When arbitrary policies conflict with patient care

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The news came when Aaron Newcomb, DO, was on vacation. A few patients have called the office to say the local pharmacy is refusing to fill their prescriptions for pain, anxiety, and opioid use disorder (OUD). One was a long-term medicare patient who Dr Newcomb had treated for several years for chronic pain and anxiety.

She was stable, the medications had not changed, but the major national television channel told her “all of a sudden” that her doctor had been blacklisted and refused to have her refill her medications. Later that day, Dr Newcomb received a letter from the chain stating that she would not fill any of her prescriptions for controlled substances.

Dr. Newcomb cares for thousands of patients at a small, federally licensed health center in northern Illinois. As a licensed physician in family medicine and addiction medicine, he is one of the few physicians in his area who treat patients with chronic pain and substance use disorders. His practice is located not far from where he did his residency at Southern Illinois University.

“When the CDC [Centers for Disease Control and Prevention] guidelines fell in 2016 basically saying that we had to remove as many people as possible from opioids, I knew my patients were going to have problems, ”Dr Newcomb said. “I was particularly concerned about my patients who were stable on low dose opioid therapy for years. And my worries have translated into an even worse reality for me and my patients. Being blacklisted by a national channel that had no idea about my practice was a professional error, but it also hurt my patients and my community.

The solution was not as simple as simply asking your patients to find another pharmacy, as the community is small and other pharmacists did not want to “take the risk” of the Drug Enforcement investigation. Administration, said Cassie Korando, the head of the cabinet. General Counsel.

Korando and Dr Newcomb, however, took action by providing practice data regarding how prescribing practices were in line with guidelines using specific patient profiles for illustration, as well as others. information explaining the treatment of chronic pain with the use of opioids and buprenorphine for the treatment of OUD. A major topic included was how the 2016 CDC guidelines had been misinterpreted.

“When they got back to us, they basically questioned a specific formulation of buprenorphine that I was prescribing to stable patients with cost or tolerance issues that is not a preferred type unless there is a clinical reason, ”explained Dr. Newcomb. “They were also concerned about opioid therapy in general as well as the dose of buprenorphine used to effectively treat patients, and their out-of-context algorithm paints a false picture of my controlled substance prescribing habits.

“It took us a long time to explain why an unknown algorithm misses the whole picture of what is happening with individual patients,” he added.

Dr Newcomb also explained that the detailed clinical nuances of treating patients with chronic pain or OUD did not appear to be scrutinized very carefully by the company pharmacy. After months of correspondence, and finally identifying a doctor to help plan a virtual meeting, the situation changed.

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“It was a virtual meeting, but it allowed us to address some very complicated medical questions about treating patients with buprenorphine for TOU,” he said. “Topics included the standards of drug testing in my program, pharmacological interventions for concurrent medical conditions such as attention deficit disorder, treatment of patients who continue to use drugs, access to treatment without mandatory behavioral health interventions and why some patients on buprenorphine required different dosages than others.

“I have been at or near my limit of 275 patients since 2018 and I tailor each treatment regimen to the needs of each individual based on my clinical experience, background in addiction medicine and of course medical evidence. and science, ”he added. “It was clear during the discussion that there was not a good understanding of the basics of treating patients with buprenorphine for TOU. Oddly enough, the topic of opiates for chronic pain was never discussed in this virtual meeting.

A little over a week later, Dr Newcomb received an email indicating that the corporate chain would be refilling its prescriptions for controlled substances. It was a six-month ordeal in which many more joined the fight, including the Illinois Academy of Family Physicians, the Illinois State Medical Society, and the AMA.

WADA has fought this battle in other states as well.

“WADA strongly urged the CDC not to include specific numbers in its 2016 guidelines because we were concerned that state legislatures and corporations would use these numbers as blind strict thresholds, causing harm to stable patients. on high-dose opioid therapy, had severe trauma, or had cancer or were in hospice or palliative care, ”wrote AMA Executive Vice President and CEO James L. Madara, MD , in a letter to the head of the Georgia House of Representatives in support of a bill dealing with this issue. .

“Unfortunately, we were correct in predicting that corporate drugstore chains and others would adopt some version of the 2016 guidelines,” adds Dr Madara’s letter. “These versions of the CDC guidelines have been largely misapplied. In many cases, pharmacists have refused to fill a legitimate opioid prescription for a patient with chronic pain, or for patients with cancer or in need of palliative care. These actions resulted in patients being told they were not in real pain and sometimes faced with humiliating accusations that they were drug seekers. While this hasn’t necessarily been the norm, it has happened in Georgia and across the United States due to company drug policies inappropriately interfering with the patient-physician relationship. “

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“It was very personal to me,” said Dr Newcomb. “This is the center of my life as a doctor, my passion and what I do is dedicate my heart and soul to helping patients with chronic pain, opioid use disorders and more. chronic disease. The intervention of a corporate pharmacy called into question what was important to me and angered me, and I’m glad I didn’t back down because my patients are counting on me.

WADA believes science, evidence and compassion must continue to guide patient care and policy change as the country’s opioid epidemic evolves into a more dangerous and complicated illicit drug overdose epidemic. . Learn more on AMA’s End the Epidemic website.

The End the Epidemic website has been recognized by the Academy of Interactive and Visual Arts. As part of this organization’s 27th Annual Communicator Awards, End the Epidemic received an Award of Excellence in the Cause & Awareness website category.



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