the medical board does investigate, I expect that practice will blame the patient for misunderstanding, and say they accept all patients. Maybe…but at least they will be on notice that discriminatory practices can and will get them into problems. Hopefully they will be less likely to do this again.

No wonder local death rates increased. Not only are we dealing with the continued opioid use disorder epidemic with its opioid overdose death risk, but also with a lack of medical care for those people who survive opioid use disorder. It’s a double assault on patient health.

I live in a beautiful part on this country, but the medical care in this community often baffles me.

After a free-for-all on prescribing opioids, benzos and stimulants for a decade or two, the patients in this area for whom those were prescribed now can’t even get a primary care practitioner. It’s as if local doctors think that after the pendulum swung so far in one direction, it must swing too far in the other.

Common sense should dictate care – let’s not prescribe controlled substances willy-nilly but let’s not be stingy with opioids in cases of acute pain. And let’s not deny patients care if they’ve been prescribed opioids in the past.

What about repercussions from insurance companies? Will insurance companies allow certain prescribers to opt out of treating their covered enrollees because of past prescriptions?

Here’s another discriminatory wrinkle: life insurance companies are turning down coverage for people who have filled prescriptions for Narcan. A friend of mine sent me a link to this story:

https://www.npr.org/sections/health-shots/2018/12/13/674586548/nurse-denied-life-insurance-because-she-carries-naloxone

This is a link to the story of a nurse who was turned down for life insurance because she has filled a prescription for Narcan. This nurse works at an addiction treatment program and wanted to be able to revive people and save lives. The insurance company, Primerica, is now being criticized because it turned down her request for life insurance since she filled a Narcan prescription.

Now that they are being criticized for their stance, they issued a statement saying something to the effect that they support efforts to turn the tide on the opioid epidemic. But it appears that support doesn’t extend to offering life insurance to people who have obtained a Narcan kit.

This nurse applied at a second company and was turned down again, though she was told if she got a letter from her primary care doctor explaining why the Narcan was prescribed, they might re-consider. The trouble is, in Massachusetts, personal physicians don’t write prescriptions. To reduce barriers to receiving Narcan kits, the state allows any person who wants a kit to be able to get it under a standing order.

The physician behind this standing order is a well-known and well-respected physician, prominent in the Addiction Medicine field, Dr. Alex Walley.

Doctor Walley says he’s written other letters for similar situations where people are denied life insurance due to filling Narcan prescriptions to have on hand to save lives. He’s worried – obviously – that people will be discouraged from getting Narcan kits. These kits and their availability have been responsible for saving many lives in this nation.

These examples of poor decision making do nothing but extend the misery of people with opioid use disorder, in or out of treatment, and their families.

I’ve been working in my community for seven years, trying to inform and educate other medical providers about medication-assisted treatment. Most of the time, I feel positive, thankful to form good relationships with some providers and to coordinate care for my patients on medication-assisted treatments.

Then there are days when I feel so discouraged. it feels like there’s been no progress at all with deeply embedded bias and stigma against people with opioid use providers, their families, and the professionals who try to provide care to them.

 

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Idle Time and Our New PMP

 

 

 

 

 

 

Usually I stay busy when I work at the opioid treatment program (OTP). Every August, however, things slow down. We see fewer people presenting for admission. I don’t know why this is, but I’ve seen it happen every year for the past seventeen years I’ve worked at OTPs.

This August was no exception. Our admissions dropped down significantly, giving me chunks of time that I otherwise dedicate to doing intake admission histories and physicals. My new challenge was staying busy.

My staff knows I must be kept busy. Otherwise, I tend to Get In To Things.

For example, once when we were slow, I went on a fact-finding mission about why our toilets have no blue dye in the water. Blue dye reduces the risk of adulterated urine obtained for drug screens, yet we had no blue dye. As it turned out, the answer to my question was: it’s complicated. Our toilets have a bladder system that holds water instead of storing water in the back of the tank…well, that’s not important. But it wasn’t under my control to fix, and I only managed to interrupt people with more pressing work to do.

