Subox Docs: Analyze This!

People on buprenorphine or Suboxone often write to me with complaints about lab testing.  I received an email last week that mirrors my personal experience with lab testing companies.
Here is what it said:
Dr. Junig:
I thought you might find this interesting. I continue to see (name withheld) for addiction treatment using buprenorphine. I see the doctor every three months, and I’m prescribed a low dose of Suboxone film (below 4 mg per day). I recently got an insurance denial for over $2000 in lab charges, for ONE urine test! Evidently someone sent my tests to (lab name withheld for patient privacy) who billed for 23 tests!  This is on a test that was negative for any substances other than the proper amount of buprenorphine.   This is like a license to print money! The same thing happened three or four years ago with (a National lab provider), but that was ‘only’ $600 and it eventually got written off. I have no idea if (withheld) will come after me– but there is no way I’ll pay them a dime.
Is there any wonder health costs are so out of control? How can a company get away with this? I have a feeling this is just routine and someone on the staff sent it by mistake as after the first incident with the other lab.   My doctor doesn’t usually send my tests into a lab, but instead just does the immune point-of-care test in the office.
Have you heard of charges this high? Just thought I’d pass it to you in case it’s good info for a blog post. Talk about crazy–  How in the hell, even seeing a doctor 4 times a year, could I remain in recovery on buprenorphine with total annual costs near $12,000?  Plus, doing these expensive tests on negative samples?  I can maybe see on a positive result – but negative?  This is so wrong.
I wrote this email in response (I’ve edited my remarks for grammar and privacy):
I wrote about this issue a couple of years ago, and I understand your anger.  I used the same lab company a few years ago for about a month, after their salesperson promised they would never charge anything beyond what insurance paid.  But they did charge some patients, and then other patients complained that one lab test used up their entire annual mental health coverage!   Now I only use point-of-care tests (which cost $3 each), unless there is a clear reason for confirmatory testing.
(Note—Wisconsin health insurers used to commonly limit mental health expenses to two or three thousand dollars.  Now, because of mental health parity laws, insurers must provide the same coverage for mental health expenses, including drug testing, as they do for other types of healthcare.  I guess it’s good that the care is no longer treated differently… but one very ugly result has been an explosion in lab testing costs—which increase EVERYONE’S insurance rates).
Back to my email:
In the past few years representatives from two pain clinics asked for meetings, and told me the same thing: that insurers were tightening payments for ‘injections’ by paying only for injections that actually worked (what a concept!).  The pain clinics now make more money from lab testing than from their bogus injections.  The problem?  Insurance would only cover one urine test per month unless an addiction doc was on staff, which would allow them to do unlimited numbers of tests.  They said that lab companies set up turn-key operations for docs providing equipment, technicians, billing codes, etc—and they could bill over $1000 for a test that used $4 in raw materials.   Even Medicaid paid over $500 for one urine test!
I would love to blow the whistle on this garbage, but every agency seems to have the attitude that doctors need to test people more, not less—no matter the cost.  Talk about a situation ripe for abuse!
Opioid agonists are a Godsend to patients with severe pain, whether the pain is acute or chronic.  Opioid agonists are also highly-abused, so some degree of monitoring is appropriate.  I wonder about the motives of some doctors, who prescribe ever-increasing doses of potent opioids, and then suddenly stop prescribing when a urine test shows traces of THC.  Those doctors know, or at least should know, that acutely stopping opioids results in severe withdrawal.    About ¾ of my addiction patients turned to street pain pills when a doctor, often the same doc who started them on pain meds, kicked them out of treatment for testing positive for THC or for running out of medicine early after treating a flare-up of their pain.
Even for the sadistic docs who practice that way, it doesn’t take a thousand-dollar test to discover a drug habit.  If society is truly concerned about healthcare costs, is it appropriate to spend $2700 testing for non-existent metabolites of non-existent substances, when one $3 test will detect the presence or absence of cocaine, buprenorphine, oxycodone, hydrocodone, amphetamine, THC, propoxyphene, PCP, heroin, or benzodiazepines?  Is the extra $2697 justified on every routine follow-up visit?  Inexpensive or free measures, such as pill counts or random 3$ point of care tests– are far more useful to determine if someone is selling or sharing a prescription.
