What chaos would follow the potential losses of societal contributions from these parents, teachers, construction workers, EMTs, grocery store employees, home health workers, farmers and human beings, who would need once again to devote time, energy and money to obtaining illicit drugs? How soon would we see unnecessary spikes in overdose, hepatitis C, heart valve infections and HIV when intravenous drug use suddenly became a daily need again for so many?

But soon after COVID-19 hit our state, just in time for us to keep our patients safe in lockdown, government and private insurance organizations expanded coverage for telehealth. In a short space of time, increased payment to clinics for telehealth services and enhanced flexibility in the rules for connecting virtually with patients have dramatically transformed our practice.

Now we understand that we must fight to keep these changes.  

Our health equity medical organization, REACH, in Ithaca, New York, has seen an unexpected and remarkable increase in our ability to help the under-served populations we have historically struggled to keep engaged and healthy. Now we understand that we must fight to keep these changes—not allowing them to expire when President Trump declares an end to the current National Emergency.  

COVID-19 Demanded Telehealth, Not Barriers

Our young, nonprofit medical practice serves people from, at last count, 26 counties. We provide them with buprenorphine, the gold-standard, lifesaving daily medication for opioid use disorder (OUD).  

REACH Medical is a low-threshold, harm reduction medical practice, additionally offering integrated primary care, testing and treatment for HIV and hepatitis C, and robust behavioral health, care management, and outreach services.  

We serve over 1,000 people with OUD in rural and under-served swaths of the Central, Western and Southern Tier areas of New York State. Over 80 percent of our patients are enrolled in Medicaid, 30 percent have no or insecure housing, and many regularly travel hours for their care because help closer to home does not exist.

The pandemic of a century was only the next wrench tossed into our operations.  

The March COVID-19 public health emergency declaration put a rapid moratorium on in-person visits. We had no existing infrastructure for telehealth, and we weren’t alone. US medical practices have been devastated by the pandemic, seeing a “55% decrease in revenue and 60% decrease in consumer volume because of COVID-19.” In human terms, this means that six out of 10 times a person would otherwise consult a medical provider, they are now staying home. Many healthcare centers cannot afford to pay employees or keep essential items, like hand sanitizer, in stock.  

With our country’s population unable to seek the medical help they need, we began to see one of many secondary crises emerging from the pandemic.  

As of March, managed Medicaid and most other insurers paid only a pittance to healthcare providers for telehealth services. With 80 percent of our patients relying on Medicaid—a government program often outsourced to private, profit-driven companies—we would not have survived financially. Providing telehealth services only, we could not have paid our staff. That’s why we faced the overnight removal of a safe alternative to an unpredictable and deadly drug supply for 1,000 people in Upstate New York.

As an organization committed to health equity, we have spent the two years since we opened in 2018 upending and circumventing seemingly arbitrary restrictions on healthcare delivery. 

These include extra and expensive training to prescribe buprenorphine; limits on the number of patients to whom we can prescribe it (not required for full opioids like oxycodone); the inability to prescribe while patients are incarcerated, setting them up for high risk of losing tolerance and overdosing upon release; and court mandates that patients participate in non-evidence-based treatment programs with mandatory counseling.  

The pandemic of a century was only the next wrench tossed into our operations.  

How We Got to Work

We tightened our financial belt for a few weeks, briefly furloughing our part-time, contracted medical providers (all fully employed elsewhere) and re-imagining the job descriptions of our staff to maintain our commitment to being a living-wage employer.  

We researched telehealth platforms that didn’t require patients to pay for, or even download, apps. We adapted our electronic medical records with new telehealth templates and kept abreast of changes in billing policy. We retrained our front staff to act as “traffic controllers,” directing our online clinical days. 

We expanded our outreach program by sending a community health worker to our local homeless encampment, known as “the Jungle,” to connect people without functional smartphones with on-the-spot telehealth visits, utilizing the worker’s phone. We also opened our virtual doors to patients around the state whose practices were unable to support them through the pandemic.  

We kept our collective eye out for expected news of overdose deaths and a growing list of patients “lost to treatment.” We braced ourselves to stave off economic ruin until REACH could be reestablished some time in a distant, different future.  

But it turned out, April 2020 was perhaps our best month ever. Part of the evidence for this was the overwhelming positive feedback from the many additional people we reached—adding 53 new OUD medication patients that month. 

