Archive for the ‘Doctors Behaving Badly’ Category

After the Overdose

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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

Mandating Physician Education

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In May of this year, Massachusetts Senator Ed Markey proposed a new bill titled the Safe Prescribing of Controlled Substances Act. This Act, among other things, calls for mandatory education of the nation’s physicians about, as the name implies, safer prescribing of controlled substances. It also calls for mandatory education about identifying patients with substance use disorders.

Physicians get very little education about this tremendously important problem. Some medical schools and residencies have added addiction trainings, but change happens slowly. Plenty of doctors in the U.S. are still mis-prescibing

Physicians are not going to like this legislation. We hate being told we have to do anything, especially by politicians. But obviously, the present generation of physicians is NOT able to prescribe controlled substances properly, as evidenced by our epidemic of prescription drug addiction.

The bill extends to any prescriber of controlled substances, meaning that physician assistants and nurse practitioners will also be required to take this training, at least in states where they are allowed to prescribe controlled substances.

Senator Markey’s bill says the Department of Health and Human Services is responsible for producing this training and that it will be free and available online.

The bill specifies the training should include, “methods for diagnosing, treating, and
managing a substance use disorder, including the use of medications approved by the Food and Drug Administration and evidence-based non-pharmacological therapies.”

If everyone interprets this paragraph as I do, this would mean all doctors who want to prescribe controlled substances should be educated about medication-assisted treatments of opioid addiction, among other things.

That would be wonderful. How nice it would be for my patients to go to their other doctors, and hear, “So glad you are on methadone for the treatment of addiction. Good job.” instead of the usual insults about being on of MAT. How nice for me to be able to call other doctors who don’t think I’m a drug pusher for prescribing MAT!

Also, Senator Markey sent letters to the VA, Defense Department, and IHS, urging them to included prescribing information to their patients on their state’s prescription monitoring program. Many patients being cared for by these agencies are prescribed controlled substances, but doctors outside those systems have no way to know what is being prescribed. Presently, they don’t report to the prescription monitoring programs. I hope these military agencies chose to participate in the PMPs. It would be a way to keep those patients safer when they seek care outside the military system.

On May 15, 2015, the Huffington Post had an online article about another bill, the Recovery Enhancement for Addiction Treatment Act, also sponsored by Senator Markey and Senator Rand Paul. This legislation would lift the one-hundred patient limit placed on office-based buprenorphine doctors.

In the past, I supported lifting the one-hundred patient cap, but I’ve come to believe the cap isn’t all that relevant, at least in my area. Around here, I think the only physicians who honor the cap are conscientious doctors who would do a good job without legislation.

Around here, physicians have more than one hundred buprenorphine patients, and skirt the regulations by saying some of them are prescribed it “for pain.” Physician extenders without DEA “X” numbers already prescribe buprenorphine in this state. When the North Carolina medical board was notified about this, they declined to take any action.

In other words, the present regulations are flouted without consequence, so lifting them isn’t going to make a big difference. (That may not be the case in all areas of the country.) But mandating education about addiction and its treatment may help treatment providers deliver better care.

The Benzo Conversation

Glass head full of pills

Not all of my patient interactions are easy. One of my colleagues, after reading my blog, remarked, “It sounds like you have really easy patients.” While that’s true for the most part, of course there are more difficult patients, as in any practice. Some patients, eager to get into treatment to stop opioid addiction, may not be at all ready to stop other drugs of addiction. That’s not a deal-breaker for me, unless those drugs could be fatal when mixed with methadone or buprenorphine. This means the use of alcohol, benzodiazepines, and sedatives of other kinds must be discussed in detail.

I’ve noticed a conversational merry-go-round that I call “the benzo conversation.” I’ve had versions of this conversation more times than I can remember.

