Posts Tagged ‘primary care for patients on MAT’

Primary Care Difficult to Find for OTP Patients

This area where I now live is odd in some ways. It’s beautiful country, but odd. Around here, people must “apply” to become patients of local medical practices. This isn’t because of COVID; it was like this before too.

Many of my patients tell me they keep getting turned down when they apply to be patients at local practices. Some of these patients have no insurance, some have Medicaid, and some have private insurance. Sometimes they wonder aloud to me if they were turned down because they truthfully revealed they had opioid use disorder and were being treated with either methadone or buprenorphine.

There’s just no way to know. It would be illegal, of course, for practitioners to turn down a patient for primary care because they have opioid use disorder, whether they are in or out of treatment. But usually these patients aren’t given an exact reason why they are being turned down for care. They are usually told something vague, like, “Our providers don’t have the expertise to treat your medical conditions.”

I’d love to do a little undercover investigation of this situation, but just don’t have the time.

But last week, I saw a new patient seeking treatment for her opioid use disorder. She had other medical issues that had long been neglected. This is not unusual, because active substance use disorders often push other health issues into the background of a patient’s attention. However, this patient told me she had gone to a local medical clinic for help, both for her drug use and for other medical issues. She was turned away without being seen. She was told she had to get help with her drug use first.

She went to an FQHC, an abbreviation for Federally Qualified Health Clinic.

It isn’t easy for a medical clinic to get FQHC designation. These clinics need to meet certain standards, including making medical care easier to obtain by using a sliding scale for payment. That is, the less money a patient has, the less they are charged for care. The benefit of being an FQHC is that they get paid more for Medicaid and Medicare patients, because they are providing affordable care for low-income people.

But my patient got no care.

As she told it, at her first visit she disclosed her regular illicit opioid and methamphetamine use and asked for help with those problems along with other medical problems. She had severe joint pains of her hands and a few other common medical symptoms. She says she was told she could not receive care until she got her addiction under control. The patient sensed this wasn’t right, and asked to talk to the office manager, who told her the provider didn’t feel comfortable treating any of her medical problems because her drug use would interfere. Again, she was told she could return when she got her addiction “under control.”

She says she received no referral for treatment of her addiction.

I asked the patient if she wanted me to call this office to tell them she’s now in treatment, and she said yes, but please wait until she could see if our treatment was going to work. I agreed.

On her seventh day of treatment, she looked and felt much better. She felt stable on her dose of buprenorphine 16mg per day and she had no cravings for opioids or opioid withdrawal. She had not used any heroin since admission, though she did smoke a small amount of methamphetamine on her fifth day of treatment. This is not unusual, and she was talking to her counselor about her triggers for methamphetamine use.

I asked again if she wanted me to call the FQHC, for her to get her needed primary medical care done there. She said yes, she had to go there, since they were the only care available for low-income patients near her home.

So I called them. I was angry for the way she had been treated, and truth be told, spoiling for a verbal fight. Fortunately, I had a pharmacy student shadowing me that day.

As an aside, pharmacy students who rotate through our local hospital for part of their training have asked to come one day a week to shadow me, to learn about opioid use disorder and its treatment with medication. I’ve been delighted to be given a chance to blather on about my favorite topic. I always make sure to have a few willing patients tell the students their stories of recovery, and about how treatment benefitted them. The students are always amazed, and a few have asked if there’s any place for pharmacists at opioid treatment programs. I say yes, some programs do use pharmacists, though currently ours does not. I’ve been happy with their enthusiasm and willingness to learn.

Anyway, a student was with me that day, and I tend to be better behaved when people are watching me. As I made the phone call, I kept repeating to myself, “Be collaborative, be collaborative…”

I got the receptionist, and described who I was, and which patient I was calling about. Immediately I was put on hold and the office manager came on the line. As I remember, our conversation went something like this:

“Hi, I’m Dr. Burson and I’m seeing Mrs. X.  I understand she was seeking medical care at your office and was told she needed to get help with her addiction issues prior to seeing a provider there. I’m calling to let you know she is getting care with us and has made a great deal of progress with…”

“We absolutely did not refuse to provide care for her. I remember her very well. She was hollerin’ in our lobby about us denying her care. We only told her that we couldn’t treat any of her medical problems until she got off the drugs. That’s not unreasonable. That’s all we told her. We did NOT deny her care.”

“Yes, that’s why I’m calling,” I said, smooth and unruffled as silk, “She found help for her opioid use disorder and stimulant use disorder, so I was wondering if I can tell her to make another appointment with your provider. And by the way, anytime you have a patient with opioid use disorder, please refer them to us. We want them. We can help them.”

A bit of a pause ensued. I sensed – or perhaps imagined –  she didn’t really want my patient in that practice but was smart enough to know she’d be breaking the law if she refused.

“Of course. Tell her to call today, we’ll be happy to see her.”

“Thank you so much for your help. I’ll tell her.”

The student, having heard the whole conversation, said something to the effect of how is that not denying care? I said I thought it was the same thing too, but didn’t want to argue or offend, since I get more cooperation with politeness and cooperation.

The Americans With Disabilities Act, known as the ADA, makes it illegal to discriminate against someone due to their medical conditions. It is illegal to refuse to provide medical care to a person only because they have substance use disorder.

How should this FQHC have handled my patient? Of course, drug use can influence other medical problems. But the answer isn’t turning the patient away. The answer is to see the patient, form a therapeutic alliance with the patient, and assess her needs. Start treatment of medical problems and include referral for treatment of substance use disorders, while also addressing her other medical problems.

Instead, it feels to me – and her – like they said to her, “You’ll have to take your nasty bad habit somewhere else and stop your bad behavior before you are allowed to see our providers.”

They absolutely bungled it.

Out of curiosity, and to try to see who their medical director was, I went to their web page. Ironically, splashed in large letters over their home page was this statement: “We promise not to deny services based on a person’s race, color, sex, national origin, disability, religion, sexual orientation, or ability to pay.”

Well OK.

One nurse practitioner was listed as a provider, but I didn’t see a medical director listed. I plan to call this nurse practitioner soon, when I am calm and cheerful, in the hopes of doing some gentle education.

I’ll let her know about our opioid treatment program, and that we are happy to receive referrals for patients with opioid use disorder, and that she can refer them any weekday. (Just as COVID hit, we started doing admissions five days per week). I also hope to convince her to refer patients with substance use disorders for treatment, just as she would for any other illness, and to give her my cell number to call if she ever has any questions about what to do for a certain patient with substance abuse, even if they don’t have opioid use disorder.