“I am so grateful for all of you,” said one young woman who was engaged through our in-person telehealth outreach. “I don’t know where I would be without you; you are all so positive. I just appreciate being treated like a human being.” As she spoke, tearing up, she was sitting in the Department of Social Services, trying to get a decent place to live. 

“You’re helping me with my fucking medical PTSD.” 

Structurally, a flurry of do-or-die decisions came down from federal and state government insurers: Public payment for telehealth was increased from negligible to on par with in-person visits; new patients could now be started on buprenorphine by video or telephone; telehealth visits no longer required the patient to be physically in a medical office. Central to our survival, local managed Medicaid companies opted to honor these guidelines.  

Against myriad systemic disadvantages—spotty rural broadband, limited access to electricity or the funds needed to charge and add minutes to phones, part-time jobs with no allowed leave for medical appointments, chronic food insecurity, childhood abuse, domestic violence and violent trauma—our patients showed themselves to be unbelievably resourceful. They save phone minutes for visits, sanitize and share camera phones, walk half an hour to public Wi-Fi at their appointment times.  

They are making it happen, even if they give us credit. “As much as I’ve been discriminated against in the past—and I’ve been treated so badly—when I tried to be honest with my doctors in the past, it wasn’t actually a good idea, it turned out,” said one father of four, employed for the first time in five years. “Now I keep having to remind myself, ‘REACH isn’t like that’ and I really can tell you guys how I’m doing and what I need. You’re helping me with my fucking medical PTSD.” 

21st-Century Home Visits

In the two months since COVID forced this transformation on our practice, I’ve met three newborn babies whose parents stay healthy with OUD medication.  

“This is a REACH baby,” wept one dear patient. “She’s your miracle so please tell everyone on staff what they made possible, that we did it!” I had been able to visit with her virtually in her quiet room on labor and delivery and not only refill her Suboxone but discuss and treat symptoms of postpartum anxiety before the pair were discharged.

We’ve realized how much we’d been missing from the stories we thought we knew.

The insights telehealth has given into the daily lives of our patients have been incredible. We have been taken on virtual walking tours of dairy farms, shared work breaks with essential workers, ridden empty buses through distant Upstate towns, been shown awful tent living conditions and provided sleeping bags in response. 

We’ve realized how much we’d been missing from the stories we thought we knew, and this has enabled us to provide more informed care.

Our patients, too, are fully aware of the benefits telehealth has brought—lowering barriers to care and above all, continuing their access to the medication they need.  

“If I lost my medication and lost you as my physician, I would probably die and am serious about that,” wrote one.  

“I would have already been stealing to buy heroin. I hate to say it, but it’s true,” said another.

The inherent intimacy of rural addiction medicine in the context of people’s homes and lives pulled us from our standard practices and promoted the honesty and trust that is so critical to doctor-patient relationships. As in obstetrics and palliative care, these relationships skip the niceties and demand real connection. We cry daily, swear regularly, ask and answer embarrassing questions, and swell with pride at the teamwork that binds our staff to this service. More than anything, we bring our full selves to work. 

This Won’t Fit Back in the Bottle

The rule changes which have allowed REACH to thrive during this emergency transition to telehealth will expire when President Trump declares an end to the National Emergency. But we, and our patients, are unwilling to go back to the old restrictions which insurance agencies were forced to remove.  

These are massively overdue advancements which promote health equity for rural and underserved communities. Our patients’ health should not be dependent on decisions driven neither by commitment to evidence, nor by equal access to care for those at the highest risk, but by political and financial motives.   

This flickering moment in which we have felt the handbrake taken off shows what power insurers hold over the lives of millions of Americans who contend with the daily threat of our healthcare-created overdose crisis. How blind to this we all have been.  

Now that these needless barriers to care for the most vulnerable in our communities have been removed, we must fight to make this permanent. 

Justine L. Waldman, MD, the founder, CEO and medical director of REACH, and Judith L. Griffin, MD, its director of research, both contributed to this article.

Photo by Joint Base Pearl Harbor-Hickam/15th Medical Group via FE Warren Air Force Base.

The post Telehealth Must Stay After COVID-19 to Save Our Patients From Overdose  appeared first on Filter.

