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!
Comments:
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.

Obsessed with Suboxone Diversion? Raise the Cap!

Last week, HHS Secretary Sylvia Burwell announced that the cap on buprenorphine patients will be raised above the current limit of 100 patients per doctor.  This move, should it actually occur, will potentially save tens of thousands of young lives per year, given that over 30,000 people die from narcotic overdose each year.  But instead of cheering the good news, some doctors used the occasion to rant about diversion.  Those doctors get on my nerves, and I’ll explain why.

Buprenorphine, the active ingredient in Suboxone, prevents opioid withdrawal in heroin addicts while at the same time blocking the effects of heroin and narcotic pain medications.  Many heroin addicts keep a dose or two of buprenorphine handy for times when the heroin supply, or money to buy heroin, runs low.  Other opioid addicts use buprenorphine in attempts to detox off opioid agonists.  Their efforts almost always fail, as freeing one’s self from addiction is much more complicated than getting through withdrawal.  But the statistics don’t keep addicts from trying, over and over again.  After all, the belief in personal power over substances is part of the addictive mindset.

Buprenorphine is viewed as just one more drug of abuse when viewed through the superficial lens of news reporters. Even some buprenorphine prescribers fail to understand the important differences between buprenorphine and opioid agonists. But the differences are important.  While over 30,000 people die from overdose of opioid agonists each year, less than 40 people die each year with buprenorphine in their bloodstream.  Of those deaths, most were caused by opioid agonists, and would have been prevented by more buprenorphine in the bloodstream.

I admit to a great deal of irritation when I hear doctors who should know better spreading ignorance and stigma about buprenorphine—an ideal medication for the current epidemic of overdose deaths.  To you doctors:  Really? 40 deaths per year—deaths not even caused by the drug— are the horrible cost to society that you are complaining about?  The same number of people die from lightning strikes!  Maybe, while you are at it, you should complain about tall trees on golf courses!

Forty deaths.  FORTY!

I think of fields of medicine where doctors take the lead to guide society to do the right thing.  Getting insurers to treat AIDS was the right thing.  But when overdose is the biggest killer of young adults, my colleagues spread fear about buprenorphine?!

Buprenorphine diversion is a complicated issue. Contrary to the media-propagated image of addicts getting ‘high’, opioid addicts always, eventually, become desperate and miserable. Some miserable addicts learn about buprenorphine, a medication that almost instantly blocks the desire to use heroin or other opioids.  When buprenorphine was approved for treating addiction, a cap was placed on the number of patients treated by each physician.  Reasons for the cap range from a desire to prevent ‘treatment mills’ to political compromises.  But whatever the reason, treatment caps and other restrictions prevent doctors from prescribing buprenorphine.  In the absence of legitimate prescribers, addicts purchase buprenorphine at a street price determined by supply and demand.

Some patients sell their prescribed buprenorphine medications.  Such sales are against the law, just as selling Oxycontin or Vicodin is a crime.  But in a world where heroin can be purchased more cheaply than Suboxone, and where pain pills kill tens of thousands of people each year, I’m sorry if I don’t get hysterical about the ‘buprenorphine problem’.  If there was any evidence or suspicion that buprenorphine serves as a gateway into opioid dependence (there isn’t), I’d think differently. But use of buprenorphine, at this point anyway, is confined to miserable heroin addicts looking for a way out of active addiction, who can’t find legitimate prescribers of the medication.

So to the people who wrote on government websites over the last week that ‘it makes no sense to treat one addictive drug with another’: You don’t have a clue.  Buprenorphine has unique properties that treat the essence of addiction—the compulsion to use ‘more’. And addiction is a chronic illness that deserves treatment as much as any other chronic illness.