Another time when I wasn’t busy, I wanted to know why there were five WTA vans in our parking lot at the same time. WTA is the transport service that picks up our Medicaid patients to bring them to the OTP for treatment. We’ve asked them to stagger their arrival time, so that we don’t have multiple vans disgorging five to eight people arriving to dose at the same time. This causes a delay in dosing for all of the patients, and no one likes that – not the patients, staff or our dosing nurses.

Apparently, our request to WTA was a river too wide, a mountain too high. I can’t remember the last morning when I’ve arrived at work at 7am when there were fewer than three WTA vans. Their drivers chat amiably amongst themselves while tempers flare because of dosing delays due to a clump of patients arriving all at the same time.

I know I can be annoying when I’m not kept busy, so yesterday I kept going to the lobby to ask if anyone needed to see me. I got to see five or six people this way, a good use of time.

During the other free time, I looked at patients on our state’s new prescription monitoring program.

While I recognize I’m never good with new technology, I have some complaints about our new system.

Last week, I settled in on a Thursday evening to look at the reports of the office-based buprenorphine patients I had scheduled to see in my private office the next day. Every time I entered the patient’s first name, last name, and date of birth, I got an error message.

When technology fails to work for me, I become enraged. Many times, it turns out to be my own fault, which enrages me all the more. But this time, the new system clearly wasn’t working.

There was a phone number listed on the web site to call for problems. Since it was after hours, I expected a machine, but a human answered. I told him of my problems, and he said, “Try entering just the first three letters of the first and last name, and check the boxes that indicate partial name.”

I did so, and it worked. My short-term problem was fixed. However, feeling a little crotchety with this delay, I asked him how any provider could know it only works with the first three letters of first and last name, unless they made the effort to call the help number.

He said as long as it worked, it was good enough. In my mind, I pictured all those “There, I fixed it” photo memes often seen on the internet. I grumbled a little more, but ended with a thank you. To be fair, since then, the system has been working with the full names again.

On our old system, we could adjust our search to allow for an error in the date of birth. That is, we could select the exact date, or options for one to two years surrounding this date. You’d be surprised how many times the date of birth is recorded wrong in our charts or by the pharmacy. With this new system, the date of birth data entry must be entered exactly by the pharmacy and by the physician searching the system.

I also don’t care for the first page of this report, dedicated to overdose death risk and MME of the patient. MME stands for morphine milligram equivalents. This gives an “overdose score” which may be helpful to some prescribers.

But it annoys me, since it gives big scores to patients who are only filling prescriptions for buprenorphine products. Buprenorphine isn’t translatable into MME numbers, and MMEs were never meant for this purpose. In the fine print, the MME score for patients on buprenorphine is zero, but there’s still a high overdose score. This glitch doesn’t cause any harm so far as I can see…except for the annoyance it causes. I want my patients to get credit for being on buprenorphine, arguably one of the safest opioids in existence.

This mess of data on the front page, in large type, makes it harder to find what I’m looking for, which is the actual printout of all controlled substances filled by the patient, the date they are filled and the prescriber. While the front page must have that overdose score in a font of twenty-six, the actual data is printed in – I’m not making this up – in ten font.

I’m on the shady side of my fifties, and ten font is unsatisfactory to me.

We’ve also encountered another problem, which is that the patient’s name is only listed on the first page. Some of these reports can run to six or more pages, even with the ten font. It’s a real problem to figure out which sheets go with which patients. It’s not a huge problem at my home, where I’m the only person printing. But at work, my papers can get shuffled by other personnel getting their printed papers. I’ve had loose sheets with no name on them, which had to be discarded because I couldn’t tell for sure to which patient they belonged.

No system is perfect, and the new system has some improvements – I can print the page I’m viewing, rather than the two-step process of the past, when I had to select the option to create a pdf, then go back in a second step to print that pdf file. So it’s not all bad. Plus, we can search more states. Now providers can select our own state, plus all of our bordering states. We can select a total of eighteen states.

