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Pharmacists and Insurance Companies

 

 

Over the past few years, pharmacists have become important allies to my patients in medication-assisted treatment. I’m thankful for that, since it makes my patients’ lives easily, and mine. But recently, there have been some minor bumps in the road, made more pronounced because of their decreasing frequency.

Sometimes, I get cranky.

I got a message from my office staff person that a pharmacy had called because I didn’t write any dosing instructions on a prescription I had just written. “Wow,” I thought, “I must be losing my mind.”

We copy all prescriptions, so I looked at our copy. It looked complete, except under instructions, I’d written 1 ½ SL. I had neglected to write “Qd” which means once daily.

My bad. I should have written it. How else would a pharmacist be able to guess what the instructions are…except I wrote for #45, a month’s worth. And the patient has filled prescriptions for 1 ½ SL qd for about three years now, all filled every month at this pharmacy. Nope, no way for the pharmacist to decipher this riddle.

Well, I can’t really blame them; it was my mistake.

Last night I got a call from a patient who was enraged because the pharmacy was refusing to fill his prescriptions. I know this patient very well, and though he’s been doing well in recovery for about ten years, he can get angry if he misunderstands things. I told him I would call the pharmacy to try to figure out the problem.

I see this patient every two months, and my last prescription was written with a refill. He filled the first prescription a few days after I saw him. When I finally got to speak to the pharmacy manager, he said they had ordered the medication for the patient, and he would be able to pick it up the next day.

OK, I said, but that’s actually five days late, due to the pharmacy not having the medication in stock. The pharmacist didn’t seem disturbed that his patient would have been out of a life-sustaining medication for five days, so I asked why it was that the medication couldn’t be ordered so that it would be in stock when the patient was due to pick it up.

The answer shocked me with its honesty. He said the pharmacy didn’t want to risk getting ‘stuck” with the medication if the patient decided to go somewhere else to fill it, and that “these patients” flew from one pharmacy to another all the time, in order to save one dollar.

What I should have said…was something along the lines of, “You’re an asshole who shouldn’t be in the helping professions. Do you do the same thing to diabetics on insulin?”

What I did say was…nothing. I was so stunned at the lack of compassion that I didn’t say anything. I’m disappointed in myself for this, since I’m usually a little spicier. His honesty took me completely by surprise, as did his naked disregard for the well-being on my patient.

Then there was the phone call last week from a pharmacist who wanted to make sure the patient hadn’t changed the prescription. Again, this was a patient in recovery for years, whom I see every two months. I wrote her prescription for Suboxone 8mg films, one per day, #30, and I printed out “ONE” under the line for refills, as I’ve done for the past four years.

The pharmacist wanted to know if I had written a zero and the patient falsified and wrote the “NE” after it.

I suppose that’s possible, but I except I print very clearly, and the “O” that the pharmacist thought could be a zero was way on the left side of the blank for number of refills.

This problem that will go away after electronic prescribing, mandated by the state of North Carolina, is in place. I’ve stuck with old-school paper records and hand-written prescriptions for as long as I can, but that will be a thing of the past by January 1, 2020.

I’ve saved the most insane for last.

A local pharmacy called, stating that my one-month written prescription for a patient for suboxone films was partly voided because of the insurance company’s decision.

Huh? How does this happen, I wondered.

I’m still not sure, but here’s what I was told that the pharmacist was told by the insurance company representative.

The visit prior to this one, I had written only a two-week prescription. I don’t recall what was going on, but I needed to keep a closer eye on the patient, and changed from my usually monthly prescription.

Apparently, this was the root of the problem. I wrote for #45, a 2-week prescription. Then at this last next visit, two weeks later, I decided the patient could go back to monthly visits and wrote for #90. This caused a red flag on the patient, because he had now was trying to fill #135 films within a thirty-day period. Yeah…except for the patient already took the forty-five films during a two week period that was already past.

I can’t make this stuff up.