This conversation occurs during my initial assessment of a new patient presenting for medication-assisted treatment. I always look on my state’s prescription monitoring program for each new patient on the day of admission. If they have prescriptions for benzodiazepines (like Xanax, Valium, or clonazepam), or other sedatives (Soma, Ambien, etc.) I need information about the pattern of use. Is my patient taking his prescribed daily dose? Is he then physically dependent on benzodiazepines? Is he selling them? Is he giving part of the prescription away, and taking the rest? Does he binge on benzos for the first few weeks of the month, and then run out for several weeks? Or is he bartering the benzos for opioids, and not taking any of them, despite filling a large prescription each month?

I really don’t care if the patient is breaking the law or not; I just want to get the complete picture of my patient’s health status.

Following is a typical conversation with a new patient whom I will call “Bob.”

Bob sought admission to our methadone maintenance treatment program for his opioid addiction. He had snorted pain pills for six years, and wanted help. He had little if any denial about his opioid addiction. He denied taking any prescription medications, saying he got all his opioids off the street, used no other drugs or medications, and had no other medical problems.

However, when I checked his name on my state’s controlled prescription monitoring program, he was filling a prescription for Xanax 2mg, ninety per month, from a local Dr. Feelgood. This prescription had been filled every month for the last four years. My patient’s admission urine drug screen also tested positive for benzodiazepines.

As part of my initial history and physical, I asked him about the Xanax prescription. I explained to Bob that benzos have the potential to cause a fatal overdose when mixed with opioids. I told him that benzos are especially risky with methadone, and I was concerned about his use of them.

Bob said, “Oh, I don’t use benzos now. I haven’t used Xanax for years.
“But you’ve been prescribed it every month and picked up the last prescription of ninety pills just two weeks ago.”
“Yes, but I don’t take them. I quit them long ago.”
“And you do have benzos in the urine sample you gave us.”
“Well, that’s probably from a little piece of Valium I used four days ago.”
“Ummm…, Valium’s also a benzo, in the same family as Xanax, so when you say you’ve stopped, that doesn’t make sense to me.…”
“As I told you, I don’t take benzos anymore.”
“But four days ago is pretty recent.”
“No,” he said, getting a little worked up. “As I’ve already told you, I stopped benzos years ago!”
“So what do you do with the Xanax pills you pick up at the pharmacy every month?”
“I don’t know. They’re in the house somewhere. But I don’t take them.”
“So you have…how many bottles do you have at home?”
“Bunches, I don’t know.”
I could tell I was annoying him, but this as an important clinical issue, so I pushed on.
“Would you be willing to bring all those bottles in tomorrow so the nurse can watch you dispose of them?”
He sighed deeply, annoyed by my questions. “Yes. I suppose I can. Now can I get my dose?”
“No, I’ll leave an order for you to be able to start tomorrow after you bring in the medication to dispose, since you tell me you haven’t taken them. I worry about a fatal overdose if methadone were combined with all that Xanax you have at home.”
Now he was mad. “I don’t have any Xanax at home! I’m not going to overdose! I know what I’m doing.”
“Will you give me permission to call the doctor prescribing the Xanax, so we can talk about your entry into treatment here? Maybe your doctor would be willing to taper your dose so that we can make it safer for you to be in treatment with us.”
“No! I don’t want everybody to know my business. My doctor is friends with my ex-wife and if she finds out I’m being treated for addiction, she’ll cause trouble. He can’t find out.”
“I’m sorry, but that’s a deal-breaker for me. I’m not going to prescribe methadone for you unless I can talk to your other doctor. It’s just too risky. All of your doctors need to know all medications that you’re on.”
“So you’re telling me to go back out there and use drugs? That I can’t get help unless my ex-wife finds out I’m an addict?” The veins in his neck were standing out.
“No. I’m not telling you to use drugs. I’m telling you…
“I want my money back, since I’m gonna have to go buy dope again ‘cause you won’t help me. It’s just not right. I came here to get help.” He stalked off toward the receptionist, where I heard him demanding his money back, despite the hour he spent with a counselor and the time spent with me in an evaluation. (For some reason, patients who don’t get admitted to the program don’t feel they should have to pay for their evaluation)

This was a difficult, tense conversation, and one I’ve had too many times to count. This patient wasn’t a bad guy, but he was not ready to address his benzodiazepine use. The outcome wasn’t what I’d hoped, and this patient didn’t come into treatment.

