Posts Tagged ‘post-op care for patients on methadone’

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.