So his insurance company said nope, you can only get #45, which will make only #90 in a thirty-day period. And the pharmacy “cancels” the rest of my ninety day prescription.

Insurance companies would make the Buddha want to bitch slap someone.

I told the staff member who took the call, “Please get the insurance company’s physician reviewer on the phone. I’ve got to hear this logic. I also need to speak to the pharmacist. I want to know exactly who thought they had the right to cancel a prescription, written by a physician, for no medical reason.”

I was riled, and kind of looking forward to what could be a very interesting conversation. But it was not to be. When my staff called the pharmacy, this situation mysteriously resolved itself. No problem now. Patient can come by to get the other #45 films, and insurance won’t give him a hard time when he comes next month with a month’s prescriptions.

Despite these experiences, most pharmacists know how important buprenorphine products are to the recovering person, and are positive and supportive of my patients on medication-assisted treatment. There are far more of these than the pharmacists who have biases against patients on MAT. It’s just that the troublesome ones stand out by their behavior.

I am a peaceful person. I intensely dislike confrontation and can get along with almost anyone. But there are times, large and small, when I have to get out of my comfort zone and make some noise.

 

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Stigma and Substance Use Disorders

 

 

 

I’ve been thinking a lot about stigma lately.

Recently I was asked to do a short presentation about stigma against people with substance use disorders. I thought I could put something together easily to satisfy the intended audience.

But as I created power point slides with all the usual stuff, I dug a little deeper. I thought about how everyone in my intended audience probably already agrees that stigma is bad. What would I be telling them? Everyone was opposed to stigma, right?

But then I thought, if that is so, then why is there stigma? Or perhaps there’s only stigma in people who don’t have knowledge about the nature of substance use disorders. Perhaps the problem is lack of education, and after hearing facts, people won’t support stigma against those with substance use disorder.

I did internet searches about stigma in general and stigma specific to substance use disorders.

I went down some interesting rabbit holes, as one can easily do on the internet. I came across web pages that reminded me of something I’d read about ten years ago, by a physician, that was pro-stigma. I found it on my bookshelf and re-read it.

It was a peculiar chapter in a book about substance use disorder treatment, titled, “Addiction Treatment: Science and Policy for the Twenty-first Century,” edited by Henningfield et al. Just as I recalled, there was a chapter in that book that stood out from all the others, titled, “In Praise of Stigma,” by Dr. Sally Satel.

I’ll try to summarize her viewpoints without the sarcasm that begs to be included. In that chapter, Dr. Satel says stigma against substance use, and people that use substances, is a good thing because stigma discourages deviant behavior and has a civilizing effect on society. She says it’s a normal and necessary part of society. She views the behavior of people with substance use disorders as irresponsible and says it’s bad policy to “cleanse the addict’s image.”

She feels stigma encourages people to get help for substance use disorders, and that eliminating stigma will not make it more likely for people to get help for substance use disorders.

She says people who relapse back to drug use repeatedly is “…a behavior almost always under one’s control…”

Aha, I thought. That’s the key to understanding her point of view. She believes people with substance use disorders have at least some degree of control over their drug use. However, loss of control over substance use is one of the hallmark criteria for the diagnosis of substance use disorder.

It is confusing. Some people who use substances heavily can stop on their own, if given a good enough reason. Most Addiction Medicine experts don’t feel those people meet criteria for diagnosis of substance use disorder. But those are the people Dr. Satel is thinking of, and she fails to make a distinction between those two very different people. Of course, her conclusions are different from most of the rest of the field. She’s talking about apples and the rest of us are talking about oranges.

Her ideas may have some validity for people in the early stages of drug use. Just like the “Just say no” campaign of the 1980’s, early intervention can prevent formation of substance use disorder. But they are of little use when addressing substance use disorder.

To further complicate things, sometimes people with substance use disorders can partially control their substance use, or control it for a short time. Or they may have full control over one drug for a time, but no control over another drug. That’s confusing, and is why friends and family of a person with substance use disorder can become frustrated and puzzled by the behavior of the affected person.