Legislators in my state of New York are currently considering a marijuana legalization bill designed to do exactly that. The stories of two of my patients illustrate why we desperately need it.

Henry

Henry*, a black man in his 40s, went to high school with me. Unlike me, he knew what he wanted to do after graduation: He wanted to be a chef. A giant at 6 feet 7, he has an unfailingly outgoing and kind demeanor. He used to get off the bus from the high school culinary program and divvy up fresh pies and cakes amongst eager adolescent recipients.

A few years after college, Henry took a bad fall down a flight of icy stairs and landed with a crunch on his neck. Combined with a mild congenital spinal deformity, this injury has resulted in 20 years of chronic, unremitting pain and arm tingling.

When he came to the REACH office in Ithaca, we hadn’t seen each other in 20 years. Henry had lost so much weight that I hardly recognized him—until, that is, he performed an impression of his high-school self in the waiting room. He had just consulted with local neurosurgeons to discuss treatment options and left their office determined to avoid surgery or prescription opioids—he had seen their use go south for too many people to want to try them.

Other medications like amitriptyline and cyclobenzaprine left him groggy, so he turned them back to his doctor. Staying active and social has long been his main recourse. For years, he did regular physical therapy, lap swimming, stimulating electrode therapy, massages (when he could afford them) and yoga. He also took enough ibuprofen to tear up his stomach, all without enough relief to let him stand and cook in a kitchen for more than an hour.

“Suddenly, I wasn’t [seen as] an active single father who helped with homework and baseball practice, I was a lazy black dude who lay around smoking weed.”

Henry lives downtown in subsidized housing with his son. He recently got approved for SSI (supplemental security income), as he hasn’t been able to work due to pain.

In the evenings, he smokes marijuana to ease his pain while playing video games. He finds that it calms his mind and lets him get recuperative sleep. Marijuana has helped him to deal with anxiety, and to make peace with a life that hasn’t aligned with the one he envisioned.   

He came to REACH to request certification for medical marijuana, which we completed that day. Despite the much higher out-of-pocket expense, he wanted to obtain marijuana legally to avoid further trouble.

Henry’s son is now in high school. Years ago, when Henry and his white girlfriend broke up, they endured custody hearings together. During proceedings, she reported to the judge that he “smokes marijuana and plays video games.”

“Just the mention of it changed everything in that courtroom,” Henry told me. “They immediately decided to take my custody. I didn’t have any charges!” The judge’s sudden shift in tone made him feel he was being seen as “that stereotype of a neglectful black dad smoking away my days and ignoring my child.”

“That couldn’t have been farther from the truth,” he pointed out. “At that point I hadn’t had any interruption in my employment and my resume was impeccable—but they couldn’t see that. I wasn’t an active single father who helped with homework and baseball practice, I was a lazy black dude who lay around smoking weed.”

His full custody was reduced to visitation every other weekend, until he had completed drug and alcohol counseling. He eventually got full custody back. Scarred by this experience, he is acutely aware of how high the stakes would be for him if he were found using marijuana from an illegal source.  

Amelia

Amelia* is a laid-back, intensely smart white kid with academic parents and a social justice heart. I saw her at my previous practice five years ago for her 16-year-old physical. Besides a meningitis vaccine, our agenda was to catch up and have the requisite talk about sex and drugs.  

Amelia then shared with me that, though she didn’t smoke marijuana more than a few times a year, the prior spring she had sold $20 of marijuana to a friend on school grounds.

Someone had told the police, and she had been arrested and charged with a felony for selling to a minor. She was expelled from her school district for a year; her family hired a lawyer and paid a $5,000 fine.

After stressful hearings, mandated community service (which she totally enjoyed) and repeated urine testing, the judge made his decision. He told Amelia that, because she was “such a promising young woman,” he was able to seal the felony under “youthful offender status.”

When I spoke with Amelia, she was a devoted Political Science student and serious rower. She joked, with a grimace of white guilt, that unless she wants to join the FBI, her marijuana incident won’t get in the way of her goals. Besides the worry heaped on her parents, she noted, the worst part was her acute awareness that “such a promising young woman” felt like code for “good white kid.” Had she been a woman or color or less well connected, her education and employment future would have looked dramatically different.

“If this happened to one of my black friends, it would be a totally different story.”