Opioid agonists cause tens of thousands of deaths each year, so maybe someone could argue for that type of overkill with those medications. But this degree of drug testing for patients treated with buprenorphine?!   Buprenorphine is identified in fewer than 50 overdose victims per year in the US–  the same number of people killed by lightning.  Even in those few cases, buprenorphine didn’t cause death, but rather was present because the person used a buprenorphine product at some point in the days or weeks before overdose.  In fact, most of those 50 overdose deaths would have been prevented had MORE buprenorphine been present.
I find it bizarre that more and more ‘PA’s’ for buprenorphine products ask the question, ‘are you doing drug testing’?  I’m curious– what do the people who create those forms WANT to happen with their patients?  I’ve thought about writing back…. “Yes, I did drug testing.  He tested positive for marijuana, so I kicked him out of my practice, and he died of a heroin overdose last week.”  Would the insurer see that as a good outcome?  Would I get a pat on the back– “Great job!  That’s some GREAT drug testing you’re doing!”
Why So Much Testing?
When did doctors stop trusting their patients?  Doctors used to provide a confidential refuge for troubled people.  Med school ethics courses questioned whether doctors should take any action that interfered with patient autonomy.  Doctors must go against their patients’ wishes in certain situations, such as cases of child abuse.  But when did we start assuming that people voluntarily seeking treatment were lying?
I wonder why my colleagues are so eager to get behind aggressive testing.  I’ve already suggested one motivator—i.e. greed.  But that doesn’t explain the entire phenomenon, because many docs get just as excited about testing while leaving all the profit for the testing companies.  In those cases I’ve wondered if their willingness to distrust their patients relates to their backgrounds as addiction doctors.
Many addiction docs are psychiatrists, a specialty that attracts the most risk-averse medical students.  Consider the risks that doctors in other specialties accept as a matter of course.  A neurosurgeon speaks with a patient a couple of times, and then opens that person’s skull and removes part of the person’s brain.   Consider the CT surgeon who meets with a patient, reviews the tests, and then splits the sternum to sew grafts into arteries that supply blood to the heart.  Those doctors are entrusted to cut people open, remove diseased tissue, and provide appropriate follow-up care.
But when you talk to addiction docs about drug testing, they all say the same thing:  They have to do the testing ‘or they will lose their license.’   They claim that they don’t have the power or autonomy to decide which patients need to be treated like criminals, and which patients have proven themselves as trustworthy and stable.  They have no choice, they say, other than to test every single patient on every visit.
Then there is the true cynic in me, who wonders of some doctors just ‘get off’ on catching people.  Patients who come in for addiction treatment are in dire straits, and have a lot of work to do.   After living like animals, they are taking on the challenges of giving up their drugs of choice, learning to trust their physicians, giving up self-medicating, and learning to tolerate their emotions.   Many new patients struggle with giving up marijuana, a drug they’ve used to treat withdrawal for years, and a drug associated with mixed signals from a couple states (and from the President).   Kicking a heroin addict out of treatment for smoking marijuana is the worst type of of bullying I can imagine.
I admit that I drug-test patients.  But I don’t use drug tests to kick someone out of my practice, any more than an endocrinologist would stop prescribing insulin for a diabetic patient who can’t stay on a diet.  My patients know that I don’t kick people out for struggling, so I usually hear, at the start of the appointment, if a patient has relapsed.    I’m sure there are docs who think I’m naïve, who believe that patients are getting away with something ‘on my watch’.  But I can live with that.   In return I get to be a doctor who treats people like human beings, not criminals.
If buprenorphine was causing death (it isn’t), serving as a gateway drug (it isn’t), or was used in some nefarious way similar to GHB (it isn’t), I would likely think differently.  But honestly—the docs and DA’s who spout that ‘buprenorphine is just like heroin’ are idiots.  I suggest that they learn a bit of neurochemistry before spreading such nonsense.  In fact, just pay for my travel and I’ll walk you through the science, and show you WHY you’re idiots.
To the doctors who aren’t yet making a profit from lab testing but considering jumping on the bandwagon, reconsider. What type or relationship do you want with your patients?
To the doctors who gave in to the slick sales pitch from a lab company’s salesperson who brought you a nice lunch, and promised to only bill insurance so that ‘nobody loses’, stop kidding yourself.  You are a big part of the problem.
And to the docs who make money from treating all patient like liars, driving up insurance rates for the rest of us…  Shame on you.

