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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.

 

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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.

Mismanagement of Opioid Use Disorder

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I’m going to give an overview of what happened to one patient with opioid use disorder, changing enough details to keep people from recognizing the person. I’ve changed non-essential data, but not the medical facts as I learned them from the patient. The facts were confirmed by medical records that I obtained from two local hospitals, a local cardiologist, and a teaching hospital. I could not get records from the mental health clinic that is mentioned because none were made. All of this happened a few years ago.

This 31 year-old man had years of opioid use disorder which progressed to intravenous use for a little over a year before he started feeling ill. He went to his local hospital and was correctly diagnosed with endocarditis, which is a serious and life-threatening infection of the delicate valves of the heart. He was transferred to a teaching hospital, had a surgical repair of a heart alve, given six weeks of antibiotics, and sent home.

He says no one mentioned any sort of addiction treatment, but he admits he probably would not have agreed to treatment anyway. He also admits it’s possible he just doesn’t remember and treatment was discussed. His records contain no mention of substance use treatment referral upon his discharge from the hospital.

About a year later, he was re-admitted to our local hospital with fever and suspected endocarditis. His attending physician in the hospital started treatment with appropriate antibiotics but correctly identified he needed to be seen by a specialist too. As his medical record reveals, two teaching hospitals refused to accept this patient in transfer because he had no insurance, no money, and because he didn’t quit using drugs after the first illness. The physicians that could have accepted the patient in transfer said they don’t want to waste resources treating him again.

His admitting physician explained all of this to the patient. Since it appeared he would die without surgery, Hospice care was arranged to ease his remaining days. He was sent home to die. Somehow, qualifying for Hospice care also got him approved for Medicaid.

After his Medicaid came through and he’d been on antibiotics waiting to die for some weeks, he started wondering what would happen if he arranged an appointment with a cardiologist on his own. Since he now had Medicaid, he was able to make an appointment with a local cardiologist. Though he hadn’t died yet, he was very sick, with fluid building in his lungs and backing up into his feet and legs.

I got the cardiologists’ records, and between the lines I could sense he had been as puzzled as I was now– why was this man turned down for medical care? The cardiologist correctly suspected the patient didn’t have a severe endocarditis, since he probably wouldn’t still be alive at that point. He arranged a referral to a cardiologist friend of his at the local teaching hospital, and a more sophisticated evaluation was done. It showed a hole in the patient’s heart. Blood was flowing in the wrong direction, causing heart failure and severe shortness of breath.

The patient was admitted to the hospital and had a procedure to patch this hole. As it turned out, this procedure could be done without open-heart surgery.

All is well, right? Nope. The original problem, opioid use disorder, has still not been comprehensively treated, although this teaching hospital did at least give this patient a few days of buprenorphine during his short hospitalization. He was told to follow up with a Suboxone doctor in his area.

He tried. He called several office-based buprenorphine physicians in his area. But he had Medicaid, and couldn’t find a doctor to accept this form of payment, or else the few that did accept Medicaid didn’t have appointments for many weeks.

He relapsed to intravenous opioid use, and became sick with fever, had trouble breathing, and went to his local hospital’s emergency department. He was given some fluids, some antibiotics for “pneumonia,” and told to go home.

Before he left, he asked if he could be referred for treatment of his addiction, and was told he would have to go to the local mental health provider that contracts with Medicaid in his county.

He went in person to that facility the next day, and asked the receptionist if he could be referred to the local methadone clinic. He was told they didn’t make referrals to the methadone clinic, so he left, discouraged. He never imagined it could be so hard to get treatment for his addiction.

He continued to feel very bad, with fevers, cough, and then developed severe back pain. He went to another local hospital’s emergency department, was again told he had pneumonia, and that he needed different antibiotics. He was sent home from the emergency department, but went back a few days later, when his back pain worsened.

He says he got the feeling the hospital personnel felt he was drug seeking for pain medication. He admits he did want pain medication, but mainly because of severe back pain. He was told to be patient, and give the antibiotics time to work.

The day before he came to our opioid treatment center, he went back to the first local hospital with fever, back pain, and trouble breathing. He was told for a fourth time that he had pneumonia, and was sent home with new antibiotics.

He got the address of our opioid treatment program from one of his friends, and came in person to see if we could help him. Since I wasn’t there that day, we set him up with an intake appointment for the next day, and he arrived bright and early to start the intake process.

