Archive for the ‘Doctors Behaving Badly’ Category

This Should Never Happen

 

I had a frustrating admission to the opioid treatment program last week. The patient wasn’t frustrating; she was delightful. Her experience with the healthcare system was frustrating and disappointing.

This nice lady (details have been changed to protect her privacy) has been going to a local pain management group for several years, with some success. About five months ago, she expressed a desire to taper off her prescribed opioids because she didn’t like worrying about running out of medication. She thought if she worried about withdrawal, it was a sign of opioid use disorder (which she called addiction).

The pain clinic provider listened to her concerns, then switched her to Suboxone in divided doses. It’s not clear if the provider thought the patient had evidence of opioid use disorder, or if he thought switching the patient to suboxone would help manage symptoms of pain, or if he was trying to keep the patient happy.

At any rate, the patient felt well on a relatively low, divided dose of Suboxone. She was able to go about her daily business with relatively less pain for some months.

Then she unexpectedly became pregnant.

That’s when the problems began. The patient says her prescriber got excited about her treatment, and what should be done during her pregnancy. This doctor told her the suboxone could damage her pregnancy and he couldn’t prescribe for her any more. She was also told it was very dangerous to come off Suboxone while pregnant.

As an aside, I need to inform readers that in the past, only the monoproduct buprenorphine was approved for pregnancy. Researchers and physicians worried the combination product, with both buprenorphine and naloxone, could cause withdrawal and side effects. Now, I have information from experts that the combo product is just as safe as the monoproduct. Professionals at the University of North Carolina’s Horizons Program, which treats pregnant women with opioid use disorder, say that the combination product, buprenorphine with naloxone added, can be safely used. This program, which was part of the landmark MOTHER trial back in 2010, has done renowned work for years.

Anyway, after hearing conflicting information from her pain management physician, the patient didn’t know what to do. She was terminated as a patient at this pain medicine practice because she became pregnant, but also told that if she stopped taking Suboxone, it could kill her unborn child. The pain clinic referred her to office-based prescribers of buprenorphine products in a nearby city.

When she called these practices, she was asked questions over the phone about her opioid use disorder. The patient answered honestly, but she was turned down for treatment since she didn’t meet criteria for opioid use disorder.

Not one of her providers or potential providers mentioned going for evaluation at an opioid treatment program. Her obstetrician didn’t give specific instructions for her, instead telling her to taper off her Suboxone if she could.

Thankfully the patient had a friend who knew about our opioid treatment program. This friend thought we could either help this patient or tell her where to go for help.

A day or two after the patient called our opioid treatment program, I did an admission history and physical exam for her. This means I listened to her complete history of opioid use, asked questions for clarification, and did a limited physical exam. When we finished, I told her I didn’t think she met criteria to be diagnosed with opioid use disorder,

How did I come to this conclusion? I asked a series of questions to determine if she met the criteria for opioid use disorder. She had tolerance to and withdrawal from prescribed opioids, but that’s not enough to meet diagnostic criteria. She hadn’t misused her medication by snorting or injecting and hadn’t taken more than prescribed. She didn’t use extra opioids from friends or family and didn’t ever run out early on her medications. She didn’t overuse her medication to the point of intoxication and didn’t use her medications to treat emotional states. She didn’t use alcohol to intensify effects. In short, she wasn’t my average patient.

But what was she supposed to do? Abandoned by her pain management physician, she was in a pickle. Clearly, continued treatment with buprenorphine, either mono or combo product, was the best thing for this patient and her fetus. Since she didn’t seem to have any alternatives, I admitted her to our opioid treatment program. It was the right thing to do.

I took her dose back to the 8mg per day that she’d been on, and I saw her again this past week. She felt fine, with no withdrawal, and we talked more about what to expect while on buprenorphine during pregnancy. I think she will do very well.

After she delivers, she can seek treatment at a pain clinic if that’s what she desires. Right now, she plans to taper off buprenorphine after delivery. That may work well, though tapering with a new baby at home sounds daunting to me. We will help her with whatever she desires.

We aren’t a pain clinic, and the once daily observed dosing isn’t necessary for this patient who has not developed opioid use disorder. It’s a much more intense level of care than she really needs. But we were willing to help her until she can find a better solution, for her well-being and the well-being of her baby.