And to the doctors who prescribe buprenorphine products and get their undies in a bundle about greater access to buprenorphine:  With all due respect, you must be doing something wrong.  I have 100 patients right now who tell me, at each visit, that I saved their lives.  I credit the medication, since the unique properties of buprenorphine are far more important than anything I have to say!  But I know that something saved their lives, because their former friends are dead, and they are alive– working jobs, raising families, and occasionally reaching out to lucky friends who survived long enough to hear them talk about the wonders of buprenorphine.

To those same doctors:  How can you not be excited by a medication that has saved so many of your patients?  If you don’t have such patients, I suggest you give some thought to what you’re doing wrong!  In this field, with this medication, saving lives isn’t that difficult. After 20 years in medicine (including 10 years as an anesthesiologist), I’ve never had the opportunity to benefit human life as much as with these patients, with this medication.

I hate to mess up a passionate article with talk about neurochemistry, but a couple facts deserve clarification. Diverted buprenorphine is not a ‘pleasure’ drug.  I’ve heard stubbornly-ignorant doctors compare buprenorphine to heroin, as if their stubborn beliefs alone can turn an opioid partial-agonist into an opioid agonist.  Surely they know that if someone with a tolerance from regular use of heroin takes buprenorphine, the drug will precipitate severe withdrawal?!  And if the same person injects buprenorphine, the withdrawal will be even more severe!  On the other hand, if someone addicted to heroin goes without heroin for over 24 hours and then injects buprenorphine, the buprenorphine will reduce the withdrawal.  But since the maximum effect of buprenorphine is far below the maximum effect of heroin, there is no way for the person to get ‘high’ from buprenorphine.  This is all simple neurochemistry! When a person injects buprenorphine, opioid withdrawal will be relieved more quickly.  But that’s a far cry from thinking that buprenorphine causes a ‘high’ similar to the effects of heroin.

After treating hundreds of patients over the years and talking at length about every aspect of their drug use, including their use of buprenorphine products intravenously before they found prescribers of the medication, I have always heard the same thing: that buprenorphine relieved their opioid withdrawal.

When I ask why in the world they injected buprenorphine, I hear the same reason– because the drug is expensive, and lasts five times longer if they inject it.  That answer, by the way, is consistent with the 25% bioavailability of submucosal buprenorphine.

How depressing that patients with addictions are treated like idiots… when they have a better understanding of neurochemistry than some doctors!

