Should Social Services Require a Mother to Stop Suboxone?

First Posted 11/4/2013

I recently saw a new patient who described treating her own opioid dependence with diverted Suboxone.  She sheepishly described reading everything she could find about buprenorphine and meticulously using half of her friend’s medication to avoid other opioids, without fail, for four years. She would likely be treating herself now, if she hadn’t become pregnant and  told her OB and a hospital nurse what she was doing.  Her disclosure prompted a call to CPS, leading to the assignment of a caseworker and the threat to remove her baby from her home.  CPS eventually allowed her to keep her baby providing that she stop using medication illegally—prompting her to call my office.

My first reaction was that everything worked out well, and justice had been served.  But since the visit I’ve thought about some of the inconsistencies in how HIPAA is applied, and in the general attitude toward doctor/patient confidentiality.

I’ve also given thought to how things could have worked out, had my patient count been at 100 rather than 99.  There are not many buprenorphine-certified prescribers in my area, and she very likely would have been unable to find a doctor if my practice was full.  Had that been the case, what would have happened?  Would CPS have backed off and told her to go back to doing what she had been doing?

More likely she would have been given the choice of stopping buprenorphine or going to the methadone/buprenorphine clinic an hour’s drive away.    In the latter case, how would that work, exactly, traveling an hour at 6 AM each day as the single mother of a newborn infant?

I suspect that if my practice had been full she would have stopped buprenorphine or Suboxone, and joined the ranks of either the 4% of people who remain clean after stopping buprenorphine or the 96% who relapse within a year.  Would anyone at CPS have noticed which group she became part of?

Her case is an example of how complicated the ‘diversion’ issue has become.  And perhaps I’m paranoid, but I feel the need to say that I am against diversion of buprenorphine.  I’m saying so because I know the righteous attitudes of some physicians who claim to be more careful than others.  So to avoid confusion…. diversion is bad.  I’m on THAT side.

But death is bad too.  And breaking patient confidentiality is bad.  My new patient is someone’s daughter, and I found myself wondering what I would have recommended had she been MY daughter?  What would the reader recommend for his/her daughter?  She is 22 years old.  She became addicted to opioids at 16, when her best friend shared Vicodin that she found in her mother’s medicine cabinet.  By 18 had tried to quit a number of times on her own and with the help of meetings.  She failed intensive outpatient and residential treatment, like the vast majority of patients who take those paths, before her parents asked her to move out.

She tried calling numbers on the NAABT and SAMHSA databases but found that all listed practices within an hour’s drive were full, or more often were out of the ‘Suboxone business.’  She went on methadone for a few months but had trouble making the 50 mile drive to the clinic in the middle of January—an understandable problem for people who know the area.

At some point she met someone who agreed to share a prescription of Suboxone, splitting the script if she picked up most of the cost.  Compared to a buck per mg for oxycodone, she thought she found a bargain.

I’m usually able to let go of conflict in such cases by arguing for the common good, or by pointing out the things that she should have done to avoid her current problems.  But those positions are more difficult when one imagines the hypothetical case of a son or daughter.

I was going to make a number of points, but it is getting late, the Packers lost, and I’m in the mood to just call it a night.  I was going to ask whether or not her isolated case truly threatens the ‘public good.’  I was going to ask if it is appropriate to call CPS about someone who has done all that she can to create a better environment for her baby.  I was going to ask if breaking her confidence for the good of the child would be a bit paternalistic by modern medical standards.  I was going to ask if there are different types of ‘diversion’, and if self-treatment, in the absence of any other option, should always be condemned?

I think I’ll just leave it here, and ask people to imagine their own daughter in the situation that I described.  Would you be angry that she met someone who shared Suboxone?  I know that some will claim that there must be other options— an argument that I’ve already heard from several people claiming the doctor did the right thing to turn her in.  But if there were any options I didn’t mention, I am not aware of them.

What would you have recommended for your child?  Things worked out this time, but I have a waiting list of 90 people who are looking for a doctor who prescribes buprenorphine, and I had just discharged a patient the day before her call.  Nobody was out there making certain that after the call to CPS, she would find a reasonable option.  With that in mind, how was the call to CPS consistent with the thought of ‘first, do no harm?’

A few comments from the original post:

WisdomQ:
What is a pregnant woman taking buprenorphine supposed to do? Stop being addicted to opioid’s for 11 months? A 2010 study (http://www.nih.gov/news/health/dec2010/nida-09.htm) found bupe to be less problematic than methadone. Perhaps the most powerful tool is to never tell the child about it unless the child starts to abuse opioid’s on their own; considering the power of suggestion.

Tic:
This patient had been diverting suboxone for four years. I doubt that she was looking for a provider for four years without any success.

Me:

I don’t know what things are like in your area, but patients in northern Wisconsin have no access to buprenorphine-certified physicians. Some are listed– but they are all people who either signed up but never actually prescribed buprenorphine, or who shut down that aspect of their practice.

I’ve been at the 100-patient limit since shortly after the limit went from 30 to 100. My waiting list has 90 patients. Note that I do no accept any insurance panels– not just for the 30% of my practice that comes for addictive disorders, but for all patients– but patients wanting buprenorphine have no choice (the other patients choose to see me because I provide much longer appointments, guarantee to start on time, provide easy access, etc). There were two other docs in the county that at least prescribed the medication; one left a year ago, leaving one person.

Even in areas where there are more doctors, many doctors arbitrarily discharge patients after one year (or Medicaid in a state may stop covering the medication after one year). Studies show 94% relapse rate in people treated with buprenorphine for a year– i.e. the medication is best considered as similar to most other medications, as a TREATMENT, not a CURE. There are also practices who abandon the people who struggle the most– a cruel way of practicing medicine that is unique to addiction. So again, I imagine there are places where a patient has been kicked out of the practice of the only provider, perhaps for taking a benzodiazepine– instead of seeing the illicit use as one more aspect of her ILLNESS that deserves better treatment. Perhaps you consider it fair to give a 17-y-o woman one chance– and if she fails, tough luck—- and if that is the case, I hope you’re not someone’s doctor.