There’s no way I could know what this patient was doing with his benzodiazepine prescription. I couldn’t tell if this patient was telling the truth, in denial, or lying. Without being able to talk to his prescribing doctor, I wasn’t willing to start medication-assisted treatment. This didn’t mean he didn’t need treatment, only that perhaps a different form of treatment will be safer for him. I wish I could have given him information about other treatments, but he left too quickly and too angrily.

Sometimes patients tell me I’m violating their privacy by looking at their information on the prescription monitoring database. I tell them I don’t see it that was at all, since they are asking me to prescribe a medication that could have a fatal interaction with other medications. Not only is it my business, it’s my responsibility.

Some doctors would fault me for not admitting this patient despite his refusal to allow me to talk to his prescribing doctor, given the increased risk of death for patients in active opioid addiction who are not in any treatment. But I would feel terrible if I’d admitted this patient and he died during the first few weeks of a methadone/benzodiazepine overdose. Either way, there’s a lot at stake, and I feel stress about these decisions.

The Billionaire Pill

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In a recent Forbes magazine article about this nation’s twenty richest families, the Sackler family was number sixteen on the list. The Sacklers are estimated to be richer than the Mellons, Rockefellers, and Busches. (http://www.forbes.com/sites/alexmorrell/2015/07/01/the-oxycontin-clan-the-14-billion-newcomer-to-forbes-2015-list-of-richest-u-s-families/

You say you don’t know the Sackler family? I’ll remind you. They own one-hundred percent of Purdue Pharma, a pharmaceutical company best known for manufacturing their block-buster drug OxyContin.

This is a bitter pill for me to swallow.

I started working in the field of opioid addiction treatment in 2001. At that time, nearly every opioid addict I saw was using OxyContin as their main drug. Opioid addiction in general and OxyContin addition in particular plagued many small towns and rural areas where I worked.

OxyContin was widely prescribed for pain. This powerful drug was advertised as “The one to start with and the one to stay with,” during sales pitches to rural physicians. OxyContin flooded the black market. Opioid addict quickly discovered OxyContin’s time-release coating could be easily defeated, and the pill was often snorted or injected for the rush of opioid euphoria it produced.

I was certainly not the only doctor to notice the rise of OxyContin addiction.

Barry Meier’s book Pain Killer: A “Wonder” Drug’s Trail of Addiction and Death (Rodale Books, 2003), tells the story of small town doctors trying to get the attention of Purdue Pharma, the government, or anybody else who could help change the destruction OxyContin was doing to Appalachia around that time.

I remember attending a pain and addiction conference around sometime around 2003 or 2004. At the end of the lecture explaining how opioids could be prescribe safely, a doctor from Virginia dared to ask the experts something along the lines of, “What are we going to do about OxyContin?” I thought to myself that I was glad someone had finally said what I was thinking.
This was a long time ago; I don’t remember exact words, but my memory is that he was soundly rebuffed for daring to mention one specific drug by name. He was scolded and told that the real problem was with opioids in general, and one drug company (who happened to have some of the lecturers on their payroll) should not be singled out as the problem.

I remembered wishing those experts could spend a day at my treatment program talking to the OxyContin addicts.