Two years later, at her pre-college physical, Amelia gave me her update. She had gotten into a great university in the Midwest and was in an awesome relationship, but was again feeling guilty about “something stupid” she had done.

Now 18, she had been pulled over for using her phone while driving. The officer discovered 10 ounces of weed and $2,000 in cash. She had been charged with possession with intent to sell,  forfeited her car, and felt sure this was a death-knell for her life plans.

But once again, the judge had gone to bat for her, handing her a five-year conditional discharge. This meant only that if she got in trouble again, she could be retried for the earlier offense. The judge also sealed this charge under “youthful offender status,” even though most don’t get that reprieve the second time around.  

She was even more certain than before that the leniency she experienced was due to her privilege. “If this happened to one of my black friends, it would be a totally different story.”

Amelia is now a semester away from graduating, debt-free. She doesn’t miss smoking weed, is bringing her boyfriend home for Christmas, and is busy with interviews for left-leaning think tanks. The leniency she was shown is clearly good news for her, for her family, and for her ability to contribute to society. The problem is the racial chasm it illustrates.

New York’s Marijuana Regulation and Taxation Act

Currently about a million New Yorkers have had criminal justice contact because of marijuana charges. Black and Latinx people make up 80 percent of those affected—despite using marijuana at similar rates to whites and constituting only 32 percent of the state’s population.

New York’s 800,000 arrests for small-scale marijuana possession in the past two decades have played out in individual pieces of suffering—custody loss, incarceration and the resultant family separation, and loss of life opportunities—that have devastated families and communities of color.

We now have hope. There is a New York State bill in the Senate and Assembly (S03040-C Krueger, A03506-C Peoples-Stokes) that can begin to ameliorate this shameful disparity—if it is passed without removal of its critical racial justice provisions.

The Marijuana Regulation and Taxation Act (MRTA) will reduce or eliminate many prior marijuana offenses—clearing records for acts which are no longer crimes, and reducing barriers to work, custody and housing.

Critically, it will also lower legal and financial barriers to entry into the legal marijuana industry—particularly important for people of color who have been excessively harmed in economic ways, as well as so many others. It will create a micro-licensing program like that for New York’s thriving microbrewery industry, facilitating gainful employment and enterprise for people without substantial savings.

Half of all tax revenues will be committed to a Community Grants Reinvestment Fund.

The expected tax revenue is large—the state comptroller’s 2013 study put it at $400 million annually at least—and MRTA demands that a substantial portion of these funds be directed toward repairing racial injustice.

Half of all tax revenues will be committed to a Community Grants Reinvestment Fund, which will include, according to the Drug Policy Alliance “funding for community-based projects including adult education services, job training, the expansion of afterschool programs, re-entry services, and other community-centered projects.”

Further, “25 percent of the revenue [will support] the state department of education to keep public schools open and provide a quality education to New York’s children. The final 25 percent … will be directed to funding drug treatment programs and public education campaigns geared toward preventing drug misuse, reducing opioid overdoses, and saving lives.”  

It’s wonderful that New York could soon become the 11th state to legalize marijuana. But equally importantly, this bill can provide a powerful example of how to go about undoing some of the ongoing harms to communities of color rendered by the War on Drugs.

The Responsibility of Unearned Power

“The crack epidemic was like Raid in a bottle,” Henry recalled during our discussion. “What do you do when you see roaches? You spray it all over them. Just like cops and crack back then. The punishment hits everyone and gets deep in the bloodline of families. You can’t get it out. [Marijuana enforcement] is the same.”

As a 1995 Los Angeles Times articles reported, “Whites are more likely than any other racial group to use crack, according to surveys by the National Institute on Drug Abuse. But the US Sentencing Commission reports that about 96% of the crack defendants in federal court are nonwhite. And, records show, the majority are low-level dealers, lookouts and couriers rather than drug kingpins.”

In this ugly context, it’s little wonder that when we discussed marijuana legalization, Henry said, “I’m all for it.  

“White supremacy takes away the ability to see someone else’s pain.”

As a white physician without an arrest record, living and working in an 80 percent white city, I am both obliged and honored to use my unearned power to listen to, learn from, speak out with, reach out to, and fight for my sisters and brothers with far less privilege.

