Patients with Prior Overdose Still Prescribed Opioids & Benzos

 

 

 

 

I read an interesting article in the latest issue of Journal of Addiction Medicine, titled “Prescribing of Opioids and Benzodiazepines Among Patients With History of Overdose,” by Griggs et al.

This article described a retrospective chart review of patients who had a previous history of opioid or benzodiazepine overdose. They identified patients who were prescribed either an opioid or benzodiazepine in a one-month period, in 2015, then reviewed their charts to see how many of these patients had a previous overdose. Then they studied the patients and prescribing situations to see what they had in common.

This study was done at a large healthcare system based in Charlotte, NC. The system is based at the same hospital where I did my residency in Internal Medicine about a billion years ago. OK, maybe it was only thirty-two years ago, but it feels like another lifetime. This hospital system has a robust Addiction Medicine department now, led by Dr. Stephen Wyatt, an addictionologist of national and perhaps international renown, who co-wrote this study.

The article began by reminding us of the recent increase in morbidity and mortality with opioid use disorder. Then it cited another article that I have written about (see my blog of January 23, 2016) authored by Larochelle et al., 2015, where it was found that in patients who survived an opioid overdose, 91% resumed opioid prescription within the next nine months.

Based on those previous findings, this study proposed to examine the prevalence of prior overdose among patients being prescribed benzodiazepines and/or opioids, and to examine patient and healthcare characteristics in these circumstances.

The study found 543 patients with prior opioid or benzodiazepine overdose history who were prescribed benzodiazepines or opioids during the designated month of the study. All the providers involved in this study use the same electronic medical record (EMR) which contained information about prior overdoses from 2007 forward, though no specific alerts appeared in the EMR.

Interestingly, opioids were involved in just under half of the overdose episodes among these identified patients, and benzodiazepines without opioids were involved in just over half of the overdoses.

Most of the identified patients received opioid or benzodiazepine prescriptions within two years of their documented overdose. Opioids accounted for around 72% of these prescriptions, with benzodiazepines accounting for around 23%, and 5% of the patients got both an opioid and a benzodiazepine, which is a particularly worrisome combination.

Of the patients prescribed opioids and/or benzodiazepines who had a prior overdose, 70% were between the ages of 35 to 64 years old. The leading cause, at 51%, of the prior overdose was unintentional, though 40% were suicide attempts. Many patients had mental health diagnoses: 54% had an anxiety disorder, 55% had depression, and 24% had bipolar disorder. Nearly a third, at 29%, had a diagnosis of substance use disorders.

Around a third of the opioid prescriptions were given for chronic pain issues, despite the prior overdose history. Over 25% of the opioid prescriptions were for more than 50mg daily morphine milligram equivalents. Around half of the patients had a prior drug screen in their record that was positive for marijuana, cocaine, or alcohol.

Most of the post-overdose prescriptions for opioids or benzodiazepines were given in outpatient clinics or emergency departments, but over a fourth of the prescriptions were issued after a medical phone call consultation. Only 5% of opioid or benzodiazepine prescriptions were issued from behavioral health providers, and less than 1% were from cancer care providers.

In the discussion section, the authors of this study voiced surprise that in a fourth of the patients, benzos and/or opioids were prescribed after a telephone consultation. The authors appropriately caution prescribers against this practice.

Having practiced in primary care for ten grueling years, I understand the telephone consult. Heaven help me, but sometimes I was tempted to allow medication to be called in because it would save me time and effort. It would also spare me the unpleasantness of having to see the patient in my office, and the extra time required.

I’m not intentionally being insulting to patients, but I felt patients who repeatedly asked for controlled substances were often miserable people who weren’t fun to take care of. They hurt, both physically and emotionally. I felt hopeless when I saw them, like nothing I could do or say would help them anyway, so where’s the harm in giving them a much-desired controlled substance?

Of course, now that I’m older, wiser, and better educated, I suspect many of these patients had treatable substance use disorder and/or mental health disorders.