Suboxone as Problem, Suboxone as Solution

Originally Posted 3/14/2013
A local District Attorney wrote to me last week to express his concern about the increased diversion of buprenorphine.  I often sense an undercurrent of tension when I cross paths with attorneys, aware of the different attitudes that we hold that arise from our different roles in society.
The DA wrote about the dramatic increase in overdose deaths in the Midwest.   Overdose scenes are often littered with a variety of substances, ranging from bags of heroin to the orange plastic vials used by pharmacies to dispense medications.  If the overdose victim was on Suboxone or buprenorphine, the prescribing doctor is often contacted about the death and the ensuing investigation.  Doctors notified about patient deaths have reactions beyond the grief over the loss of someone they cared about, including guilt that they couldn’t save the patient, and even fear of being blamed for doing something wrong. Every doctor has seen headlines featuring peers accused of reckless prescribing, and the addiction world is somewhat unique from other specialties in the way that patient deaths cause a sense of ‘guilt by association.’  Oncologists, for example, are not viewed with the same degree of suspicion when their patients succumb to cancer.
I felt a bit defensive about the DA’s letter.   I know that buprenorphine saves lives, beyond a doubt.  I also notice that the positive actions of medications are often taken for granted, while the risks are cited as scapegoats.  I notice how quickly people complain about others ‘on buprenorphine’, without taking the time to ponder what would likely happen were buprenorphine not available.
Some physicians’ fears stem from dilemmas faced in treating addiction that are difficult or even impossible to resolve.  For example, a DA may point out that the doctor’s patients are not behaving like ideal citizens, not realizing that the doctor is every bit as aware of the problem, yet unable to make things better.  In some cases doctors do the very best they can (or that anybody could do), yet their patients struggle to maintain sobriety.  Doctors may be tempted to abandon the problem patients altogether, to avoid being seen as impotent or worse—as ‘part of the problem.’
I know, right now, that three of my patients are struggling with buprenorphine treatment.  Maybe I’m naive and the true number is higher, but I’ll focus on the people who I know, for certain, to be struggling.
The patients I refer to as ‘struggling’ are taking buprenorphine or Suboxone, but taking it imperfectly.  For years they were conditioned by heroin, as the misery of withdrawal was relieved by the poke of a dull needle and the injection of foul liquid, hundreds and thousands of times over.   They are now ‘freed’ by buprenorphine from the need to relieve physical misery, but the urge to penetrate their skin with needles continues. Buprenorphine binds opioid receptors so tightly that heroin or oxycodone, when injected, cause no high or change in sensorium, yet users are still drawn to inject, a status referred to as ‘hooked on the needle’, where the painful piercing by a dull needle fills an otherwise-intolerable emptiness.
Their actions appear insane to people who have never ‘shot up’.  Why would someone risk endocarditis—or worse– through shared needles, when the injection causes no pleasure, and in fact causes pain? The bizarreness of the situation doesn’t, unfortunately, make it less common.  The situation exists.
I tell my patients that the one thing that results in immediate discharge from my practice is sharing or selling medication that I prescribed.  Even in the midst of insanity there must be some absolutes, and from my perspective, an absolute boundary exists where one person’s behavior harms someone else.  A patient who sells a portion of his/her Suboxone to score heroin, or for any reason, has crossed a line.
But what about the person just short of that boundary—the person who is still ‘hooked on the needle’ who is trying, most of the time, to stay off needles and smack but at 3 AM, in a room with other users—a room where he hit the needle hundreds of times before—hits the needle again?
There are plenty of reasons to terminate treatment for such a person.  He shouldn’t have done it, shouldn’t have been there, shouldn’t have been with those people… and many doctors would stop treatment at such a point, even knowing that doing so contributes to another overdose death.
We don’t treat other difficult patients the same way.  Our noncompliant teenage diabetics are given second, third… endless chances to get their insulin right.  People with post-op hemorrhages are rushed back to the OR for more treatment—not tossed to the curb, labeled ‘difficult patients.’
And I know from experience that some people hooked on the needle, in the position I described, can be saved.  For my struggling patient, maybe tonight wasn’t his night.  But tomorrow, the balance between cues, cockiness, and desperation might allow him to say ‘no’.  And with the right sequence of events, and maybe the right words of encouragement, he might put enough days together to make ‘no’ a regular thing.
Or he might not.  Maybe saying ‘yes’ one more time will end any lingering hope that he will pull it together and give life on life’s terms a try.  For this guy on Suboxone, there is still too much disease in the mind and body for any prediction beyond a guess.  And if, at any time, he happens across something larger and purer than he’s ever experienced before, the respiratory depressant effects of whatever he uses may cost him his life.
It is at this scene where I suspect the DA and I would have different opinions.  I’d expect many DA’s, viewing pictures of a cold body with a needle in the arm and a half-full bottle of Suboxone on the bathroom shelf, would say the guy had his chance and lost the right to take medication a long time ago.  I respect the DA’s position, and wouldn’t expect it any other way.  The DA’s doing what he is supposed to do.
But at the same time, I hope the DA understands MY thoughts, reviewing the same pictures.  I’d think that had my patient made it past tonight, he might have strung a few better nights together. And by the odds, I’d know that had I kicked him out of treatment for screwing up the first time, he would have died weeks ago.
Of course I don’t enjoy prescribing a medication for someone who doesn’t take it correctly, despite my strongest warnings and admonishments. But had I simply kicked him out of treatment and THEN read his obituary, I’d wonder if I’d done everything that I’M supposed to do.