Kassandra Frederique, New York state director for the Drug Policy Alliance, has said, “White supremacy takes away the ability to see someone else’s pain … It takes compassion away.”  If we are to right the wrongs of our collective past, if we are to bring justice and health equity to our state, we must summon our compassion now and pass legislation to explicitly benefit those most harmed by our racist past and our racist present.

Governor Cuomo, you have more power than anyone to make this right for New York. Use that voter-elected, wealthy, white, male, educated power. Prioritize passage of the MRTA in January without removing its strong provisions for racial justice.

*Names and some identifying details have been changed; subjects gave permission for their stories to be used.

Image via The Tornado Times.

The post Ugly Disparities Among My Patients Demand Marijuana Racial Justice appeared first on Filter.

When he was younger, Jed, was a professional skateboarder. But he had suffered horrifically during his upbringing in Upstate New York farm country. He lived under threat of beatings from a physically abusive and frequently drunk father, and was preyed upon by an uncle who visited and raped him repeatedly throughout elementary and middle school. His mostly absent mother had untreated schizophrenia. His sister was eventually diagnosed with bipolar disorder, and was rarely stable enough to be an ally. Jed had his first beer and cigarette at seven, freely offered by his dad, and often found alcohol an escape.

Skating helped. He found that it enabled him to “live in the moment” and turn off the intrusive flashbacks and worry—like when he got drunk, but without the negative consequences. Through skateboarding he mastered risky tricks, garnered respect from older kids, traveled for competitions in locations further away than his dad had ever ventured, and learned to test the edges of physical danger. He wrote a new story for himself—one in which he was in charge.   

Jed had been on Suboxone for eight years. But he was vibrating with suppressed emotion, with daily thoughts of suicide.

It all fell apart when he suffered a serious skateboarding accident at the age of 21. The fall fractured his pelvis, ending his career. Without skating, and clearly facing many life challenges, Jed spent the next 14 years taking an increasingly diverse and high volume of whatever drugs he could get his hands on, ideally heroin.  

He got Hep C from a shared needle. A few month-long stints at what he calls “shitty rehabs” only deepened his hopelessness. Individual and group therapy that was mandated after trouble with the law brought up enormous shame, another challenge to picking up work shifts, and no real solutions.  

Suboxone changed his life, he says. Other changes in his circumstances undoubtedly helped, too. When he started taking Suboxone he was 35 and in love with Tracy*, who is also my patient. Tracy said she was also working on “getting clean,” and together, they were planning to open a food co-op. Jed managed to cure his hepatitis with treatment, which gave him some more daily energy.  

When I met Jed last year, he had been on Suboxone for eight years. But he was vibrating with suppressed emotion and had scored a 27 out of 30 on his intake depression screen, with daily thoughts of suicide.

“It brings me right back; I feel like a piece-of-shit little kid.”

I didn’t understand. Their business was going great; they had secured a new investor and found a vocal supporter in the local town’s government. Tracy had had a scare when we investigated her worsening headaches and discovered a significant brainstem malformation. But surgery went smoothly and she just needed the occasional 5mg oxycodone to manage the pain.

Why, then, was Jed so anguished at our first meeting at REACH, the low-threshold, harm reduction primary care clinic in Ithaca, New York where I work?

It turned out that he had failed his urine screen—the first time this had happened in eight years of weekly testing—and was therefore being dismissed from his long-time doctor’s office.

He knew I could prescribe Suboxone at his current level—8mg twice daily—without interruption. But it wasn’t the loss of a prescription that had crushed him. Instead, he said, it was “being treated like a junkie for the first time in eight years. They didn’t believe me when I told them I didn’t take [Tracy’s] pills,” he told me. “I thought I’d earned some type of respect.”

He sounded defeated. He said he had felt like relapsing, and knew where to find dope, but had sequestered himself to bed for a few days instead.

“It just brings me right back; I feel like a piece-of-shit little kid.”

Urine Screens Are Overused and Misused

It is still common for abstinence-based practices to require urine toxicology screens at every visit. The results are used to decide who gets treatment—essentially retaining only those who are flawless, and providing a selection bias in favor of less sick patients.  

I often see patients who have been dismissed from another practice for just one illicit THC- or opioid-positive urine screen. Even at a clinic in a nearby city that describes itself as “generous,” a two-strike urine policy is used to dismiss patients for a whole year.