Drug Testing, Prescribed Opiates, and Employment

Im in a methadone maintenance program and am currently at 130 and I have pre-employment drug screen coming up in about a month. I wanted to see how low I could get off the methandone and switch to suboxone. if it is not detectable in a drug screen. Also, I have a prescription for methadone can they not hire me because a Dr, prescribes methadone.? Any thoughts, ideas?

My thoughts:
There are laws that prevent a person from being fired because of certain illnesses or disabilities, but those laws are complicated. Drug addiction is a ‘protected disability’, so theoretically you cannot be fired for being a RECOVERING drug addict. On the other hand, you can be fired you for any other reason, or for no reason at all! So except for the occasional boss who is a total idiot who says ‘I don’t like recovering addicts so I am firing you’, disability law is not involved.

In general you cannot be fired for having an illness… unless the illness interferes with your job. A surgeon can be fired for being HIV positive, as there are just some risks of transmitting the virus during surgery that cannot be TOTALLY avoided– an accidental needle stick during a frenzied attempt to get a suture around the splenic artery, for example.  I used to be an anesthesiologist and miss those days– in the situation I’m referring to, a person came in with a ruptured spleen from a car accident. The blood pressure was stable, but in such a case the intra-abdominal pressure is often holding the spleen together, and as soon as the belly is opened the spleen will pour blood into the belly and the patient will crash…  so the anesthesiologist gets several large-bore lines in the patient, hangs fluids and blood through blood-warmers, maybe even get an infusion of a pressor set up and at the ready to maintain the pressure as best one can when there is a large hole in the spleen…    I loved that work but like the HIV-positive surgeon, it just was not the place for me anymore.  How could I keep all of my attention on the patients under my care, when there were buckets of opiates right next to me under my control?  I think that on Suboxone I would be OK– I think the cravings would be treated so that they would not be a distraction– but I understand, and accept, that I would never be able to convince an employer of that fact.   Alas…. I miss that job, but I am surprised by how I enjoy being a psychiatrist in a different way, and the enjoyment grows as each year passes and I get to know my patients more and more.    OK, enough about me– back to the letter:  A person on methadone can be fired, regardless of getting it legally for pain or from an addiction program, if the job requires operating heavy machinery– because taking methadone, other opiates, sedatives, etc are simply not compatible with operating machinery. Yes, you might feel fine, and even be fine– but it would be so easy for an injured party to file a lawsuit and win by saying that ‘the company had a person taking these drugs, and it says right here on the bottle not to operate machinery!!’ So you will never win the ‘right’ to work while taking impairing medication.

As for drug tests, first realize that methadone shows up in tests for a LONG time– for weeks in some cases. Whether Suboxone will show up is hard to predict; it sometimes shows up and sometimes doesn’t, depending on the manufacturer of the test. I have many patients who have undergone drug testing, and none have come up as positive, but I have purchased test kits that have shown buprenorphine as positive for ‘opiates’. The problem is that you have to list your meds at the start of the test, and if you hide it and then it does happen to show, you are in trouble.  One solution to that problem is to say you take Suboxone for chronic pain; that you use it because it causes less CNS effects (sedation, etc) and you want to be ‘super sharp for your job!!’. Of course you would need your doctor to verify that when he is called by your company.

If you are switching to Suboxone, do it sooner rather than later– get the methadone out of you as quick as you can. And in MOST cases, the Suboxone that you would take would not show up in any test. It isn’t the number of panels on the testing kit– it is the manufacturer of the kit, and there are many manufacturers. I have kits with many different panel set-ups– the companies will make whatever collection of tests that I ask for. I have kits that detect buprenorphine (suboxone), or OC, or methadone, or whatever. If a company wants to test for buprenorphine they could get a buprenorphine test strip for about 3 bucks. But the companies know that they would be challenged for ‘snooping’ into your personal medical history, rather than searching for active drug abuse– that is the only reason they don’t test for buprenorphine.

Wouldn’t it be nice if addiction was treated like any other illness, and you could explain to your employer that you ‘caught’ opiate dependence when your doctor prescribed high-potency narcotics for your back pain, and that now you are under treatment…  and for that, you weren’t fired?  Maybe some day.