She was thankful to have a solution and some answers but puzzled as to why other providers didn’t want to help her.

Pregnant ladies taking opioids, with or without opioid use disorder, are hot potatoes, at least in my region. No one wants to take care of them, so they get tossed to one provider after another. This patient’s experience is common.

You would think, now a few decades into this opioid use disorder epidemic, that we would have evidence-based guides to the treatment of these patients. We do, but providers are still reluctant.

Doctors get nervous about pregnant women taking drugs, licit or illicit. They fear extra liability comes with the extra person, the fetus. For many physicians, pregnant ladies are someone else’s problem, preferably their obstetricians’.

But obstetricians in this area, with rare exceptions, don’t want to take care of the substance use disorders. Some providers still think people who develop substance use disorders are bad people, or have bad morals, or are weak-willed. They prefer their patients take their drug use somewhere else for treatment.

How could this have been handled better?

I think the pain clinic should have continued to treat this lady with no interruptions in her care. They should have communicated with her obstetrician and coordinated care with the obstetrician. They should have been given the information that it’s now acceptable to continue the patient on Suboxone, and that pregnant patients don’t necessarily need to switch to the buprenorphine monoproduct, although that would have worked fine, too.

If the pain clinic physicians couldn’t manage this patient, they should not have dropped her until/unless they found her a new provider, instead of giving the patients a few phone numbers to call to seek help on her own. It felt to the patient like they were punishing her for becoming pregnant.

This opioid use disorder epidemic started about two decades ago. How long is it going to take for medical providers to learn how to manage or refer patients with opioid use disorder for proper care?

It’s kind of like flying a plane…if you don’t know how to land, maybe you shouldn’t take off in the first place.

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Criminally Pregnant, Again: Tennessee’s Fetal Assault Law Won’t Die

 

 

Tennessee lawmakers are trying to revive a version of the Fetal Assault Law, originally passed in 2014 but allowed to sunset in 2016, after the state saw worsening outcomes for pregnant moms and babies. [1, 2]

I wrote two blog entries when this law was first passed – you can read “Criminally Pregnant in Tennessee” Parts 1 and 2 from April 12, 2014 and April 26, 2014. The second blog entry was supposed to be satirical. (I won’t try that again, after two out of six commenters thought I was being serious about putting the “addicted babies” in jail.)

This is the proposed law, in part: Notwithstanding subdivision (c)(1), nothing in this section shall preclude prosecution of a woman for assault under §39-13-101 based on the woman’s illegal use of a narcotic drug, as defined in Section 39-17-402, while pregnant, if the woman’s child is born addicted to or harmed by the narcotic drug and the addiction or harm is a result of the woman’s illegal use of a narcotic drug while pregnant,”

To summarize, the Fetal Assault Law says that a pregnant woman can be criminally charged if her baby is born addicted to or harmed by an illegal drug used by the woman.

The wording of the bill is scientifically wrong, of course. Babies can’t be born addicted, since addiction is diagnosed only in the presence of obsession and compulsion to use the drug despite adverse consequences. Babies don’t have obsessions or compulsions, and even if they did, we wouldn’t know it. But I know what lawmakers meant. The lawmakers likely meant to say, “physically dependent,” but lack knowledge about substance use disorder science to know the proper terms.

These types of laws are nothing new. We know the problems that occur with these laws, and Tennessee should learn from examples from the past – their own recent past.

Amnesty International released a 69-page report in 2017, titled “Criminalizing Pregnancy: Policing Pregnant Women Who Use Drugs in the U.S.” This report summarizes research about laws that criminalize behaviors during pregnancy and give some overall data, but the report focused on two states: Tennessee and Alabama.

https://www.amnesty.org/en/documents/amr51/6203/2017/en/

It’s an interesting report, and worth a read. I wish Tennessee lawmakers would read it, because they would have more information about what happened during the two years the Fetal Assault Law was enacted in the years 2014 – 2016.

According to the Amnesty International report, here are the biggest problems seen under the law:

Deterrence of prenatal care: Predictably, pregnant women are less likely to seek prenatal care if they are using drugs and fear being arrested. Even the women who did seek prenatal care were sometimes drug tested without their consent and even without their knowledge.