As August turned into September and then into October, my brief problem with free time resolved. We are busy again, though not as busy as we will be later in the year. Being busy is a good thing for everyone; more patients getting admitted to treatment means more people are getting their lives back. That’s always an awesome thing to observe.

And I am prevented from bothering staff members with more important things to do than figure out how to put blue dye in the toilets.

 

Update

 

 

 

 

 

 

I have an update to my blog of September 16. The patient, who was hospitalized with life-threatening endocarditis (infection of the heart valve), was finally granted the right to have visitors – about fourteen days into his hospital stay. Mission Hospital administrators gave no reason for the change of policy, but I have reason to believe they were feeling some heat from the many people advocating for the patient.

Since this was the patient’s second admission for endocarditis, the chart said cardiovascular surgeons were not going to do a second heart surgery, per hospital policy, because the patient had continued to use drugs intravenously. The patient was told no other hospital would accept him in transfer because he had no insurance. The palliative care team was called in to manage his case, which appears to mean his physicians thought he was going to die without surgery.

Thanks to the efforts of several very tenacious providers at the opioid treatment program where the patient had just been admitted, this case got the attention of many people. Emails flew about the state. The outrageousness of this case got people involved, who got other people involved. Besides the patient’s providers at the OTP, advocacy efforts were undertaken by personnel at the NC State Opioid Treatment Authority (SOTA), the Medical Director of DHHS in NC, the General Counsel for DHHS, and out-of-state help from a lawyer with the Legal Action Center in New York. Patient advocacy groups were helpful, and several other people whom I won’t list by name but know who they are.

Thanks to advocacy efforts, the patient was transferred to Chapel Hill last week, to be evaluated for surgery of his infected heart valve.

I have good reason to believe Mission Hospital had complaints filed against it with the Joint Commission. The Joint Commission is an independent, not-for-profit organization that gramts accreditation to hospitals if they meet certain standards. Accreditation is important, because it affects payment from payers, including Medicare and Medicaid.

I have also heard that a complaint was filed with the Department of Justice, reporting that the hospital violated the patient’s rights under the Americans with Disabilities Act.

A big meeting was scheduled for October 2, with hospital administrators and the patient’s many advocates, people who were upset with their handling of this patient’s case. Unfortunately, the day before the meeting, Mission administrators canceled, saying it hadn’t been put on their schedule, by some oversight.

By this time, I felt those administrators lacked credibility.

I hope this case gets the attention of hospital leaders. I hope the time has come where hospitals will be held accountable for their mis-treatment of patients with opioid use disorder (OUD). OUD is a completely treatable chronic illness, not bad behavior that deserves the death penalty.

 

 

The Rights of Patients with Opioid Use Disorder

 

 

I’ve been notified of an alarming development that’s come to pass at Mission Hospital in Asheville, NC.

Recently Mission Hospital decided that patients with opioid use disorder will be unable to have visitors while they are hospitalized, and they will also be unable to have any electronic devices with them. The hospital will provide “sitters” to stay in patients’ rooms at all times, for patients with opioid use disorder. It’s unclear to me if this policy also applies to all patients with substance use disorders. It’s also unclear if their policy applies to all patients with opioid use disorder, or just those in early recovery.

These measures have been imposed to prevent hospitalized patients from using illicit drugs.

The first edict – that patients with opioid use disorders can’t have visitors – isn’t absolute. Apparently potential visitor candidates must be pre-approved by the Chief Medical Officer of the hospital.  I don’t know what criteria this CMO uses, but it would seem this policy would have the effect of isolating a hospitalized patient.

I’ve only been hospitalized once, with a broken leg, but without the presence and support of my fiancé, I would have been distraught and more frightened than I already was (and I’m a doctor!). And that’s just a broken leg, completely fixable. Imagine how much worse it would be for patients hospitalized with severe or life-threatening medical problems. Isolating patients at such a time is cruel, even if it may be legal.

Banning electronic devices also has the effect of isolating the patient. Think of it – no email, no cell phone calls, no Facebook, no surfing the net to pass time…this measure also seems unnecessarily harsh.