It’s not as confusing when we think about other chronic medical problems. Nearly all have behavioral components, just like substance use disorders, and often we see the same partial/total loss of control over these behavioral aspects.

For example, a diabetic may be able to refrain from eating sweets on most days, but occasionally, perhaps on a stressful day, may eat several servings of sweets. Such a person usually faces less judgment from others, probably because so many of us have tried and failed to control our eating, and commiserate.

But imagine how much harder it is to control use of a substance that produces more intense feelings of pleasure – using substances that stimulate the pleasure centers of the brain much more intensely than eating or not exercising.

We can talk about whether stigma is deserved or not, but what about its effects? Does stigma make it more likely that people will enter treatment for substance use disorders? No, according to the limited studies done on this issue.

Studies of stigma towards people with mental illnesses show it results in unemployment, housing problems, impaired social functioning, lowered self-efficacy, and lowered self -esteem. One study (Joy et al., JAMA, 10/18/16) showed that people with mental health diagnoses are less likely to get appropriate medical care when they go to an emergency department for care for health problems.

Pregnant women with substance use disorders face the most intense stigma. They encounter harsh judgment from friends, family, law enforcement, and even medical care providers. The ultimate stigmatization is criminalization, and around half of the U.S. states have laws that say drug use during pregnancy is child abuse.

The trouble is, it’s harder for pregnant women to get treatment for substance use disorders. Pregnant women using drugs make doctors nervous. Either medical providers lack confidence in their ability to treat substance use disorder in women, or they are anxious about their legal responsibilities to report drug use during pregnancy.

Tennessee provides the best example of the harm that laws can do. In 2014, Tennessee passed the Fetal Assault Law, which said drug use during pregnancy was a crime. Over the two years this law was in effect, around thirty women were charged, almost all were poor and/or minority race. Some of the women who were charged had tried, multiple times, to access substance use disorder treatment, but were turned away. Only two of Tennessee’s one-hundred and seventh-seven treatment programs (at that time) provided pre-natal care and allowed children to stay with expecting moms, so there were few places for women to go when they did ask for help.

At the end of the two years, fewer women sought treatment for substance use disorder, and the law was allowed to sunset in July of 2016. Criminalizing drug use during pregnancy did not push women toward treatment, but away from it, out of fear they would face criminal charges if they sought health care during pregnancy.

It is interesting that Tennessee’s law covered illegal drugs, and not nicotine or alcohol. Ironically, we have more data about the harms caused by both legal drugs than about the illegal drugs.

Alcohol consumption during pregnancy is the number one cause of developmental disabilities and birth defects in the U.S. If the motive for Tennessee’s law was fetal protection, they might have included alcohol. But they didn’t; some drugs have more stigma against them than others, and some drug users have more stigma against them than others.

Thinking about stigma for my small presentation got me thinking about my own tendencies to stigmatize. I wish I could say that I don’t ever look down on other people for who they are or what they do, but that’s not true. I’m better than I used to be, and sometimes have enough insight to know what I’m doing and adjust my thinking, but the tendency towards judgmentalism is still with me.

When I stigmatize, I’m usually feeling fear – fear of people who behave differently than me. Stigmatization gives me the false sense that I’m superior to a certain group, that I’m protected from the judgment that they deserve. Stigmatization can be used to oppress certain people, or suppress a certain point of view. These motivations are not healthy. They damage the people I stigmatize, but they mostly damage me. It turns me into someone I don’t like, and that doesn’t feel good at all.

When I read Toni Morrison’s book “Paradise,” years ago, it helped me see why we stigmatize and scapegoat. That book, for me, vividly illustrated the human tendency to stigmatize and the tremendous damage it does to all concerned.

I wish all of us could resist the tendency to stigmatize, not only against people with substance use disorders, but against all groups. I pray at this difficult time in our history, we will resist the temptation to reject and stigmatize groups with whom we don’t agree. To use a quote from twelve step fellowships: “as long as the ties that bind us together are stronger than those that would tear us apart, all will be well.”