Eventually, the U.S. General Accounting Office asked for a report about the promotion of OxyContin by Purdue Pharma. By 2002, prescriptions written for non-cancer pain accounted for 85% of the OxyContin sold, despite a lack of data regarding the safety of this practice. By 2003, primary care doctors, with little or no training in the treatment of chronic non-cancer pain, prescribed about half of all OxyContin prescriptions written in this country. By 2003, the FDA cited Purdue Pharma twice for using misleading information in its promotional advertisements to doctors. [1, 2] Purdue Pharma also trained its sales representatives to make deceptive statements during OxyContin’s marketing to doctors. [3]

Testifying before Congress in 2002, a Purdue Pharma representative said the company was working of re-formulating OxyContin, to make it harder to use intravenously. This representative claimed it would take several years to achieve this re-formulation. The re-formulated OxyContin was finally approved by the FDA in 2010, eight years later. Currently, this medication forms a viscous hydrogel if someone attempts to inject or snort the medication. It isn’t abuse-proof; probably no opioid will ever be so, but it is much more abuse-deterrent than the original.

Did Purdue Pharma drag their feet in this re-formulation? Experts like Paul Caplan, executive director for risk management for the drug company, said there were issues about the safety of incorporating naloxone into the pill to make it less desirable to intravenous addicts. He also pointed out that some delay in approval was due to the FDA.

For comparison, Sterling Pharmaceutical, when it became widely known patients were abusing their pain medication Talwin, re-formulated within a year, adding naloxone to the medication and reducing its desirability on the black market. Since this was in the 1980’s, I would assume there was less technology to help back then, compared to 2002.

I’ll let readers draw their own conclusions.

In May of 2007, three officers of Purdue Pharma pled guilty to misleading the public about the drug’s safety. Their chief executive officer, general counsel, and chief scientific officer pled guilty as individuals to misbranding a pharmaceutical. They did no jail time but paid $34.5 million to the state of Virginia, where the lawsuit was brought.

The Purdue Pharma Company agreed to pay a fine of $600 million. Though this is one of the largest amounts paid by a drug company for illegal marketing, Purdue made 2.8 billion dollars in sales from the time of its release in 1996 until 2001.

None of the Sackler family members were charged, because they were not involved in the day to day running of the company.

And now the Sackler family is worth billions.

1. General Accounting Office OxyContin Abuse and Diversion
report GAO-04-110, 2003.
2. United States Senate. Congressional hearing of the Committee
on Health, Education, Labor, and Pensions, on Examining
the Effects of the Painkiller OxyContin, 107th Congress, Second
Session, February, 2002.
3. Washington Times, “Company Admits Painkiller Deceit,”
May 11, 2007, accessed online at http://washingtontimes.
com/news/2007/may/10/20070510-103237-4952r/prinnt/ on
12/18/2008.

Dr. Drew Snafu

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Oh, Dr. Drew. You disappoint me. Again.

Pontificating about the most recent episode of gun violence, Dr. Drew just spewed some gross inaccuracies about the medication buprenorphine.

After listening to his blather, I realized I was going to need to write him an angry letter. Again. I’ve written him twice in the past, back when he had “Celebrity Rehab” on television, but I’ve never received a response. But this time, instead of writing a letter and mailing it, I’m going to post it on my blog.

Dear Dr. Drew,
Just shut up. You make my ears bleed.

If you can’t add anything positive to a conversation, just don’t say anything, please. I shouldn’t have to tell you this nation is in the middle of an opioid addiction epidemic, and there you are on television, demonizing one of the medications proven to be life-saving for this condition.

In an interview about the Charleston, SC, church shooting, you say Suboxone has been linked to violence in its users, and people get “strung out” on it, making it impossible for them to have the personality changes necessary for recovery from addiction.

First of all, don’t use the term “Suboxone.” Please use the more generally accepted way of referring to a medication, by its generic name, since there are so many companies making both generics and name-brand preparations of this medication. That medication is buprenorphine.

Next, I challenge you to present one scrap of scientific evidence for what you said in that interview. What data can you show me indicating personality changes can’t be made while an opioid addict is being treated with buprenorphine?