Uneven application of the law: Some areas of Tennessee had far more cases charged than others, because of the decisions of the local prosecutors. A total of around one hundred women were charged under the Fetal Assault Law, mostly in the eastern part of the state, where there are few treatment facilities available for pregnant women, and in Memphis, in the far western part of the state.

Also, nearly all the women charged in Tennessee were either poor, minorities, or both. The county with the highest number of women charged under the Fetal Assault Law (Shelby County, where Memphis is located), was also ironically a county with lower rates of drug-exposed newborns than other parts of the state. However, that county’s residents are predominantly African-American. It looks as if the prosecutor in that county was more zealous about charging women under the Fetal Assault Law.

Adding to the problem, drug testing policy during pregnancy isn’t uniform. Poor and minority women are more likely to be drug tested, with one study showing that black women were 1.5 times more likely to be tested than non-black women, despite drug use rates that are approximately equal between races. Black women testing positive were ten times more likely to be reported to authorities than non-black women. (Kinins et al., 2007, Chasnoff et al., 1990)

Lack of availability of treatment: Ironically, more women were charged under the Fetal Assault Law in areas with fewer available treatment options. Even when pregnant women with substance use disorders desired treatment, there were few options. Only 19 of Tennessee’s 177 treatment centers open during 2014-2016 treated pregnant women. At the time this law was active, there were no opioid treatment programs in Eastern Tennessee. Even in parts of the state that had opioid treatment programs, the state-funded TennCare program doesn’t pay for methadone treatment during pregnancy, which is the standard of care as noted by experts in the Addiction Medicine field.

The Amnesty International report tells of one woman in Tennessee who tried for three months to access treatment but was turned down repeatedly. She was charged under the Fetal Assault Law.

According to calculations, even if all available treatment beds were set aside for pregnant women with substance use disorders, those resources wouldn’t cover even half of the existing need.

I hope Tennessee doesn’t go backward and re-enact this Fetal Assault law. Since substance use disorders are illnesses, it makes more sense for these women to get treatment, not jail time.

After all, that’s how we treat alcohol abuse and cigarette smoking during pregnancy. We have far more data about harm done to the fetus from maternal smoking and drinking alcohol. But because these substances are legal, they are dealt with as a public health issue. Obesity also affects the outcome of pregnancies. In one article, the dangers of maternal obesity were outlined, and the authors concluded, “Even modest increases in maternal BMI were associated with increased risk of fetal death, stillbirth, and neonatal, perinatal, and infant death.” [3]

I doubt lawmakers would be comfortable setting laws around how much weight a pregnant woman can gain. But if their main concern is fetal well-being, and if they think criminalizing behavior is a way to fix problems, who knows? Maybe next year Tennessee will be patrolling obstetricians’ office for obese pregnant ladies.

  1. http://www.wmcactionnews5.com/2019/02/12/tennessee-bill-revive-fetal-assault-law-would-prosecute-women-who-use-drugs-during-pregnancy/
  2. https://www.npr.org/2016/03/23/471622159/tennessee-lawmakers-discontinue-controversial-fetal-assault-law
  3. Aune, et al, “Maternal Body Mass Index and the Risk of Fetal Death, Stillbirth, and Infant Death: a Systematic Review and Meta-analysis,” JAMA, 2014; 311(15):1536-1546.

Advice for New Prescribers

 

 

 

The medical care providers of this nation are being encouraged get training necessary to prescribe buprenorphine products (brand names Suboxone, Zubsolv, Bunavail, Sublocade, and the generics) for the treatment of opioid use disorder in their patients. We need more good prescribers, because even after twenty years into this opioid situation, only about twenty percent of patients who need treatment can get it.

I’ve written on this topic a few times in the past, but this blog entry will contain some advice directed to new prescribers of buprenorphine products. Hopefully it will help them have good experiences prescribing medication-assisted treatment.

Here are some ideas that work for me at my office:

Treat the patient with opioid use disorder with the same attitude and compassion that you would for any other patient with a potentially fatal chronic illness. If you can’t do that, then don’t treat patients with substance use disorders. Patients detect negative attitudes such as distain and dislike even when those attitudes are communicated non-verbally. For whatever reason, if you can’t put judgment aside, then work on your own issues before you attempt to treat suffering people trying to get well.