Indeed.

 

Diagnostic Overshadowing

Perspective

 

 

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

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

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

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

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

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

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

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

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

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

What do we do about diagnostic overshadowing?

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

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

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

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

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

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

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

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

 

 

Harm Reduction and the Clothing Police

“Oh I know that’s not a marijuana leaf on your cap!”

 

 

Image result for marijuana on cap in rhinestones

I had just ushered a young lady into my office. She entered treatment the week before, and I wanted to check on how she was feeling. When I called her from the waiting room, I noticed a rhinestone design on her cap with one part of my brain. I like bright sparkly things, so it caught my eye. But by the time we walked the short distance to my office, it dawned on me what the design was, and I confronted her about it.

“What? Yeah, it’s marijuana. Sorry. I didn’t even think about it.”

“What part of you thought it would be OK to wear clothing promoting drug use to your drug addiction treatment program?” I continued.

Usually I’m more complacent about clothing our patients wear. Some programs have minimal dress codes: no pajamas, nothing too revealing, must wear shoes, no obscene tee shirts… I’ve never gotten too worked up about clothing, thinking that as long as they came into the building, it was a victory.

But for some reason, on that day, I went a little nuts. What can I say, I have bad days too.

My patient was apologetic, but said it was the only cap she had. I told her she could turn it inside out, which she did without hesitation.

Before you are tempted to write in about how marijuana is really a medication and will be legal someday, let me tell you this: I don’t care. I’d feel the same way if I saw a large, legal, liquor bottle outlined in sequins, or a big sequined Opana pill on a shirt. It’s a symbol of drug-using culture.

Today, I’m conflicted. One part of me still thinks it’s not OK to wear clothing promoting any kind of drug use, and this includes alcohol. After all, we are treating patients in whom drug use has caused significant problems. Some of them could be triggered by symbols of drug culture. Is it too much to ask our patients to think about the message they send with their clothing?

Other addiction treatment professionals endorse similar ideas. If our patients are to return to mainstream society, don’t we have an obligation to educate them about traits that may still associate them with active drug use?

For example, is it possible my patient wasn’t aware of the message she sends with her bedazzled marijuana cap? If my patient wanted to go for a job interview, for example, would wearing this cap work against her? Maybe it depends on the job, but overall I would say the cap would hurt her chances of being hired.

On the other hand, if we view the situation with a harm reduction eye, isn’t it good enough at this point that my patient is getting treatment for her addiction? If a patient wants to get help for some aspect of addiction, isn’t that good enough? Maybe it’s unreasonable to expect a patient in treatment for a short time to start viewing her wardrobe with a recovery-oriented eye. Maybe such issues can be addressed later, in counseling, or maybe not, but perhaps I should concentrate on more important issues. Like helping her get through the day without illicit opioids.

A harm-reduction model would recommend meeting that person where she is now, in her THC-wearing mindset. Harm reduction is an idea that says any change that reduces the risk of drug use is success, and that we need to accept her as she is. We should respect our patient’s choices and help in any way she is willing. Any reduction around the risk of her addiction is an acceptable goal, even if it doesn’t conform to what I may view as “real” recovery.

The question is, or course, where do we draw the line? If it’s OK to wear clothing glamorizing drug use, is it OK to allow patients to tell glamorized stories of drug use in the waiting room? Is it OK to allow patients to use drugs on the premises? Is it OK for patients to use drugs on the premises? What about dealing drugs?

I endorse harm reduction principles, but have come to realize I have limits. The longer I’ve been doing this job, the more enthusiastically I approve of harm reduction principles. However, I still draw the line when one patient’s behavior affects the other patients. That’s why I won’t tolerate drug dealing on the premises, patient violence (against other patients or staff), or drug use on OTP grounds. But that’s a hard call to make, and it’s a decision best made at case staffing with input from other staff.