Mission Hospital’s administrators probably instituted these actions because visitors brought drugs to patients in the past. Of course this happens, and it’s vexing to staff and dangerous to the patients. But surely some sort of common-sense measure can be taken short of barring all visitors and banning electronic devices.

As far as having a sitter in the room – I, for one, would be most annoyed if the hospital where I’m paying to get treatment decided I needed the constant companion of an utter stranger.

Frightened hospital patients with life-threatening illness need to discuss treatment options with loved ones. A random person sitting in the room will not serve as a substitute. The wrong kind of person could even increase patient anxiety.

These new measures taken by Mission are likely to increase the risk of a patient leaving against medical advice (AMA). The cynical side of me wonders if that’s the hospital’s intent. Many people with substance use disorders don’t have insurance, and often need long hospital stays. Are these new measures, which isolate patients with substance use disorders, intended to get rid of these “bad” patients?

I hope not.

As good as their intentions might have been, Mission’s actions might be a violation of the Americans With Disabilities Act (ADA).

I saw a presentation at the spring American Society of Addiction Medicine (ASAM) conference, given by Elizabeth Westfall, an attorney who works at the Department of Justice (DOJ). The topic of her lecture was the new Opioid Initiative started by the DOJ. Right now, there’s a push to investigate and eliminate unnecessary and discriminatory barriers for patients with opioid use disorder who are in treatment and recovery. She said the DOJ was doing an outreach to stakeholders to spread information about what counted as discrimination, and to offer technical support when needed.

She said the DOJ works with U.S. Attorneys across the country to look at these cases of discrimination. She says they can usually negotiate settlements where part of the agreement is to make sure discriminatory practices are ceased. If settlements can’t be agreed upon, the DOJ assists with litigation when needed.

Ms. Westfall told the ASAM audience that the ADA prohibits discrimination based on disability in different areas: employment, services from state and local governments, and public accommodations. She said that patients with opioid use disorder are protected under the ADA if they are not currently using illicit drugs.

That last part is what makes ADA claims tricky. Who is to say what is “current use?” Clearly, she told us that patients in medication-assisted treatment are not considered to be current users. These patients are taking medications prescribed by a physician for a specific purpose. These patients are covered under the ADA, so long as there is no current illicit drug use.

Elizabeth Westfall also gave information about how to file a claim with the DOJ. Of note, employment discrimination claims need to go to the EEOC, but even if you send them to the DOJ, she said they would be forwarded to the appropriate agency.

There is a specific case at issue right now. I will change some data to protect patient identity, but here’s the story: A patient entered medication-assisted treatment on methadone about two weeks ago. He did well, and got up to a dose at which he stabilized. Then he became ill with malaise and fever, and went to Mission Hospital’s emergency department. He was found to have a potentially life-threatening medical disorder, and was admitted for treatment.

He has not been permitted to have visitors, and his mother was apparently refused permission to visit him. He’s been isolated from any support network he might have, due to Mission’s new policies in place to prevent illicit drug use among their hospitalized patients.

Is this a violation of the ADA? Since I’m no lawyer (despite having watched every single “Law and Order” episode from the twenty years it aired), I don’t know.

Bu it doesn’t seem right to me, separating the patient from critical support during a life-threatening illness. I know the medical staff at the OTP he goes to has been talking to hospital officials, trying to negotiate a compromise.

Here is the information given at the ASAM meeting, should any of my readers know of a case of discrimination against patients with opioid use disorder:

File a complaint:
http://ada.complaint@usdoj.gov

Great website for further reading/information:
http://www.ada.gov

Benzodiazepines: The Next Wave?

 

 

 

In the February 22, 2018 issue of the New England Journal of Medicine, Dr. Lembke and others wrote a perspective article about benzodiazepines, titled, “Our Other Prescription Drug Problem.”