When I first laid eyes on this patient, my impression was that he was seriously ill and not stable enough to start treatment with us that day. He looked bad. However, I listened with fascination to his entire story, which he told in short bursts of conversation between gasping breaths.

I didn’t want to start treatment. I wanted to get him to a teaching hospital as quickly as possible. He was sweaty, breathless, wincing in pain and clutching his back, and running a low-grade fever. He did have sounds in his lungs consistent with pneumonia, but at this point he’d been on antibiotics for over a week. Clearly something more than pneumonia was going on.

But I knew I could not turn him away without doing something for him. More as a gesture than as a real treatment, I gave him an induction dose of buprenorphine and sent him to the teaching hospital, located about an hour from us.

I got a call back later that day from the resident physician who admitted this patient. The severe back pain that my patient had reported at four hospital emergency department visits turned out to be osteomyelitis, which is a bacterial bone infection needing antibiotic treatment for several months. He also had an abscess on the spine nearby the infected bone. The bacteria they finally cultured was methicillin-resistant Staph aureus, also known as MRSA.

He spent months in several hospitals. He had to undergo a debridement of the bone to get rid of infected and dead material, and had to be on very heavy intravenous antibiotics for a prolonged time.

Because he had been started on buprenorphine at our opioid treatment program, I convince the residents they could continue that medication, and gave some suggestions for increasing it a little bit.

Finally, he was healthy enough to leave the acute care hospital to go to a physical rehabilitation hospital, where he stayed for about six weeks. Thankfully, since he had already been started on buprenorphine, these providers were also willing to continue his medication. He was re-admitted to our opioid treatment program the day after he was discharged from the physical rehab hospital so that we could continue his treatment.

He had to have strong opioids early in his hospitalization but by the time he came back to our OTP, he was only on buprenorphine 8mg sublingually per day. I did have to increase his dose a little for fine-tuning, and he’s been healthy ever since, with no positive UDS, no illicit drug use.

He looks fantastic. He’s healthy, energetic, and works every day. He’s usually smiling, and he makes me smile too. I don’t think he’s using any illicit opioids for many months.

He asked me a difficult question. He wanted to know how his medical treatment could have been better. I told him that I had the luxury of hindsight and the pile of his medical records, but I did see some mismanagement of his care. I told him these were the things that bothered me about his treatment:

  1. He was turned down for medical care when he came to his local hospital for what they thought was endocarditis. It turned out to be something different, but the small hospital didn’t have the technology to diagnose and manage the problem. They did the right thing by attempting to transfer him to another hospital, but were refused. I don’t know what recourse a physician at a small hospital has if teaching hospitals refuse to accept a patient, and I’m sure this patient was refused because he had drug addiction, and judged as a person not worthy of care.
  2. There was an appalling lack of attention to his underlying medical disease that fueled all of his medical problems. He should have been told about buprenorphine and methadone as treatments for his problem, and referrals should have been made. Ideally, he should have been referred after his endocarditis infection, or by any of the half-dozen doctors who saw him after that. Then even when he specifically asked for referral for that sort of treatment, the mental health facility missed an opportunity to help this man, saying they didn’t refer to the methadone clinic.

Believe me, we notified people who supervise this mental health facility about their failure to act, and what we thought of this failure. We have been assured this will never happen again.

3.This patient sensed an attitude of distain in his caregivers, and I also sensed it in the wording of the documents from the hospital. The emergency department records are sketchy, with little documentation of the medical reasoning of the attending physician. I worry that the physician saw the patient as a bad person seeking drugs, rather than a sick person with a treatable illness. I know I’m sensitized to this issue, so it’s possible I’m jumping to the wrong conclusion.

I’ve tried my best to talk to local physicians. In a few enjoyable exceptions, I’ve had great responses and cooperation. In other cases, I’ve had rude responses. Most responses are neutral, neither rude nor friendly, and I sense a disinterest in the topic.

I wish all of the doctors who treated this patient when he was sick with opioid use disorder could see him now. He’s a happy and productive member of society, and yes, he does plan to stay on buprenorphine indefinitely. I support that decision.

This patient, and hundreds like him, are why I love my job.

Mandated Training?


 

 

 

 

It looks like 2017 is going to be the year of governmental solutions to the opioid use disorder problem.