Of course, it all depends on how you define personality change, but we know patients on buprenorphine are more likely to stop using illicit opioids, have improved physical and mental health, and more likely to become employed than opioid addicts who get non-medication-assisted treatments. They have better relationships with friends and family. These patients’ lives no longer revolve around getting and using opioids in order to get high.

Sure looks like recovery to me.

You criticize this medication because it is difficult to withdrawal from. True, some patients have an extraordinarily hard time tapering off of it, but that’s not a universal experience. I’ve had a few patients say they had no withdrawal at all. Most say they have a withdrawal, and generally it’s not as bad as withdrawal from full opioids.

Besides, I don’t start this medication with the intention of stopping it any time soon. We know the patients who are doing the best are the ones that stay on this medication indefinitely. That’s not a popular opinion, but it IS based in fact. It doesn’t help anyone to ignore what the evidence shows us, and replace knowledge with wishful thinking. Patients should plan to stay on medication-assisted treatments with buprenorphine and methadone indefinitely.

You say Suboxone has been known to cause violence. On what data do you base this? Stories on the internet? Maybe you’ve been in Hollywood so long that you’ve forgotten that stories on the internet aren’t considered medical research.

Just as a reminder, we doctors generally prefer to base our statements on scientific data. To my knowledge, not one of the dozens of studies done on buprenorphine patients over the past twenty to thirty years, both here and in Europe, found any increased tendency toward violence in patients taking the medication. So stop trying to pass off stories on the internet as real data.

Sadly, several news outlets took what you said in that interview and parroted your mistake. Now all sorts of news outlets are saying this drug makes you violent. You and I both know buprenorphine wasn’t the cause of this shooter’s dysfunction. It was highly unprofessional for you to imply that it was.

I understood from watching your unfortunate show “Celebrity Rehab,” which is now, mercifully, off the air, that you were not going to help the viewing public understand opioid addiction and its successful treatment, except to say the only acceptable recovery is drug-free recovery.

Look, I get where you are coming from. I come to this profession from a strongly 12-step, abstinence-only mindset. But time, experience, and medical literature have convinced me that abstinence-only treatment isn’t available or acceptable to many people with addiction. So let’s not deny life-saving treatments with buprenorphine and methadone to people who need them in order to recover. If an opioid addict can get off – and stay off – all opioids and have a contented, happy recovery, huzzah! That person is fortunate, and I’m happy for them that they don’t need medication. But do NOT criticize other patients who do need buprenorphine or methadone in order to live a normal life. Their recovery is just as real as the abstinence-only patients.

If anecdotal evidence is all you care to consider, I can introduce you to hundreds of patients, on methadone or buprenorphine, who are living happy, successful lives in recovery. You dishonor these patients and their journeys when you say they aren’t in real recovery.

But by now, with ever more data, and at a time when our citizens are dying from opioid overdoses in record numbers…if you can’t be helpful, please be quiet.

Sincerely,
Jana Burson M.D.

P.S. If you want to continue to promote yourself as some sort of recovery expert, please get some education. Go to some ASAM meetings, read a book like “Principles of Addiction Medicine,” or read some journals. You are embarrassing yourself, misleading your listeners, and ruining my life with your drivel. (OK, you aren’t ruining my life. But you are irritating me.)

Uncoordinated Care

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For readers who have come to expect breaking news and intelligent content on this blog, you may want to skip this week’s blog post and check back next week. This week…it’s pure bitch fest.

For my patients to get the best care possible, I must be able to talk to their other doctors. We call this “coordination of care.” Obviously, all of a patient’s doctors should know the complete medical picture of a patient: what they are being prescribed, what ailments are being treated, and so forth.

I had a pregnant patient, doing well on buprenorphine, who switched obstetricians. She wanted to deliver her baby in a town closer to her home, and was now seeing an OB I had never worked with or spoken to. I wanted to call the OB to see if she had any questions about buprenorphine. I also wanted to make sure this small hospital had buprenorphine on formulary, so they could dose my patient while she was in the hospital for the delivery of her baby.