This is both absurd and cruel when we’re trying to help people with so many personal struggles, who will almost always take some backward steps as well as forward ones. We should remember that urine screens are frequently inaccurate, giving both false negatives and false positives. And when providers dismiss patients for “dirty urines” we endorse a series of damaging alternatives to continued care. I would place these in three categories:

1. Chaotic or risky drug use and its direct consequences.

This may include exposure to different opioids—with fentanyl, for example, so prevalent in street-drug supplies. When we stop treatment we endorse the patient’s increased risks of acquiring Hepatitis C, HIV, cellulitis and abscesses, and developing increasingly resurgent endocarditis. We also endorse the enormous associated medical costs—of avoidable ICU admissions, for example, for sepsis.

2. The functional loss that rejected patients experience.

Buprenorphine is a remarkably stabilizing medication. In the eight months since our clinic opened its doors, we have prescribed buprenorphine to 392 patients, with a three-month treatment retention rate of 88 percent. Our staff has heard daily stories of first jobs in a decade landed, marriages salvaged, child custody earned, and poetry collections written. Stable Suboxone patients don’t experience the dangers and inconveniences of using drugs that are targeted by law enforcement. They don’t need to sneak away from their families to use or score, or to miss work because of withdrawal. Stable patients on buprenorphine bring their kids to fall parties and manage business teams.    

3. The consequences of primary care neglect.

When we dismiss patients from a medical practice, we also endorse the progression of their unrelated conditions. We let our patients know that, because of their drug use, they do not deserve healthcare. I often find myself doing remedial primary care for people who have lost access to other healthcare due to “dirty urines,” or violations of other shameful policies. In these circumstances, I’ve found cervical cancer, wildly high blood sugars, systolic blood pressure in the 200s, and multiple unwanted pregnancies (an astonishing 86 percent of pregnancies in women with opioid use disorder are unintended).

All three of these consequence sets are particularly damaging to patients with substance use disorder who have endured adverse childhood experiences (the vast majority). Most of our patients have experienced: childhood abandonment by, or loss of, someone close to them; abuse or neglect by someone they should have been able to trust; chronic food or housing insecurity; and other traumas.

Refusing to care for these people is not only irresponsible from a public health perspective, but retraumatizing. It erodes the trust we work to build into our caregiving relationships. Even if we offer to continue other services, rejecting patients for buprenorphine alone greatly damages these relationships.

“You did a shameful thing and I think you should go buy heroin, but please come back for your Pap” is not a genuine offer of support.

If We Use Urines, It Must Be With Consent and Compassion

In medical school we all recited a version of the Hippocratic Oath including the promise that, in the practice of our art:

“[We] will apply, for the benefit of the sick, all measures [that] are required…  [We] will remember that [we] do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability. [Our] responsibility includes these related problems, if [we are] to care adequately for the sick.”  

We are now practicing this art amidst an epic American crisis. We must remind ourselves of the most basic purpose of our work: to keep people alive and functional.  

We know that medication helps to do this. And we know that patients who revert to illicit drug use—usually exhibiting the very symptoms for which they sought help—continue to deserve access to medication.

At REACH we perform urine drug screens quite infrequently: monthly or less. We first make clear to patients that screens are never used as grounds for dismissal or negative changes in treatment—only as a way to obtain information, with their consent, which we can then discuss.

I usually tell patients something like, “I only care that the bupe is in there to protect my license,” because I’d want to know if it was never being taken. Patients are super-forthcoming about what they expect us to find. And if anyone “can’t pee,” we say, “That’s ok; we’ll get one next time,” which always gives them an out if they want it.

The results inform my practice. If there is no buprenorphine in the urine, for example, we talk about why not. There are numerous ways in which this discussion can go:

*Maybe it’s time to acknowledge that the person is not feeling ready for buprenorphine treatment and that we need to agree a new, more honest assessment of our current goals of care.   

*Maybe they can’t afford to pick it up, and we need to talk about what can be done.  

*Maybe the dose wasn’t adequate to quell cravings, and we need to consider a different dose.  

*Maybe the particular formulation was intolerable (“I keep gagging orange,” is one complaint I’ve heard) and a dissolving tablet would be better than a film.