The authors of the study concluded that providers for this patient group could have done a better job of identifying higher risk patients. The prescribers could benefit from an electronic tool, which according to the article is presently being developed, to support decision making processes and quantify the risk for a given patient.

I’ve talked in this blog before about the perils of labeling patients as “frequent flyers” or “drug seekers,” pejorative terms that create obstacles between needy patients and their providers. That old kind of labeling fosters the outdated idea that people with substance use disorders are bad, rather than sick. With that old system, patients can receive bad care, because providers stop thinking and start judging.

Instead, this article describes a better idea – one that provides information about the degree of risk for a given patient, before potentially harmful medications are prescribed. It sounds like this sort of tool can help providers mitigate risks for some patients, while not denying them appropriate medical care.

In other words, a high-risk patient with an acute pain situation, like a broken bone, may still need opioids, but fewer pills might be prescribed, with more frequent follow up, than patients at lower risk for overdose.

I don’t know if the tool this healthcare system developed is proprietary; I think I will ask for an example of how it works. I don’t work in primary care any more (addiction medicine is so much more fun), but I like to stay informed about these things.

The Opioid Lawsuits

 

 

 

 

Around twenty-seven hundred plaintiffs, composed of states, counties, and cities, have joined the lawsuit against drug manufacturers, distributors, and some pharmacy chains. Their lawsuit alleges these companies acted illegally and contributed to the opioid epidemic. Last month, some of the organizations being sued offered a common-sense solution that would benefit people with opioid use disorder. [1]

The actual lawsuit is similar to lawsuits against Purdue Pharma, manufacturer of OxyContin. Purdue filed for bankruptcy in September of 2019, offering a settlement to twenty-five hundred or so plaintiffs which included states, cities, counties, and tribes. The proposed settlement, announced in September of 2019, totaled around $12 billion, with $3 billion coming from the Sackler family directly.

Proponents of the Purdue Pharma settlements say it avoids wasting time and money on protracted litigation, which usually provides maximum benefits to the the lawyers on each side, rather than the plaintiffs. A quick settlement also – in theory – makes money available more quickly to people suffering from the opioid epidemic.

On the other side, some lawyers point out this money won’t be enough to cover the damage caused by the opioid epidemic. Some doubt that those who need it will receive much of the $12 billion. They also object to the fraction paid by the Sackler family, owners of Purdue Pharma, made rich by the sales of OxyContin over the years. The settlement, as it stands now, has no provision for admission of guilt by the pharmaceutical company, which does not sit well with some of the plaintiffs.

Both sides make good points. However, I don’t think there’s a settlement large enough to cover all the damages caused by the opioid epidemic, so that’s not a realistic demand. Deciding who benefits from a settlement needs to be determined by representatives of the plaintiffs, not the defendants.

But now last month, a group of pharmaceutical companies, drug distributors, and pharmacy chains proposed a settlement of the lawsuit being brought by states, counties, and cities across the nation. Teva Pharmaceutical, Johnson& Johnson, McKesson, Amerisource Bergen, and Cardinal Health. and announced recently a proposed settlement amounting to $23 billion including some interesting provisions.

Teva, an Israeli company, agreed to provide their part of the settlement of the lawsuit in the form of generic buprenorphine/naloxone tablets to treat opioid use disorder. They would also pay $250 million over ten years. They claim to be capable of providing all the treatment medication needed by patients in the U.S., after a few years to ramp up production.

The drug distributors agreed to distribute this medication for free, which would allow patients access the treatment medication for next to nothing except a small dispensing fee from the pharmacy, which might also be waived by the lawsuit agreement.

The common sense of this settlement is astounding. This settlement would directly benefit the people who need it most. That’s always a challenge in this sort of lawsuit; even when money is won, distribution of the money can be contentious. I’m sure we all could imagine ways the money could be mis-managed and end up in pockets of people who haven’t been extremely affected by the opioid epidemic. But the people who developed opioid use disorder – they deserve help accessing treatment.