After getting a release, I call this doctor’s office. Let’s call her Dr. M. I first spoke with the receptionist, and asked to speak with Dr. M about our common patient. She put me on hold for four or five minutes, then came back on the line to say, “Doctor is in with a patient right now. Can I help you?”

“I don’t think so. It’s about a clinical issue. Can I leave my number for her?”

“Why don’t you tell me what it’s about, so I can tell Doctor,” the receptionist said smoothly.

I thought this would be a waste of time, but obediently I said, “I wanted to make sure your local hospital carries buprenorphine in their formulary so my patient can be dosed with her usual medication while hospitalized for her deliver.”

“Bupa..what? I don’t understand.”

I say, “Yes, I really need to speak with Dr. M directly. Can you take my number and have her call me back?”

So I leave a message for her, and was pleasantly surprised when a got a call that evening from Dr. M’s office. But it’s not Dr. M. It’s one of her nurses, who asks what is my question for Dr. M. I say I don’t have any questions except I want to make sure Dr. M is comfortable caring for a patient on buprenorphine, and that I am the prescriber and that I want to make sure that the hospital will be able to dose the patient during her hospital admission.

A very long silence followed. Feeling some pressure to explain myself better, I repeat that I’m the doctor who is treating the patient’s opioid addiction with buprenorphine, better known under one of the brand names Suboxone and Subutex.

“Oh.” The nurse said.

There was a world of meaning in that one syllable. I got the feeling that the person on the other end of the phone now imagined I was a disreputable doctor who spent her days hiding in shrubbery until a pregnant woman walked by, at which time I would leap out and force opioids upon her. The nurse’s one word, “Oh,” meant I put pregnant women on drugs to get them high and put their babies into withdrawal. I was a doctor without honor, to be shunned.

There was a murmured conversation that I could still hear over the attempted muffling from a hand over the mouthpiece of the phone.

“Doctor M says don’t worry. She knows all about buprenorphine, because she’s been forced to deal with it so many times. She says the hospital has had to carry this drug on their formulary due to all drug addicted babies.

There is so much wrong with this statement that I’m momentarily too scattered to answer. First of all, babies can’t be addicted. They can be physically dependent, but not addicted. Addiction implies mental obsession, compulsion and loss of control over a drug, and obviously babies don’t have those features of the disease. Second, no one uses buprenorphine for the babies; it’s for the mother’s disease of addiction. Thirdly…and by the time my brain got to the third point, I was getting angry…your doctor appears not to know much about the treatment of opioid addiction in pregnancy. But I didn’t say any of this.

I gulp down my irritation and anger and merely say, “I’d like to talk with Dr. M so that I can be sure we’re both in agreement with this patient’s care.”

“I’ll give her your phone number. She’ll call if she has any questions.” With that, our call ended.

I was less than satisfied with the interaction, but unsure if I should risk calling back to demand Dr. M listen to me. Of course, Dr. M did not call me.

It’s not just obstetricians.

We had a pain and addiction clinic open up in our town recently. At least, their brochure says they treat pain and addiction (as if they are the same!).

Some of our patients have transferred from our program to that one, in order to get opioid prescriptions for pain. This doctor knows, or should know, that our program, an opioid treatment program, treats ONLY addiction. This means all of our patients have lost the ability to take pain pills as prescribed, due to the disease of addiction. And yet he has prescribed heavy opioid pain pills for patients previously doing well on methadone or buprenorphine, with predictably disastrous results.

I had one patient who transferred to him but quickly transferred back to us. She said she could tell after only a few weeks that she was taking her medications too fast, and it frightened her. She wanted to re-start methadone. I called the pain clinic doctor to make sure we were not duplicating care, and I wanted to talk about several issues with him.