I blogged last week about the regulation passed by the Virginia Board of Medicine. Now there’s a proposed bill making its way through the NC legislature, advocating new laws to help solve the addiction problem. Legislators certainly have their hearts in the right place. I agree with many parts of the proposed bill.

But now, I’d like to suggest a new regulation: ask all doctors to take an eight-hour course on opioid use disorder and its treatment with medication-assisted treatments, as a prerequisite to renewing their licenses.

I can hear my colleagues already howling with indignation. I’d feel the same way if I were them. It’s hard to admit you don’t have the education you need in an area of medicine. But this specialized area of medicine powerfully influences nearly all other subspecialties of medicine, so the consequences of neglecting the disease of addiction can be enormous.

Before I listen to my fellow physicians’ protests, I’d like to give examples, from my own community, of some things medical providers have done with patients prescribed opioids, and with patients who have opioid use disorder. I believe they all could have been handled better. Patient details have been changed to protect identities.

Example number one:

One of my patients needed to have surgery on his lumbar spine. He went to see the orthopedic specialist and was told he had to taper off methadone before the procedure could be done. I asked my patient why the doctor told him this, and the patient said he didn’t know. The patient said he was also told he couldn’t be “allowed” to have any pain medicine after he left the hospital after this surgery.

I’ve had other doctors in my area tell patients the same thing. One local weight loss surgeon tells patients they have to come off their evidence-based treatments (methadone or buprenorphine) for their potentially fatal medical illness (opioid use disorder) before he will agree to do any sort of gastric bypass weight loss surgery.

I was eager to have a discussion with my patient’s orthopedic surgeon, but my patient told me not to bother. He said he wasn’t going back to that surgeon anyway, and planned to get a second opinion at a nearby teaching hospital. I told him I thought this was a very good idea, though I was disappointed I couldn’t talk to the orthopedic surgeon. I was actually looking forward to that conversation. Probably the maniacal gleam in my eye made my patient tell me not to call.

Example number two:

Several weeks ago, I saw a new patient who was seeking admission to our opioid treatment program after being kicked out of a pain clinic. “Tim” (not his real name) had been going to several different pain clinics for years, and had been misusing his medication for at least two years. He was snorting oxycodone, around 150mg per day, and failed a pill count done by his pain medicine physician. His pain management doctor dismissed him from the practice, citing a “zero tolerance,” with no referral or further help. His friends told him about our treatment program, so he came for admission.

Tim was offered a choice between methadone and buprenorphine as treatment medications. He was so vehemently opposed to buprenorphine that it made me curious. He said that buprenorphine made him so sick, he nearly died.

I had already looked at his information on the prescription monitoring program, and saw that a few months ago, the physician assistant at his pain clinic prescribed Belbuca, along with relatively high doses of the usual immediate and extended release hydromorphone. This had piqued my interest.

Belbuca is a form of buprenorphine that’s approved for the treatment of pain. We don’t use it to treat addiction because it doesn’t have FDA approval for that purpose, and therefore isn’t covered by the DATA 2000 law.

Obviously this physician’s assistant who prescribed Belbucca failed to realize it would precipitate withdrawal in this patient who had been on full opioids for months.

I asked him to describe what happened after he took the first Belbucca. He said he felt like he had immediate onset of intense nausea and repeated vomiting so bad that he called EMS to take him to the hospital. He said he thought he was dying.

It doesn’t sound like anyone who saw the patient at the hospital told my patient his reaction was completely predictable.

I tried to explain to my patient that he may not get sick with buprenorphine if it were prescribed properly, but he was having none of it. That was OK, because methadone is still a great treatment for his opioid use disorder.

Example number three:

Some patients at our opioid treatment program stabilize on buprenorphine and then transfer to an office-based setting for care in a less restrictive setting. These patients have done well for months, so we wish them well, send their requested records, and encourage them to continue getting counseling in some form.

However, for some reason, some pain clinics take these patients off buprenorphine and start short-acting opioids. I’ve blogged about this problem before, dismayed at the predictable return of their opioid use disorder. They fail pill counts, and then get kicked out of treatment, having been set up to fail by their provider.

Now, things are getting weirder.

One patient, who did well for seven months at our opioid treatment program, transferred to a local office-based buprenorphine program. She did well for a few months, until she was switched to immediate and extended-release hydromorphone, which had been her drug of choice when she was in active addiction.