Medication-assisted treatment is the gold standard of treatment for opioid use disorder, so this settlement idea is based in good science and supported by tons of literature. Besides the reduction in overdose death seen in treatment with methadone and/or buprenorphine, medication to treat opioid use disorder is also associated with better physical health, lower rates of crime, lower suicide rates, and higher employment rates.

This settlement makes sure an evidence-based treatment gets funded, instead of over-used treatments that are outdated and ineffective, such as detoxification episodes. The relapse rates for patients with opioid use disorder are greater than 90% with detoxification, yet we see patients cycle in and out of detox, over and over. Detox alone also increases the risk of death. After patients leave detox, tolerance for opioids is reduced, creating a dangerous risk for overdose death when the relapse does happen. Can you think of any other treatment in the field of medicine that increases the risk of death, yet remains standard practice in many communities? If you did a procedure or prescribed a medication that increased the risk of death to people with diabetes, malpractice lawsuits would sprout all over the place.

Not so with the treatment of opioid use disorder.

Teva has made a common sense offer that allows them to do what they do best – make pharmaceuticals – in order to help people with opioid use disorder. The distributors would do what they do best – distribute – in order to help people with opioid use disorder.

Rarely in civil litigation do we see such meaningful settlements with the potential to help the people who suffer most from corporate wrongdoing. This could be a great example of corporate amends…when you break something, do your best to fix it.

Also, this solution would allow Teva and other pharmaceutical companies and distributors to stay in business. Demanding an unreasonable payday might push these big companies to declare bankruptcy and go out of business. These companies provide employment for people and provide services to our nation. We need them to stay in business, while still acknowledging the harm they did and taking financial responsibility for helping clean up the mess

Only the combination product would be donated. This means patients who are prescribed the monoproduct purely for economic reasons could be switched to the less-divertible combination product. That would be wonderful for facilities like the opioid treatment program where I work. Right now, our OTP buys monoproduct because it’s the cheapest form of buprenorphine on the market. Since we do directly observed dosing, diversion is less of an issue, though still an issue. With this sort of agreement, we would switch to the combination product, since not only would the combo product be less expensive, but it would be free.

What would this mean for opioid treatment programs? I’m not sure, but if OTPs could obtain buprenorphine/naloxone treatment medication for free, there should be a corresponding drop in treatment fees. Perhaps instead of a patient having to pay $15 per day for buprenorphine 16mg, they might pay less than $8 per day. I don’t know how much our OTPs pay per pill now, so I’m estimating. I do know that a bigger chunk of what OTP patients pay each day goes to medication costs with buprenorphine, compared to patients on methadone.

For patients who dose at OTPs who are now covered by the recent SORs and CURES grants, that’s money that could be saved, and spread farther to cover more patients. It’s a direct benefit to the taxpayers.

Some patients now on methadone for the treatment of opioid use disorder would switch to buprenorphine/naloxone if it were cheaper. At the opioid treatment program, some patients start methadone because it costs about three dollars per day less than buprenorphine. Again, it doesn’t sound like much of a cost savings, but $3 per day adds up over time. With this proposal, choosing buprenorphine/naloxone would be the cheapest (and often safest) option for treatment.

Of course, there are nay-sayers regarding the settlement. Already, I found online articles complaining that the $23 billion was based on Teva’s retail price for the medication and not their cost of producing the medication.

I suspect lawyers representing plaintiffs won’t be happy about the settlement. If they take cases like this on contingency fees, they would be happier with a big settlement where they take their percentage off the top. This solution wouldn’t benefit lawyers as much as the people who have opioid use disorder, and their families.

I’m proud that my home state of North Carolina is one of four states supporting this innovative settlement proposition along with Tennessee, Pennsylvania, and Texas. The other states, not to mention numerous counties and cities, have not – yet – agreed to the proposed settlement.