First, I wanted to ask him to at least notify us when one of our patients became his patient. Otherwise, a patient could be enrolled in two treatment programs at the same time, because not all of our patients tell us when they start seeing him. I check my patients regularly on the prescription monitoring program, because it’s the only way I know when he’s prescribing for our patients. Second, I wanted to see if he understood that a patient with the disease of opioid addiction usually has lost her ability to take strong opioids as prescribed, without safeguards in place. I wanted to make sure he understood that very bad things could happen in such a situation.

It was a chore getting him on the phone but I finally succeeded. I was friendly as I gave him the patient’s name and said she was back at our program today, and that I wanted to…

He cut me off. “What can I do for you?” He said this is a weary, condescending tone.

OK, I thought. You want to be a jerk. “ I want you to stop prescribing opioids for this patient. She’s not able to take them as pre…”

“Fine. It’s not a problem.” He hung up the phone.

Well that was a brief conversation! Feeling vexed but not surprised, I reflected that I didn’t have a chance to educate him about the difference between pain and addiction, or ask him to give us the common curtesy to let us know when he took over the care of one of our patients.

I mentally wrote him off as uncooperative and went about my work.

A few weeks later, I was checking our state’s prescription monitoring program. I was appalled to find this doctor had AGAIN prescribed an extended-release morphine medication for this same patient a week after I talked with him on the phone.

I was so angry that my hair was on fire. I repeatedly called his office but got only a message that said the mailbox was full and I couldn’t leave a message. I must have called five times that morning.

After I finished seeing patients, I went to case staffing. This is where all of the staff meets to talk about patient triumphs and setbacks. During the session, I described my findings on the prescription monitoring program, and that I would have to talk to our patient again. It must have been obvious to staff that I was angry.

After we finished case staffing, I stood and informed my co- workers that I was going to drive to the pain clinic and give the doctor an earful, since I couldn’t reach him on the phone. I would talk with him somehow.

Apparently the staff didn’t think that was such a great idea, and two of them volunteered to drive to the clinic to “show me how to get there.” It was thoughtful of them, though I’m not sure if they went in order to keep me from acting a fool, or to see the show. Either way, I appreciated the backup.

So one counselor and one nurse drove to the pain clinic and I followed in my car.

Once in the parking lot I leapt from my car and slammed the door with unnecessary vigor. I marched to the front door, mind swirling with all I needed to say.

The door was locked! Damn. I shook the handle, and knocked on the door, but no response. I called their office number from my cell phone, and the message saying the recipient’s mailbox was full, try again later. It appeared they were closed for the day, though no hours were listed anywhere outside.

I was thwarted, and in hindsight it may have been a good thing. I don’t think I would have been very nice. I certainly would not have been physically aggressive, but I may have said harsh things I would regret later.

It’s impossible to coordinate care with this doctor, and I worry about my patients. Since they have the disease of addiction, it’s not fair to them to give them a big bottle of pain pills, enough for 30 days, and tell them to take as prescribed. It sets them up to fail. Many patients see that as their own personal failure, instead of what it is: mis-prescribing by the doctor.

Opioid treatment programs are held to a much higher standard than a doctor’s office that calls itself a pain clinic/addiction clinic. Opioid treatment programs have oversight by the DEA, by the State Opioid Treatment Authority, the state’s Department of Health and Human Services, and the state’s Division of Health Services Regulation. We are inspected by CARF (Commission on Acreditation of Rehabilitation Facilities). If the OTP takes Medicaid, add on several more layers of scrutiny. OTPs are inspected more heavily than any other health service provider.

Private doctors’ offices aren’t looked at by any of these agencies. A physician in private practice answers only to that state’s medical board and perhaps the DEA.

Is that enough? Depends on the doctor.

Starting Buprenorphine in the Emergency Department

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

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

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

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

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

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

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

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

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

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

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

Why do we treat the disease of addiction any differently?

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

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

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

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

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

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

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