The authors voiced concerns that amidst all the attention being given to opioid use disorders and opioid overdose deaths, we are ignoring the harms from overprescribed benzodiazepines. They felt it would be a tragedy if the present attention to opioid overuse and misuse led to more people being prescribed benzodiazepines, leading to a growing problem with this type of medication

While I am firmly in the amen corner on this one, I know physicians in my state have not ignored this problem. Since the South has the highest rate of benzodiazepine prescribing per capita of the U.S., [1] the opioid treatment program physicians frequently talk about how to reduce the overabundance of benzodiazepines, and the dangers they present to our patients.

We’ve seen the adverse events from benzodiazepines for more than ten years. The National Institute on Drug Abuse (NIDA) says deaths where benzodiazepines were involved quadrupled from 2002 to 2015. NIDA also says that when benzodiazepines are mixed with opioids, the risk of death increases ten-fold, and that three-fourths of all opioid overdose deaths also involve benzodiazepines. About two years ago, the FDA issued a black box warning about the overdose dangers from combining benzodiazepines with opioids.

As the Lembke article says, the number of people in the U.S. who were prescribed benzodiazepines increased 67% from 1996 to 2013. The quantity prescribed more than tripled over that time, indicating higher dose have been prescribed. In 2012, for every 100 adults in the U.S., 37.6 prescriptions for benzodiazepines were written. That’s an amazing – and scary – statistic.

It’s so bad in my area that Xanax functions as a form of currency. Forget bitcoin; Xanax works just like money. For example, it costs two Xanax 1mg pills to get someone to run you to the grocery store and back, assuming no other stops. That’s the going price. If you want to go to the hardware store too, you’d probably have to throw in another Xanax or clonazepam.

It’s a cultural thing. People feel like after they fill a prescription of Xanax or another benzodiazepine, it’s theirs to use as they wish. They can sell them, barter them, or even take them. People don’t even view this as wrong or illegal.

Most experts feel ordinary benzodiazepines are overused and prescribed for too long. Besides their risk when taken with opioids or other sedating drugs, and they have serious hazards when taken long-term. In a blog entry on September 1, 2014, I described a study published in the British Medical Journal that showed people who used sleeping pills died prematurely at a rate three times higher than controls who did not use sleeping pills, in a dose-related fashion. [2]

Studies show people on benzodiazepines (and other sedatives, like the “z” drugs like Ambien, Lunesta, and Sonata) were more likely to die from cancer and were more likely to have falls. Studies show an increased risk of dementia in patients who take these medications, though we can’t say for sure that it’s causal.

To make matters worse, analogues forms of some benzodiazepines are being made overseas in clandestine drug labs. Some are extremely potent. For example, an analogue of clonazepam is so potent that it needs to be dosed in micrograms rather than milligrams and can be bought online. We don’t know the magnitude of harm that could be caused by such drugs, because they are difficult to detect in urine drug screens.

I cringe when I encounter a patient who says, “I’ve been on my Xanax now for ten years. I can’t do without it.” Prescribing guidelines say these medications were never intended to be used long-term. They can be effective for a period of weeks to months, but daily use over three months isn’t recommended.

Certain providers seem to prescribe them for the flimsiest of reasons. I know this because when I request patient records, I see on a problem list: “Anxiety – continue clonazepam.” There’s no mention of other treatment that have been tried, no notation about any sort of counseling, which is very effective for some anxiety disorders. There’s no specification about the type of anxiety being treated. Sometimes benzodiazepines are used to treat depression, but since benzos are central nervous system depressants, they tend to worse depression. Sometimes benzodiazepines are prescribed for post-traumatic stress disorder, even though we know from VA studies that benzodiazepines tend to make PTSD worse. [3]

Other experts feel their positive aspects are overlooked, and that they are effective at relieving short-term anxiety, and at inducing sleep. As the Lembke article points out, benzodiazepines can be helpful when prescribed for less than one month, and when used intermittently. When used daily and for months, those benefits disappear, and the risks of benzodiazepines increase.

We aren’t the only country struggling with the negative effects of benzodiazepines. Other countries have attempted to mitigate the negative effects by putting prescribing guidelines into place for physicians to follow. As you will note, some of these countries have had guidelines in place for decades.