Patients will resent a physician with a bad attitude. That will contaminate the relationship with predictable results.

For example, I talked to one physician who had his waiver to prescribe buprenorphine from an office setting. I asked him why he wasn’t using his waiver to treat patients, since there were so many in our community that needed help.

He told me the visits with the first two patients went poorly. He said both these patients threatened his life and the lives of his family members. After that, he decided not to risk treating anyone with opioid use disorder.

I was shocked. I’ve never, in the thirteen years I’ve been prescribing from an office practice, had any patient threaten my life, though I’ve made some angry at me. I had to wonder what kind of bedside manner this doctor had, for his first two patients to want to kill him. That sounds like I’m blaming the doctor, and maybe I am, but his experience was so contrary to my own that I had to wonder what was going on. I suspect his patients didn’t feel respected by him.

I’ve had one patient threaten me with bodily harm, but that was at an opioid treatment program in Gastonia, NC, more than a decade ago. The patient was an avowed KKK member, tall and large, with tattoos of hate groups on his muscular arms. I might have been worried, except at the time he threatened me, he was so impaired on benzos that I could have pushed him over with a finger. I’d just told him he couldn’t dose with methadone that day, due to impairment. The next week, he greeted when we passed in the hall. I assume he had been in a blackout from his benzodiazepine ingestion the week before and didn’t remember our previous interaction.

Be clear with your patients about your expectations. At the first visit, I sit with the patient and go over a patient agreement form. I adapted it from a SAMHSA website where you can find helpful forms, tools, and ideas.

https://pcssnow.org/resources/clinical-tools/

https://www.samhsa.gov/medication-assisted-treatment/training-resources/publications

In that agreement, I outline my expectations. I have paragraphs indicating that disruptive or violent behavior won’t be tolerated and are grounds for immediate dismissal from my practice. In thirteen years, I’ve never had one patient become rowdy or disruptive. Having said that, I do realize other prescribers have had different experiences.

I ask patients to keep and be on time for appointments, and if they don’t show up and don’t call, they will be charged for the missed visit. I tell patients I won’t call in prescriptions if they miss a visit. Having said that, I’m also flexible enough to know that things do come up – cars break down, traffic jams occur, etc. In the winter, travel can be treacherous, so that’s another factor to be dealt with. All I ask is that the patients communicate problems early so we can find a reasonable solution.

Patients who miss appointments, don’t call, and won’t answer our calls to find out what’s going on will have problems at my practice. It may or may not be their fault, but if it doesn’t work out they will need to find a new provider.

My agreement also says I won’t “fire” a patient before I talk to them face-to-face. Patients tell me they’ve been dismissed by a practice by letter, for some issue or another. I think that’s cowardly, and disrespectful to the patient. If there’s a reason I feel I can no longer to continue treatment as we are, I owe it to the patient to tell them exactly what the problem is. Sometimes we can find solutions short of termination and sometimes we can’t. At least the patient will know I respect them enough to talk to them, and they will know the basis of my decision. They will also get a referral to a new provider, or at least a recommendation.

Be careful with patient selection and try to match the patient with the best level of care.

Not every patient will do well in an office-based setting. For example, if a patient has been using buprenorphine products illicitly by insufflation or injection, that patient probably is best treated in an opioid treatment program, where observed dosing is done.

Most patients need to be on the combination products buprenorphine/naloxone. Adverse reactions do occur with the monoproduct, but they are rare, and drug diversion is not. If a new patient needs the monoproduct, I refer them to an opioid treatment program where they can be properly observed.

If that patient has been treated in another office-based setting with medical records that support their progress and compliance on the monoproduct, my recommendation would be different. Many factors influence my treatment decisions, so I need all the information I can get to make the best decisions.

This leads me to my next recommendation: get old records. Make the effort to get records from a previous practice. Sometimes patients, to curry favor with a new prescriber, will tell tales about how awful their last prescriber was. That may be true…or there may be more to the story, so get records to get a better idea of what happened at the last practice.

Don’t falsify your own records. It’s unethical and probably illegal to bill for services you document but don’t provide. To get higher insurance reimbursements, physicians sometimes chart long review of systems and/or physical exams than were performed. This is called “up-billing.” I suspect up-billing when I see records with four pages of single-spaced type for each visit, but then notice the same four pages for each monthly visit, with no changes.