Harm reduction is a difficult idea for many of us. What one person sees as harm reduction, another sees as enabling. Here are some other quotes I’ve heard from other people. I’d like to give credit, but my memory’s not that great.

 

“Don’t allow the perfect to be the enemy of the good.”

“The enemy of the best is the good.”

“It’s OK to meet a person where they are, but it’s not OK to leave them there.”

“I don’t promote drug use. I don’t promote car accidents either, but I still think seatbelts are a good idea.”

“Dead addicts don’t recover.”

 

Readers, any thoughts?

Taking a Break

Medicaid’s Limits for Non-compliance

 

The opioid treatment program where I work accepts Medicaid as payment, starting a few years ago. Overall, it’s been so beneficial for hundreds of our patients. However, when Medicaid patients have repeatedly positive drug screens, Medicaid overseers threaten to cut off their funding for treatment.

Our state’s Medicaid system is divided into counties, and these counties contract with agencies to provide oversight for the mental health and substance abuse treatment dollars. I’ve had several conversations with the doctors who do peer review for payment to our program.

We discuss patients’ progress, and whether more Medicaid money will be approved for their treatment. This agency says they have the right to cut off payment for treatment of Medicaid patients who don’t become drug-free within a reasonable period of time. So far, they haven’t cut off payment for any patients, but we have many patients at risk for this. If patients lose Medicaid coverage, they can remain in treatment with us, but have to pay out of their own pocket.

I feel torn about this issue.

On the one hand, I know my patients will do better if they are able to stay in treatment on MAT. If Medicaid quits paying for their treatment, many will leave treatment and go back to illicit drug use. I know from various studies that patients who leave MAT have high relapse rates. Relapses back to illicit opioid use can cost more to the Medicaid system than staying in treatment. Plus, patients who leave treatment are at greater risk of overdose death.

On the other hand, as a taxpayer, I understand why people object to using tax dollars, in the form of Medicaid, to pay for addiction treatment if the patient is still using illicit drugs. Some people may feel this is a government subsidy to continue drug use.

Most people feel we do have an obligation to the disabled and the poor to provide medical care. But should we apply different criteria for payment of substance use disorder compared to other chronic medical illnesses, which also have behavioral components?

The doctors who decide when to stop paying for MAT could use similar criteria to decide when to stop paying for other medical care of chronic illnesses.

Imagine this conversation:

“Hello, this is Dr. X. I am calling regarding approval of payment for the treatment of Mrs. Sweet, the diabetic you are seeing. I’ve authorized ninety days more of payment for her, but if her blood glucose readings and her hemoglobin A1C don’t improve, I will be recommending we stop paying for her treatment. She will have to pay for her diabetic medication and her medical care from her own pocket.”

“I don’t understand. I’ve been treating Mrs. Sweet for years…her diabetes is about as well-controlled now as it has been for years.”

“Our point exactly. She isn’t showing any improvement. You told her to follow a diabetic diet, lose weight, and exercise, and she hasn’t done any of these things. If she’s not willing to follow physician recommendations, Medicaid won’t approve payment for the medical care she needs for diabetes.”

Can you imagine the outrage at such a decision?

Let’s use an example of another chronic illness: heart disease. Let’s say I have a patient who has coronary artery disease. He had one heart attack and had to have a coronary stent placed. He has very high cholesterol, but despite dietary instructions, he continues to eat fatty foods and plenty of red meat. He also isn’t compliant taking his cholesterol medication.

He has another episode of chest pain, goes to the hospital, gets admitted with another heart attack, but the Medicaid overseers say his medical care will not be paid for, since he hasn’t made the changes recommended by his physician.

Are these scenarios starting to hit a little close to home?

Let’s be careful when we start deciding who deserves or doesn’t deserve to have their medical treatment paid for, if we use behavioral change as the yardstick for such decisions. Few of us with chronic illnesses do everything perfectly.

It’s part of human nature.