 

Ireland: https://health.gov.ie/wp-content/uploads/2014/04/Benzodiazepines-Good-Practice-Guidelines.pdf

Australia: https://www.racgp.org.au/your-practice/guidelines/drugs-of-dependence-b/

United Kingdom: https://www.benzo.org.uk/commit.htm

Canada: https://www.benzo.org.uk/hcb/index.htm

Several countries have adopted the guidelines written by the United Kingdom as their guidelines.

Several states and health organizations have taken on the challenge of writing benzodiazepine prescribing guidelines in the U.S.

Like the authors of the Lembke article, I too hope we see a push to use evidence-based data when prescribing benzodiazepines in the U.S.

  1. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6326a2.htm
  2. Weich et al, “Effect of anxiolytic and hypnotic drug prescriptions on mortality hazards: retrospective cohort study,” British Medical Journal, 2014
  3. https://www.ptsd.va.gov/professional/newsletters/research-quarterly/v23n4.pdf

Update on Jail Death Lawsuits

 

 

 

 

Long-time readers of my blog will remember the story of Eric Stojcevski, a young man who died from withdrawal from prescribed medication while in jail in Macomb County, Michigan, for unpaid traffic tickets in 2014.

I blogged about this case on November 3, 2017, February 5, 2016, and October 20, 2015.

I’ve given readers periodic updates because to me, this case is the most extreme example of how poorly sick inmates are treated by jailers. I feel this is one of our country’s biggest moral failings, because it goes on all the time, usually with little to no publicity.

Someone once said we can judge the quality of a society by how we treat the most vulnerable members of that society. Incarcerated people are among the most vulnerable, since they can’t take themselves to a hospital for medical care if they get sick. They are dependent on the jailers to get them care when ill.

This did not happen in the case of David Stojcevski. In June of 2014, he went to jail for failure to pay parking tickets, and it turn into a death sentence. According to news sources, he was being prescribed methadone, clonazepam, and alprazolam by a physician. He was not given any of these prescribed medications when he was in jail.

According to his autopsy, he died from acute drug withdrawal on the seventeenth day of his thirty-day sentence. Despite intense suffering, his pleas for medical attention were ignored. When he exhibited bizarre (withdrawal) behavior, he was sent to a mental health cell, where his last eleven days on earth were videotaped. His family, livid at the lack of medical care that resulted in his death, released the videotape online, where it went viral. The recording showed him naked, having repeated seizures on the jail floor as he died.

His family filed a civil case against jail personnel, and against Correct Care Solutions, the health organization that was contractually obligated to provide medical care to prisoners in the Macomb County jail.

There was a criminal investigation that went nowhere.

The Department of Justice investigated, and said they found no evidence of criminal intent on the part of jail personnel or personnel of Correct Care Solutions. The FBI had to be forced by the family to release its investigation records, and only released part of them.

These records should be helpful to the family’s civil case, and now depositions for this civil case are underway.

According to news reports, [1] Sheriff Wickersham’s sworn testimony revealed that David lost forty pounds in his last seventeen days, spent in the county jail. Over the last three days of his life, he drank almost no water. Of the thirty-three meals served to him over the last eleven days of his life, he ate perhaps three of them.

According to news reports, jail guards thought the medical staff was responsible for deciding when a patient should go to the hospital. Medical staff thought it was the guards’ responsibility to monitor the amount of food and water inmates are consuming.

Sheriff Wickersham admitted he was responsible for the well-being of the inmates, but also admitted he rarely enters the jail. Even though his office is located a few feet from the jail, he enters the jail perhaps once per month. He said he delegated oversight of medical care to another employee, who had no medical training.

News reports didn’t say whether Correct Care Solutions employees had been contacted about the state of health David was in during his last days.

News reports did say that David’s prescribing physician, Dr. Bernard Shelton, was charged with unlawful delivery of controlled substances. [2] This report says he prescribed four million “addictive pills” to Macomb County residents, though it didn’t specify over what period of time or what type of pills they were. From what he prescribed David Stojcevski, it appears to have been opioids and benzodiazepines.

