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.