Our goal is to get treatment to everyone who wants it, making extra effort to get it to the patients most in need—whether or not that treatment is periodically interrupted by illegal or harmful drug use. As in other areas of medicine, illness should be a trigger for treatment, not for abandonment.  

If a woman with diabetes had a blood sugar level of 300 mg/dl at an office visit, we would educate her, offer support for healthy food access, check renal function and make medication changes—such as a statin to protect her from the harms of high-circulating blood sugar on the blood vessels. Creating a policy of denying treatment when sugars are high, suggesting lunch at a nearby Dunkin’ Donuts, and offering to arrange dialysis when her kidneys fail would be grounds for a malpractice suit.  

The fact that that scenario sounds so ridiculous, while denying OUD treatment because drug use is often seen as acceptable, reveals the overlay of Puritanical morality we must reject.

Whatever the reason, stopping his treatment for opioid use disorder would be unethical and medically irresponsible.

To return to Jed, let’s try a thought experiment. Assume for a second that Jed did take a few of his wife’s oxycodones (though actually I suspect it was a false positive, perhaps set off by his naloxone). Maybe he wanted to treat his chronic pain, or wanted that old feeling of escape. Maybe he simply reacted to a moment of hopelessness.

Whatever the reason, stopping his treatment for opioid use disorder would be unethical and medically irresponsible. He should be offered support: perhaps an increase in his Suboxone dose for a period of stress; perhaps better treatment for his depression; perhaps an increase in his visit frequency (but not his urine screenings!) to provide external accountability and build trust.

I actually saw Jed last week for our monthly check-in. He was eating a scone from the fresh collection donated by a local bakery every Monday. Tracy was with him. She hugged me on my way in and then gave us some space while she chatted with staff and tidied our messy rack of clothing offerings.  

Jed will be meeting soon with our psychiatric nurse practitioner to discuss changing his antidepressant medication. Last week, he asked me for nicotine patches and gum, as he is aiming to quit smoking by the New Year. We adjusted his blood pressure medication, refilled his Suboxone and gave him a flu shot.  

It was a normal and lovely visit.

*Names and some identifying details have been changed.

The post In Healthcare, Urine Screens for Drugs Are Routinely Used to Justify Cruelty appeared first on Filter.

Her panicked boyfriend cradled her dripping head and told us, “I don’t know what happened; we didn’t take anything!” For fear of arrest he delayed, even as I breathed for her through a mask, finally telling us that she had just sucked fentanyl from patches and overdosed.

Naloxone revived her immediately. After a spate of projectile vomiting in the back of the ambulance, her vital signs completely normalized and a look of resigned shame set into her face.

I don’t know what happened after we dropped her at the ER but, like others in her chain of care, I had no responsibility to find out.

“I didn’t know that every person on chronic narcotics should be sent home with Narcan,” Dr. Justine Waldman, who was likely the receiving ER physician that day, now reminds me. “And I didn’t know that every time I or my staff added shame to a person she became less likely to ever return for help.” 

After practicing medicine for years, I’m now back in Ithaca. I’m a mother, a family physician and the associate medical director at REACH: a low-threshold, harm reduction primary care clinic with embedded medication-assisted treatment (MAT) for opioid use disorder.  Justine is the medical director. Under her brave leadership and mentoring, we opened our doors in February in response to the growing opioid crisis sweeping through Upstate New York.

Patients from no fewer than 17 counties have come to us for MAT in the six months since we opened. There is simply no help where they live.

Rural populations like ours are especially vulnerable to opioid use disorders. Small clinics in small communities are less likely to have sufficient staff to support a treatment program, less likely to have buprenorphine-waivered providers, and less likely to have nearby specialists to consult.

Rural communities have fewer social support systems for patients, such as housing, public education and job opportunities. They may also lack accessible peer meetings, affordable healthy food, and reliable public transportation.

There are an estimated 2.1 million Americans with opioid use disorder. Overdose is the leading cause of death in our country for everyone under the age of 50. Last year there were an estimated 72,000 overdose deaths in the US, a 10 percent increase from 2016.

In our state of New York, the increase in overdose deaths has been much faster than the national average. But there is a profound urban-rural split: Between 2010 and 2015 New York City saw a 45 percent increase; the rest of the state saw 84 percent.