In 2017, according to the state of Michigan’s medical board documentation, Dr. Shelton lost his medical license for inappropriate prescribing of controlled substances that were outside acceptable practice. His charts were reviewed by other physicians, who have the knowledge to judge such things. They said he didn’t check patients on the Michigan prescription monitoring website, he didn’t keep complete records, and lacked essential documentation.

The medical board suspended his medical license for fifteen months, fined him $10,000, and said he wouldn’t be considered for license re-instatement unless he could prove, with clear and convincing evidence, that he had good moral character, the ability to practice medicine with reasonable skill and safety, the ability to follow the guidelines of re-instatement, and for it to be in the public interest that he be licensed again. At present, he does not have a license to practice in Michigan.

Now it appears Dr. Shelton will face criminal charges as well as losing his medical license.

But getting back to David Stojcevski’s case…even if his doctor prescribed opioids recklessly and inappropriately, it doesn’t release the sheriff of his obligation to make sure inmates receive medical care. Watching David suffer on the recordings made by the jail, I can’t help but wonder why no one took any action to help a man obviously in serious need of medical attention.

What if Sheriff Wickersham (or one of his deputies) walked down the street of whatever town is in Macomb County, Michigan, and he came to a man lying on the sidewalk, barely conscious, having a seizure. What would he do? I expect he would squat down beside the sick man, check for a pulse, and summon 911 for help. That’s what most citizens would do, out of common decency and concern for a fellow human.

In other words, it did not take any medical knowledge to know David was in serious need of medical help, yet no one in the whole jail called 911.

You can believe I’ll be watching this case unfold. It has the potential to be a multi-million -dollar case. In other similar cases, awards were in the three-million-dollar range. It’s sad that is takes a large financial award to change the way people do things, but in this case, it appears necessary.

It’s too late for David, but a large settlement or award against Macomb County and against Sheriff Wickersham could be another paving stone on the road of appropriate medical care for vulnerable inmates.

  1. https://www.clickondetroit.com/news/defenders/sheriff-answers-questions-under-oath-about-death-of-inmate-at-macomb-county-jail (accessed 7/4/18)
  2. https://www.clickondetroit.com/news/defenders/doctor-charged-with-distributing-opioids-to-inmate-who-died-from-withdrawal-at-macomb-county-jail (accessed 7/4/18)

Not Dying: A Worthy Goal

 

 

A new study about opioid overdose death and treatment of opioid use disorders was published in the Annals of Internal Medicine this month. [1]

It showed that people who experience a non-fatal overdose have a significantly reduced risk of death if they start on medication-assisted treatment with methadone or buprenorphine. Naltrexone was also examined but limited data prevented conclusions about the use of this medication.

This large cohort study, done in Massachusetts on adults age 18 and older, covered the four years from 2011 and 2015. Subjects were identified as people who experienced at least one non-fatal opioid overdose and survived at least for 30 days afterward. Patients were excluded if they had a diagnosis of cancer.

This turned out to be a huge study, with over seventeen thousand study subjects.

In the year prior to the overdose event, 26% had received at least one medication to treat opioid use disorder. Twenty-two percent received opioid detoxification at least once. Forty-one percent had received an opioid prescription in the preceding year, and 28% received a prescription for a benzodiazepine within the previous year.

For these same patient, in the year after their nonfatal overdose, 30% received at least one medication for opioid use disorder (13% got buprenorphine, 8% got methadone, and 4% got naltrexone. The other 5% received more than one medication.)

People younger than 45 were more likely to received treatment with medication, as were people with diagnoses of anxiety or depressive disorders.

In the year after overdose, 4.6 of the people with a prior non-fatal overdose died, and of those, 2.1% died from opioid-related causes.

For patients treated with medication for opioid use disorder, both the all-cause mortality and opioid mortality rates were significantly reduced; they were cut approximately in half.

