I hope all my readers had a nice Thanksgiving weekend. I did. It was a low-key, small family event but I felt gratitude appropriate to the season.
Those of us who work in the substance use disorder treatment field must take time to feel gratitude. In this job it’s way too easy to be overwhelmed with negative thoughts and feelings. For me, that can be a quick slide into cynicism and pessimism and then I block myself from all the many positive things of life.
The few weeks before Thanksgiving presented challenges to several of my patients, and I felt anger on their behalf. Several patients experienced difficulties with our healthcare system. Usually, I’m able to interact with other healthcare professionals in a friendly, collegial manner to coordinate care for my patients, while trying to educate in a gentle, low-key way.
This last week, I felt like breaking things.
Some things were trivial but so irritating: one patient has been seeing me for fifteen years, with well-established recovery from opioid use disorder. He’s on a relatively low dose of buprenorphine/naloxone film and I see him only once every two months, given his overall stability.
He moved to Tennessee a few years ago. This was during COVID when telehealth was common, and after COVID subsided I told him I could see him every other visit in person and every other visit via telehealth. This meant he’d have to drive to my office three times a year. He still visits friends and family in North Carolina, so this works well for him. That’s what we’ve been doing but last week we hit a wrinkle.
The small family pharmacy he’s been using told him he would have to find a new doctor, licensed in Tennessee, to prescribe his buprenorphine/naloxone 8/2mg film, which he takes once daily. This pharmacy decided they would no longer fill a prescription from an out-of-state physician, even if that physician (me) had been treating that patient for fifteen years.
He switched to this pharmacy after having problems with the Walgreens in his town. They told him they could not guarantee they would have his buprenorphine/naloxone films in stock on the day it was due to be filled, because of limitations on the amount they could sell. (I talked about this in an earlier blog). He had to wait a day or two and then they might have only five films and he’d have to return for more. We told him that small pharmacies seem to have less problems filling prescriptions on time, so we recommended he go to this small family pharmacy.
When he called my office to ask what to do about this latest, I told him it was his decision. I’d be happy to keep seeing him under our arrangement, but he’d have to find a pharmacy willing to fill my prescription. Or he could find a new prescriber. Tennessee has dose limits on buprenorphine/naloxone but he was well under that, and he wasn’t on the monoproduct, which is also regulated in Tennessee.
He called around and found a friendly pharmacist just over the border, in North Carolina, who says he’s willing to fill the prescription and stay stocked for refills. It’s a forty-five-minute drive for my patient but he’s happy with this solution.
We’ll see how this works out.
Another event happened with a patient who went to our local emergency department with trouble breathing. He walked into the ER and told someone in triage that he was short of breath. During the assessment, he mentioned he was on methadone. He says the moment he said that everything changed. He says policemen were summoned and he was told he would be receiving a dose of Narcan and if he refused, he would be held down and given the Narcan anyway.
He said he thought it would be easier to agree to get the shot, even though he knew it would make him sick. Of course, the Narcan precipitated withdrawal. Now he was still short of breath but had a bunch of unpleasant opioid withdrawal symptoms, such as nausea and vomiting, headache, and intense body aches with pronounced restlessness.
Why did the provider force him to take Narcan? The provider claimed in the record, when we got a copy, that he had to give Narcan to see if methadone was suppressing his respirations, giving him hypoxemia (low oxygen).
Many of my readers, unlike this medical provider, will already know that with opioid overdose, patients become so sedated that breathing slows, decreasing oxygen in the bloodstream due to hypoventilation. But this patient was sitting up and talking to them. He was ventilating just fine. He was not oxygenating, though, and the reason for this showed up on his chest x-ray: he had pneumonia.
I was livid.
I talked to my colleagues about this event, puzzling over how to prevent similar future episodes. One colleague knows some friendly contacts at the hospital. Perhaps we can try to use this contact to engage Emergency Department providers. This patient is also considering legal options, which may promote change.
My challenge is staying open to my patients and their problems while not holding on to a negative, nasty attitude towards other providers. Because of my own issues, I sometimes already feel inferior to many of my fellow doctors, so I especially love to indulge in a little self-righteous indignation on behalf of my patients. That fits right in with my existing character defects. But self-congratulation at another doctor’s expense doesn’t help anyone including the patient.
When I’m in a good place spiritually, I’d rather see if there’s a way to educate the other doctor in a pleasant manner. If there’s not, maybe I need to accept it’s not my job to change their minds or educate them. Maybe my patient needs to pursue legal means to push back against stigma.
For example, last week during a routine yearly assessment, a young patient to whom I prescribe buprenorphine told me he was accepted for a job at a local factory but when they discovered he’s on buprenorphine, they told him he could not work there. I asked him if they put all that in writing and he said they did.
I smiled like a hungry crocodile eying a slow-moving wildebeest. I told him that though I’m no lawyer, I strongly suspect that’s illegal discrimination. I gave him the web address and toll-free number of North Carolina’s disability rights program: https://disabilityrightsnc.org/ and 1-877-235-4210. I encouraged to call this agency for help and information.
I feel like I helped him by giving him information that he could act on if that’s what he decides to do.
I have one more sad example from last week.
I was seeing a new patient who was relatively stable compared to most new patients. He had opioid use disorder but had been taking a steady dose of buprenorphine for years, piggybacking on a relative’s prescription that was going to be ending. He wisely wanted to get his own prescription, and already knew the dose that made him feel stable. He wasn’t using any other drugs except marijuana and had only a few minor medical problems. He had no mental health issues, was in a stable marriage and employed full-time.
At the time of his first visit with me, he said he had a primary care doctor whom he’d been seeing for years and had a great relationship with. I informed him of the recent change of law about who could prescribe buprenorphine, and suggested he ask this primary care provider about prescribing it for him. I told him I’d send in the first prescription and at his follow-up visit in a week we could see if he could get all of his care with this doctor.
The following week, he told me he had called his doctor’s office, and was rebuffed. That was his word: “rebuffed.”
He couldn’t talk to his doctor over the phone but talked to the nurse who worked with his doctor, and she called him back. He says she sounded angry and told him that he should know their practice rarely prescribed any narcotics. He said yes, he knew that. Then she said that he should know better than to ask his doctor to prescribe something like buprenorphine. He said he felt as if he’d done something wrong just by asking his doctor to prescribe it.
I felt bad for suggesting my new patient even ask his primary care doctor, but I honestly thought it was the most logical course of action. Of course, I will continue to see him and that’s not a problem. I just hate that he was made to feel bad for asking for appropriate medical care.
In this situation, I’m not going to try to change the other doctor’s mind. If that’s his position perhaps it’s better if I manage the care of this young man.
With all these situations, I need to keep a positive attitude because slipping into anger and cynicism does not help me or my patients. I want to do what I can to advocate for them, and I want to know where to point them for legal help. Things are getting better in the field of opioid use disorder treatment, even when it feels like the pace of change is glacial.
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