There are sure to be talks about pros and cons of the settlement, but I’m hoping this proposed settlement moves forward, because I love a common-sense solution.

  1. https://www.biopharmadive.com/news/teva-opioid-settlement-offer-23-billion-suboxone/565493/

I’m Back

 

 

 

 

 

 

I’m back to blogging, after a short break, during which I took my Addiction Medicine board re-certification exam. I think I did well on it, but with those sorts of exam one never knows for sure. If any of my readers are planning to take the exam soon, I have a bit of advice: it’s great to go to the annual Review Course hosted by the American Society of Addiction Medicine, but you should also read the textbook, “Principles of Addiction Medicine.”

I listened to both the 2018 and 2019 Review Courses online. Those courses are great if you want to know all the essentials of the field. However, many of the questions on the test went a layer deeper than the review courses covered.

For example, rather than just asking which receptor type a drug of abuse activates, the test would ask what subtype of that receptor was involved. I don’t find that sort of question to be clinically relevant, but then I’m not a researcher, just a worker on the front lines of the opioid epidemic.

So now I’m happy to back into my routine, seeing patients and doing the work I love.

However, this month I’ve had to confront issues that I thought were resolved months ago. For example, I’m vexed by new prior authorization forms. It seems that large insurance companies like Cigna might be asking smaller companies to do their management of prescription costs, a service euphemistically called “pharmacy benefit management.”

This is an example of a form I got last week:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

As you can see, it asks for chart notes, drug screen results, documentation that the patient isn’t on any other opioids, per the state prescription monitoring program, and a plan and evaluation/assessment for potential to taper.

This happens to be a patient of mine who has been in successful, relapse-free recovery for over nine years. She is extremely high functioning at her job, and a delightful patient. I provided all the information they needed to approve her generic buprenorphine/naloxone medication, but I don’t think that should be required for coverage. They approved it for only six months, so we’ll have to repeat this process twice per year.

I think it’s discriminatory to demand this of a patient in treatment for opioid use disorder, but not for diabetes. It also discourages providers from wanting to treat patients with buprenorphine products, since it requires considerable time and energy to respond to these prior authorization demands.

Another company, called Southern Scripts, working for a larger health insurance company, asked for this form to be completed on a patient prior to paying for his buprenorphine/naloxone tablets:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

After completing the form and asking for an expedited review, I got this letter:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

There’s no way I’m sending notes regarding a patient’s substance use disorder treatment to an insurer, so instead I wrote a summary letter, in which I described the progress this patient has made & how well he is doing, and that delay in coverage for his medications could have catastrophic medical consequences to his health.

In response to my letter, Southern scripts issued a six-month approval for coverage of his medication. So, in six months, we’ll do this whole thing over again, I guess.

We are now twenty years into this opioid epidemic. I thought we were all at the point where we realized that it’s not good public policy to have insurance companies erect barriers to treatment with buprenorphine products to treat patients with opioid use disorder.

I’ve saved the best for last.

I’ve dealt with my share of frustrations with pharmacists and pharmacies.

Readers know I went to electronic prescribing a month or so ago. Last week one of my patients, stable for years, went to get his refill from his pharmacy. I submitted it electronically, and put one refill on it, since I see him only every two months at this point.

When the Walgreen’s pharmacy refused to give my patient his refill, he called my Health Services Manager, who called the pharmacy. They said my patient’s refill had been cancelled, and that I would need to submit a new electronic prescription. Worried I’d made an error, I went to my E-prescribing program and found I did write for a refill. Confused, I asked my Health Services Manager to call the pharmacy back, to discover why they wouldn’t honor the refill.

They told him that Schedule 3, 4, and 5 opioids could not be refilled, and that a new prescription had to be submitted.

This is not accurate, of course.

I wasn’t in a mood to argue. I just re-submitted the prescription and my patient filled it. Of course, now on my e-prescribing software it looks like I issued two prescriptions for the same month, which I did. I’ll have to document in his chart about the problem with the pharmacy.