This patient predictably lost control of how she was taking this hydromorphone, started injecting it, and failed a pill count. Her doctor then told her she must go for an assessment at a substance abuse treatment facility in order to continue being prescribed hydromorphone.

Ummm…here’s the thing…she was started on buprenorphine in the first place because she had an opioid use disorder.

I’m not saying every patient with opioid use disorder immediately loses control of their medication if they’re prescribed opioids. But after less than a year of recovery from severe, intravenous opioid use disorder, you don’t have to be psychic to predict this would happen. Handing this patient a bottle of her drug of choice with a thirty-day supply triggered a relapse back to intravenous drug use.

Example number four:

I’ve saved the craziest for last. This example is tragic, both because of the bad patient outcome, and because so many doctors dropped the ball on this patient.

The patient, who developed opioid use disorder during treatment of chronic pain syndrome, developed severe mid-back pain. He told the emergency room doctor that he had been injecting the pain pills prescribed to him by a local pain medicine practice, and the emergency department physician noted track marks on his arms.

The patient had a limited work up and was sent home with a diagnosis of non-specific back pain and referred back to his pain clinic. The patient, miserable with intense and severe pain very unlike his chronic pain, returned to that hospital’s emergency department three more times. On the next to the last time, he says he was told that the doctor would not see him because he was a pain medication seeker.

Several days later, on his last visit to the emergency department, the patient was nearly comatose, with a high fever and labs indicating sepsis, and overwhelming blood infection. The patient was immediately admitted to the hospital and started on a range on antibiotics, but failed to improve. His relative demanded transfer to the local teaching hospital, an hour away.

Upon arrival at the teaching hospital, this 44 year -old man was diagnosed with a spinal abscess that extended from the neck all the way to the end of the spinal cord. This infection had obviously started at the area of his intense back pain. His spinal cord was being bathed in pus rather than spinal fluid.

He was not expected to live.

He was taken to the operating room, where the infection was drained and washed away, and dead tissue removed. Against all odds, the patient survived, though he was a quadriplegic when he woke up after surgery.

After being treated with antibiotics for many weeks, he was sent to a physical rehabilitation hospital for months. Eventually, he regained some strength in his arms and legs, and against all odds, improved to the point he could feed himself, and could walk with great difficulty, with two canes. He was eventually released from the physical rehabilitation hospital.

Eight months since his last appointment, he went back to his pain clinic. The doctor resumed prescribing the same medications that the patient had been misusing.

Wait a minute, you will say. Surely that doctor wasn’t told about the whole IV use, spinal abscess, quadriplegia thing, right? Wrong. Records show he did know.

The patient, after trying very hard not to inject these medications, finally came to our opioid treatment program, and asked for help. He was referred to us not by our local hospital’s physicians, not by anyone at the teaching hospital, not by social workers at that hospital, not by the physical rehabilitation hospital, and not by his pain management doctor.

His friends, in treatment at our OTP for their opioid use disorder, and told him to come to us for help.

He was started on sublingual buprenorphine and has done beautifully.

One day, after he’d been on a stable dose of buprenorphine for a few weeks, I asked him what he thought when his pain management doctor offered to put her back on hydromorphone. He said, “I was surprised. I didn’t think it was a good idea, but I was in pain and in withdrawal, so I just took the prescription.”

I understood. After all his time in the hospital, this patient hadn’t had any treatment for the disease of opioid use disorder. He’d only had treatment of the sequellae of opioid use disorder.

At that time, saving his life was the most important thing. But later, why not address the original disease that caused this million-dollar hospital treatment admission? Why not direct the patient to treatment of his opioid use disorder when released from the hospital and/or physical rehab facility? Why not pause for more than a moment before writing a prescription for the same drug that caused the whole mess?

 

All physicians make mistakes, usually out of ignorance, and I’m no different. But now, the opioid addiction problem is so bad that each state is passing laws to fix the problem. Isn’t it worth passing a law that makes sure all physicians are part of the solution?

At a minimum, let’s teach all doctors that substance use disorders are diseases, and that we do have treatments available. Some treatments work better than others, and medication-assisted treatment of opioid use disorder works very well. In fact, there’s more evidence to support MAT than anything they are doing in their practices. Why not refer patients with problems rather than shaming and ignoring them?

Let’s teach physicians that failure to diagnose and refer patients with substance use disorder for appropriate treatment is malpractice, just as it is for all other medical problems.