At our Ithaca clinic, this disproportionate distribution of opioid use to rural areas is reflected by the alarming fact that patients from no fewer than 17 counties have come to us for MAT in the six months since we opened. This initially surprised us greatly. But they are coming because there is simply no help where they live.

Justine reminds us that we are working within the very medical system which taught all of us words like “abstinence” and “addict,” and that we shouldn’t enable “these people” by giving them a warm blanket. Those on whose shoulders we stood told us that all “addicts” lie and manipulate, not separating their humanity from behaviors driven by substance use disorders and many other factors.

We had both become cogs in the machine of stigma and unnecessary death which still masquerades as modern American medicine.

The more we work with people who face shame and stigma at every turn, the more appalled we become to have ever labeled a person in this way.

Justine and I are two of the lucky ones. Having entered medicine to improve our societies, and wrestled throughout our training with the reality of inequitably distributed care, we were ready for our veils to be lifted. As we grew increasingly aware of the prejudice faced by people who use drugs, we also realized how little we truly knew about opioid use disorder.

For instance, we didn’t know, earlier in our careers, the extent to which it could become long-term, or involve repeated relapses—or that people with opioid use disorder have a 10-fold higher mortality rate than the general population. We didn’t know that medications like methadone and buprenorphine were powerfully associated with improved outcomes for these patients.

Neither did we know that access to these lifesaving drugs—especially in rural America—is abysmal, and far more restricted by law than is our ability to prescribe opioids themselves. We didn’t know that providers can only prescribe buprenorphine to 30 patients concurrently in their first year after taking a special training. We didn’t know that access to treatment is often reliant on weekly urine testing and mandatory counseling—even though these further-stigmatizing measures have never been shown to save lives.

This is systematized stigma, and it must change now.

What we did know, years ago, is that we were being paid to see patients as fast as possible with as many procedures as we could justify. We also knew, from both the primary care and emergency department perspectives, that the medical system didn’t care how many times each patient visited the ER for the same, untreated problem. That’s because the insurance system doled out money based on fee-for-service—not value.

To both of us, this felt less like healing and more like retail. Though we were good-hearted and educated women, we had both become cogs in the machine of stigma and unnecessary death which still masquerades as modern American medicine.

The Value-Based Payment Model

Now we see a different path forward, a way to change healthcare while reducing human and fiscal costs to society, by offering what all people want and deserve: dignity, respect, compassion, and equal access to smart providers who care.

Under the increasingly central Value-Based Payment approach to health care reimbursement, government and other agencies who pay for care hold providers accountable for and reward them for the quality of care provided, not just its cost. Quality measures include, among other examples: how well blood pressure and sugar are controlled, whether patients get recommended vaccinations, and whether cancer screenings are up-to-date.

What, then, are the barriers to the Value-Based Payment model?

Let’s say Medicaid pays our clinic $100 for a 45-year-old patient’s visit to control her hypertension, counsel her about opioid use disorder, and refill her Suboxone. And let’s say she sees us for six such visits in a year, for a total reimbursement of $600 paid to our non-profit clinic.

Even if that work prevents Medicaid’s having to pay for a $4,000 ER visit or a $90,000 ICU admission after overdose, we can’t use that saved money to sustain our preventive treatment.

The reimbursements paid under the current Fee For Service system (eg. $100 for one visit) do not provide enough money to run a clinic. Many practices therefore either accept no Medicaid patients, or cap their number of Medicaid patients to ensure they still get paid enough to keep the doors open.

Currently we at REACH rely on grant support, primarily Medicaid reform pilot allocations. We will not be able to reliably afford our low-cost care until Value-Based Payment is implemented, or Medicare is expanded to include all Americans.

We have to make this epidemic about health equity. Those of us who went into health care to help people, not shame them into the shadows, must be willing to take the risk of offering the care that is needed, even though it is not yet financially viable.

The current crisis is our chance to change the system, and get it right this time. It’s our chance to stand up and say “The treatment system, not our patients, is the problem.” And when we force this system to change, we will improve treatment not only for opioid use disorder, but also for diabetes, for depression, for Hepatitis C—heck, even for a pesky case of adolescent acne!

This opioid crisis, in all its tragedy, can drive systemic overhaul. If we let it. If we make it.

This piece was written with collaboration and contributions from Dr. Justine Waldman.

Photo credit: rawpixel on Unsplash

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