I had hoped e-prescribing was going to remove some of the difficulties I’ve encountered with the pharmacies filling buprenorphine products. Now, I’ve lowered my expectations.

Recovery Means….

Image result for recovery month

September is National Recovery Month, so it’s a great time to review what recovery means to me. I hope my readers will write in with their own definition of recovery.

Recovery means…

….taking the worst and most embarrassing thing in my life and turning it into my greatest asset.

….becoming less judgmental of other people.

….remaining teachable.

….having more free time, after the burden of looking for the “next one” has been lifted.

…looking in the mirror, and feeling content at what I see.

….being satisfied with the small pleasures in life.

….developing a thicker skin for judgmental people. They aren’t going to ruin my day.

….re-connecting with the human race.

….re-connecting with the God of my understanding.

…reconnecting with myself.

….doing what I need to do for my well-being, even if other people don’t approve.

….being happy when I make progress, no longer expecting perfection.

….understanding it’s more important what I think of me than what other people think of me.

….talking frequently with other people who share my passion for recovery.

Recovery goes beyond 12-step programs or medication-assisted treatment. Recovery can apply to issues other than drug addiction. It can apply to eating disorders, co-dependency, gambling problems, sex addiction, or any other compulsive activity that is bad for our health. We can be in good recovery in one area of our life and be in active addiction in other areas. We have good and bad days. We relapse, and we try again, and we stop listening to the voice of addiction that tells us we should give up because we will always fail. We learn from our failures and come to look at them as opportunities for growth. We turn stumbling blocks into stepping stones. We lift up our fellow travelers when they weaken and they do the same for us.

We do recover.

 

Embracing Change

My cat knows computer

 

 

 

Kicking, screaming, and whining, I entered the 21st century today.

Thanks to my long-suffering fiancé, we started electronic prescribing in my office. It went better than I feared.

A few years ago, North Carolina passed the STOP Act, which contained measures to help make the prescribing of opioids safer. One of the Act’s provisions was that by January 1, 2020, all targeted controlled substances must be prescribed electronically. The targeted substances are all Schedule II and III opioid prescriptions.

Here’s a weird thing, though: when I went back to read the text of the actual STOP Act, buprenorphine wasn’t listed as one of the targeted substances, even though it is a Schedule III opioid. But I’m erring on the side of caution. Besides, E-prescribing is a good idea. Paper prescriptions are becoming a thing of the past anyway, to my dismay.

I struggle with technology. Readers of this blog have no idea how annoyed I feel when my posts come out weird, with extra spaces and unintended placement of pictures. I’ve sworn at my laptop many times and only self-interest keeps me from hurling it against a wall. I know it’s me, accidently making unintended changes, then struggling to change back. Sometimes I must edit four or five times before it’s satisfactory. And this is on WordPress, one of the most user-friendly blog platforms around. I’m better at it now, after nine-plus years of blogging.

My fiancé did all the research for the E-prescribing software and vetted the available vendors. We set it up last week, with some difficulty.

At one point my sweetie said something that sounded to me like, “Now we need to get the verification code to authorize the pending password credentialing security code of the product.”

I looked at him, confused as my dog when I explain why our walk must be postponed until after I get home from work. “Eh…I thought we already did that step? I’m not sure what you mean.”

Patiently, he showed me on my computer.

“Oh. Now it’s asking for a password, but the one I chose isn’t working.”

“Yes but you must have used your login password and what it’s asking for there is the second tier pending security question and related password that you set up back under step sixty-three of the verification process. Do you remember what it was?”

“No. Maybe I used the dog’s name again?”

“Please don’t use the dog’s name anymore. That’s too easy to hack. So is your date of birth.”

“Oh. I know! I could use my social security number as my password!”

For some reason, Greg did a facepalm and shook his head slowly.