Patients who started n methadone after their non-fatal overdose had markedly reduced risks for both all-cause mortality and opioid-related mortality, with the adjusted risk at around half what it was for untreated patients. Results for patients on buprenorphine were nearly the same; they had not quite the degree of risk reduction as with methadone, but still significantly lower risk of death than patients on no medications.

There were no associations between risk of death for patients started on naltrexone, but the authors noted this was a smaller group, so any differences weren’t statistically significant. Of note, most of those patients were only treated for a month or two.

So what does this study tell us?

We have another study that shows medication-assisted treatment with methadone or buprenorphine reduces the risk of death, this time in people with at least one prior non-fatal opioid overdose. In this study, being methadone or buprenorphine reduced deaths from all-cause mortality, as well as opioid-related mortality.

We also see, again, that only a minority of people, 30%, with nonfatal overdose were started on life-saving medication.

I was surprised the percent of people referred for medication-assisted treatment was that high. This study was done in Massachusetts, a state that’s probably at the forefront of opioid use disorder treatment. They have some excellent providers and physician leaders, and better methods to pay for treatment in that state.

I don’t think rural areas in North Carolina come close to a 30% referral rate. I’d be amazed if 2-3% were referred for evidence-based treatment with medication. I suspect most people here who survive near-fatal opioid overdoses aren’t directed, referred, or even informed about medication-assisted treatments. People get referred to OTPs around here by concerned friends and family members, but rarely by physicians.

It has started to change. In our area, of the three OB/GYN groups, we have one practice that refers patients to us. The LME (local management entity, which contracts with the state to see people on Medicaid and those with no insurance) has referred less than a handful of people for treatment. That’s a dramatic improvement from seven years ago when the LME told patients to get off methadone.

But back to the study. So even in one of the most progressive states, only 30% of people got life-saving treatment.

Let’s picture a patient who has a near-fatal episode of a different chronic disorder. Thankfully, the patient survives this episode. There’s a treatment medication for this disorder that will reduce the patient’s risk of dying by half over the next year. What do you think would happen if this patient wasn’t given or referred for that life-saving treatment?

There would be an outcry. There would be wringing of hands and rending of garments, and possibly gnashing of teeth. There would be lawyers…malpractice lawyers, swarms of them.

Yet this exact situation happens over and over, again and again, in emergency departments across this nation.

To be fair, this article doesn’t say why the patients who survived a near-fatal overdose weren’t started on medication. Maybe emergency department personnel offered this medication but the patients refused.

Realistically, there are significant barriers to starting medication-assisted treatment of opioid use disorder. Methadone can only lawfully be prescribed from a properly-licensed opioid treatment program. Maybe emergency department physicians gave referrals to OTPs, but the patients didn’t show up. Maybe they referred to office-based buprenorphine prescribers.

Every time I do an intake on a patient entering treatment with MAT, I ask if there’s been an overdose in their history. Much of the time, the answer if “Yes.” I then ask what kind of recommendation for treatment they got. Most times the patient looks at me blankly. They can’t think of any kind of treatment recommendation or referral. One patients said, “They told me to quit using drugs.”

Telling people to quit using drugs IS NOT treatment for opioid use disorder. It’s sad that I even have to write this, as it should be well-known by all medical personnel.

All of us working in this field need to keep chugging along. We need to put this article in our mental back pocket, ready to talk about if/when the time comes when we hear stale old beliefs about medication-assisted treatments.

This study points to the bottom line: “We are using medications that reduce the risk of dying by half, for people who have had a prior nonfatal overdose.” Not dying is a huge benefit of treatment, perhaps the ultimate benefit.

It is long past time for medical professionals to set aside their personal opinions and what they think they know, in favor of hard data. Methadone and buprenorphine reduce the risk of dying, and patients with opioid use disorder must be informed & encouraged about these treatments. To do otherwise is malpractice.

  1. Larochelle et al., “Medication for Opioid Use Disorder after Nonfatal Opioid Overdose and Association with Mortality: A Cohort Study,” Annals of Internal Medicine, June 19, 2018