I blogged before about a patient whose records recorded an exam saying “consistent with eight-month pregnancy” for every monthly visit for over a year. Yeah…kind of suspicious…using that cut-and-paste feature, I think.

If you do telemedicine, make sure you have some sort of medical personnel on site with the patient to look for physical finding you may miss with telecommunications. I just admitted a patient to our opioid treatment program who had been on Suboxone for six months from a provider he only saw online. This patient was injecting his medication, but his prescriber couldn’t see it. His most prominent tracks were on the side of his neck, which could be hidden with a high collar. Obviously, this could have ended in disaster had the patient not realized he needed a higher level of care.

Be careful about lab schemes. If a laboratory diagnostic service is charging patients $500 for one drug screen, it’s probably a scam. In past years, these organization popped up like mushrooms in manure, saying they could do extensive lab testing for all patients, but only charge those with insurance. Uninsured would get free testing.

As it turns out, some of those companies charged outrageous fees to the insurance companies, including Medicaid and Medicare, for expensive and unnecessary testing, in get-rich-quick schemes. Here’s a link to an article that explains how this works:

https://www.healthcarefinancenews.com/news/report-urine-based-drug-tests-helping-some-doctors-soak-profits

Good providers don’t want to sully their name by associating with shady laboratory service providers. Physicians can do good point-of-care testing on site for $10 or less. Sometimes patients need more extensive testing, and this can be decided on a case-by-case basis rather than testing every patient for dozens of drugs that aren’t commonly used in the community where you practice.

Be aware of what drugs are trending in your area and make sure they are included in your drug testing protocol. In the past, heroin was rare in rural areas, but that’s changed. As I’ve discussed on this blog, heroin frequently contains fentanyl, a much more powerful opioid that’s responsible for many overdose deaths.

Ask your new patients what drugs are being used in your community. They can be great sources of information, as can local addiction medicine educational conferences, and your local law enforcement officials.

Make friends with the medical director at your local opioid treatment program. Most physician medical directors at opioid treatment programs are happy to work collaboratively with office-based providers. We share patients all the time and need to do what’s best for the patient. We don’t need to look at each other as competitors, because there are more than enough patients for everyone, unfortunately. Let’s work together to get people into treatment, and to match the patient with the right level of care.

It can be a relief for an office-based provider to know they have a facility willing to deliver a higher level of care when necessary. Sometimes the patient may need inpatient treatment, but at other times it might be an opioid treatment program, where the patient may come daily for dosing and oversight.

Again, some patients, in an effort to curry favor with a new prescriber, may talk disparagingly about another treatment facility, so don’t take a patient’s word that an opioid treatment program does an awful job.

Decades ago in my previous life as a primary care physician, I learned that the new patient who tells me how wonderful I am compared to their last terrible doctor will soon be saying the same thing to another new doctor, about how terrible I am. I know there are terrible doctors, but there are also some patients that can’t be pleased no matter how good the physician.

Finally, get involved with organizations that can help you. You don’t need to re-invent the wheel; as I mentioned above, help is available from several sources.

Go to the SAMHSA website mentioned above and you will find helpful resources. Or you can go to the American Society of Addiction Medicine website for information: https://www.asam.org/  You may decide to go to one of their excellent conferences.

Go to the Providers’ Clinical Support System (PCSS) website and search their educational offerings at https://pcssnow.org/ They have archived webinars, mentoring programs, and other great things available.

If you work in North Carolina, there is the UNC ECHO program, which offers live teleconferences three days per week on issues surrounding medication-assisted treatment of patients in the office setting. You can hear cases presented and listen to input from experts and other prescribers, while getting free (yes I said free) CME hours. Once involved, you can present your own difficult cases to get help with difficult patient situations. You can go to their website at: https://echo.unc.edu/ or leave me a comment with your email and I can connect you to the organization.

It can be difficult to persuade new prescribers that treating patients with opioid use disorder is rewarding and fun. I became a physician because I wanted to help people, sappy as that sounds. I didn’t feel the sense of satisfaction during the decade I worked in primary care, for whatever reason, that I now feel working in the field of Addiction Medicine.

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.

 

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