“OK. I’ll invent a new one. But it’s very hard to remember all of these. You know I have passwords for Methasoft, the prescription monitoring program, the ASAM website, the ABAM website, work email, home email, the OTP exception website, login at work, Ebay, the bank, Paypal, Amazon, ETSY…. “

“I thought I showed you how to store them in your Identity Safe.”

“Yes but I forgot the password to it, so…”

Another facepalm from Greg.

Eventually we had the software set up, though I was a little suspicious if we had done it correctly.

The next day, yesterday, was a relatively light day in my office. We used the system for six or seven of the patients, and it went relatively well. I got hung up only at the end, when I have to access a randomly generated code to type in within sixty seconds to match the system’s code that I request at the time I want to submit.

(If you don’t understand what I just wrote, don’t feel badly – I don’t either.)

I asked Greg to call the pharmacy after the first one we did, just to confirm all went well and the prescription was submitted. He called, and it was.

I felt euphoric. I did it, with some help. OK a lot of help.

Who knows what electronic field I may conquer next…maybe I’ll be able to stop losing emails.

 

 

Stigma Abounds in Rural North Carolina

 

 

 

 

What Stigma Feels Like

The opioid epidemic has rolled on for more than twenty years now, but misunderstandings and ignorance about best practices regarding treatment of patients still flourishes in medical and dental professionals. Part of my job as an Addiction Medicine treatment professional is the gentle education of other medical providers. Over the past years, I’m more patient than I used to be, knowing that most providers just need information in order to do the best thing for our shared patients. If I’m polite and friendly, our interaction is more likely to go well.

And sometimes, it makes no difference.

This week’s drama unfolded around a patient who was recently diagnosed with cancer. This patient, being treated for opioid use disorder with methadone at 110mg per day, had to see an oral surgeon to have all of her teeth removed before she can undergo cancer chemotherapy. This is because she had extensive decay in all of her teeth which can be sources of infection during chemotherapy.

She saw me a few days after her initial consultation with the oral surgeon to whom her oncologist referred her. She was upset and distressed at what the oral surgeon had said.

She had just found out that all of her teeth, about twenty-one in all, must be removed. And her oral surgeon had told her he wouldn’t be prescribing any pain medication after surgery because she was on methadone.

I listened closely to her and got her permission to call this oral surgeon to talk to him about appropriate pain management for patients with opioid use disorder.

When I called, the surgeon wasn’t there. I was put on hold for four or five minutes, waiting on the surgeon’s assistant. While I was on hold, I listened to their recorded announcements about their practice. The recording told about the educational backgrounds of their two surgeons, then had a pitch about the doctor I wanted to talk with, about how he did missionary work for a certain religion.

Excuse me while I go off on a tangent.

When I heard the bit about missionary work, I felt foreboding. I’ve had past negative experiences with medical professionals who advertise their devotion to a religion as a selling point for themselves or their practices. I notice that sometimes people who profess devotion to a religion seem to be least likely to exhibit the qualities espoused by the leader of their religion: tolerance, patience, love, etc. And I recognize that’s a type of stigma that I hold, which may be unfair to the oral surgeon in question.

I was ruminating on these dark thoughts when the assistant came to the phone. I explained that I was the medical director at the local opioid treatment program, and that the patient being discussed had a diagnosis of opioid use disorder and was being treated with methadone, and that I wanted to discuss the plan for post-operative care with the oral surgeon. The assistant assured me that his doctor’s policy was not to prescribe opioids post-operatively for someone on methadone, because it is a red flag.

“Red flag for what?” I asked.

“That the person is a drug addict & shouldn’t be given any pain medications.”

I took a deep breath and made as effort to keep my tone friendly and cheerful. “Yes, you’re partly correct. As I said, the patient is being treated for opioid use disorder by me. The older term for this medical problem was addiction. She’s being prescribed methadone as treatment for her opioid addiction. It keeps her out of withdrawal and prevents cravings. However, it won’t adequately treat post-surgical pain.”

“In fact, she just had cancer surgery three weeks ago. She was prescribed post-operative oxycodone, 15mg every six hours by the surgeon. We had her mother hold the bottle of opioid pills and dispense as prescribed. This patient did very well and made it through without relapse. We could do something similar after her dental surgery.”

“No,” he said, “We leave it up to the pain clinic to prescribe the pain medication.”

I slapped my forehead and tried to keep an edge out of my voice. “We are not a pain clinic. I don’t prescribe medications for pain. I treat opioid use disorder with methadone and buprenorphine products. I do not prescribe opioids for dental procedures since I’m not an oral surgeon. I don’t know what to expect as far as intensity and duration of pain after extraction of a mouthful of teeth. However, since the surgeon doing the procedure knows how much pain such patients have, he would be the ideal person to prescribe for the post-op pain associated with the procedure that he is doing.”

“Well he’s not going to prescribe anything if the patient is on methadone,” he answered.

“Yes, that’s why I called. I’m trying to educate you about best practices for post-operative care for patients with opioid use disorder who are being prescribed methadone.” I was getting louder and could feel a muscle jumping over my right eye. “What I’m trying to tell you is that this patient’s methadone will not treat post-operative pain. It does keep her out of withdrawal and prevents cravings and helps her function normally, but it won’t treat acute severe pain.”

“Yes but I’m pretty sure the surgeon won’t prescribe anything for pain.”

I thanked him for his time and left my phone number for the surgeon to call me back. This was five days ago and I don’t expect a return call.

This patient is in a bind. She has cancer and can’t start chemotherapy until she heals from getting all her teeth extracted. Time is of the essence. Ordinarily, I’d tell her about the situation and recommend she find another oral surgeon, but she may decide to proceed with this surgeon only to get the whole process moving along.

It’s a real shame that this patient will be forced to suffer pain after her dental extractions. She will get by with Tylenol and ibuprofen, because she will do what she must. I just hate that she’s being treated this way.

Then today. Southern Scripts, an insurance company that one of my long-time patients just switched to, sent my office a prior authorization to fill out before it would OK coverage of buprenorphine/naloxone 8/2mg tabs, 8 mg per day. Among a host of other requirements, they need the patient’s height and weight before they’re willing to authorize payment.

Now that’s a new one. It’s hard for me to imagine what possible height/weight would disqualify a patient for this medication, but what do I know. I’m only the doctor.

Also today, I heard about an exchange one of my patients had with a Walgreens pharmacist. She wanted to fill her Suboxone 8mg film prescription two days early. I had already called ahead and left a message with the pharmacist that it was OK with me, since she had recently tapered from 16mg down to 12mg. She had more problems with that drop than we expected, and so she ran out 2 days early. Since the decrease in dose had been requested by the patient in the first place, and since I didn’t want her to be without medication for two days, I gave permission to fill it early. I did not think this was a big deal.

The patient said that she was third in line at the pharmacy, with six or eight people standing in the area waiting for service, when the pharmacist called out to her, asking why she ran out early. My patient didn’t want to compromise her privacy, so she shook her head, declining to answer. She says the pharmacist began to harangue her in front of all the other people, saying since she wouldn’t tell her why she needed to fill the medication early, she wasn’t going to get it from “her” pharmacy.

The patient left, tearful and humiliated, but not before she demanded the written prescription back from this hateful pharmacist. She took it to another Walgreens in her area and filled it with no problem.

I’m no longer shocked or surprised at the hassles my patients endure. But we are now several decades into this opioid epidemic. I think it’s time we insist on better education and treatment from medical, dental, and paramedical professionals. I’ve been patient and tried hard to approach outdated attitudes as an educational challenge.

Now I occasionally wonder if things will ever change. I find myself having the same conversations with other medical providers that I had fifteen years ago. Are we making any progress against the stigma our patients face? Only time will tell.