Archive for the ‘Community Health Center’ Category

Duff, dog sled, and death

March 9, 2015

I wouldn’t mind being the Duff
Had my leader charisma enough
Mine did, for sure,
Though there was no cure,
He was courageous, kind, brilliant and tough.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record System (EMR) I can get along with. Right now I’m in Nome, Alaska.

I find the Gold Coast Cinema here in Nome so unique that I saw The Duff, a teen angst genre film.  The title refers to the Designated Ugly Fat Friend; while not necessarily fat or ugly, to qualify as a Duff one can’t be as attractive as one’s friends.  Find a clique, you will find a Duff. Not a surprise  though  we don’t like to think that human groups have pecking orders.  If you have an alpha, you must have someone lower on the hierarchy, and the one at the bottom, the omega, becomes the Duff.  In my experience, and in the movie, the Duff has more IQ points than the hot friends. 
The script pointed out that for every measure of social desirability (looks, strength, money, power), someone always occupies a higher position.  Thus the omega depends on the alpha as much as the alpha depends on the omega.
Taking the sled dog ride I bought at the Nome Preschool annual fundraising auction, today I learned more about sled dogs than just their hierarchies..
Tom, the musher who donated the item, picked me up on a very clear, very cold day, and brought me to his home 15 miles north of town.  Of course I quizzed him on the sport.
Working dogs are happy dogs.  Most come from the Alaska Husky breed, which lacks AKC credentials.  A team usually starts with 12.  As the years have gone on, the race has ended more quickly and the dogs do better physically.  While mushing, these animal ultra-athletes will eat the equivalent of 22 Big Macs a day.  Deciding to run the Iditarod requires a 3 month commitment and a huge monetary investment.  A good long-distance dog trots rather than gallops, in a smooth, level-back gait.
The lead dogs, furthest from the musher, have standing in the hierarchy, but must make a lot of decisions.  The next pair back, in the swing position, have the responsibility for making sure the turns aren’t made too sharply.  The pair closest to the sled, the wheel dogs, take a lot of jarring from pulling, and females have more resilience than males.  Most dogs prefer the other, team positions between the front and the back.
Tom kindly surveyed my gear, gave me toe warmers for my socks, and lent me a seal skin hat and a balaclava.  He let me mush on the return trip.
The immense work in dog sledding comes from maintenance of the team; just yelling HIKE was pretty easy compared to harnessing the canines.  Learning to keep the tug line (that nylon rope that connects to the sled) came easily.  I found my short ride in a dog sled exhilarating, in a primal way difficult to describe, and very cold.  At the end, despite my arctic grade layers, the cold had sapped most of my energy.
When I returned I learned a friend had died.  An excellent physician, a good husband, and a devoted father, he taught me a great deal about leaving judgment out of my day, and, in the process, having more energy and getting better clinical results.  My tears lasted a short time, we had watched this event approaching for years.
He led the team by example, he kept us focused on the clinic’s mission, and, in the process, kept us believing in it.  His charisma bound the group together and prevented us from breaking under terrible strain.  His guidance, hard work, and good, sound personal advice brought light to my three years at the Community Health Center. I admired his intense personal courage, maintaining a strong work ethic and a sunny countenance in the face of terrible disease.
With a leader like that, I never objected to not having the lead dog or alpha position.  I wouldn’t have minded being his Duff.

Christmas call and prepping for a new assignment

December 25, 2014

I start out this Christmas on call
As I’m trying to make sense of it all
With the unknown I’m flirtin’,
Cause I embrace the uncertain
While I walk the hospital hall.

Synopsis: I’m a family practitioner from Sioux City, Iowa. I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went for adventures working in out-of-the-way locations. After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took a part-time position with a Community Health Center, where I worked for 3 years. I left last month because of a troubled relationship with the Electronic Medical Record (EMR) system. Now I’m back from a road trip, working a bit with one of the rural docs, and getting ready for another job in Alaska.
It’s Christmas and I have call as I have had since 1979. But, fundamentally, the word carries different meaning now than it did December 2, 2013 when my group limited our inpatient responsibilities to infants and children.
Still, I printed out our hospital census and found the diagnoses of detox, alcoholic encephalopathy, and OD at the top of the list, along with COPD, respiratory failure, dehydration and urinary tract infection. I ignored those patients whom the hospitalists care for and went up to Newborn Nursery; I examined the patient and used all of my Oroomo vocabulary (less than 10 words) talking with the mother.
I read the paper in the doctors’ lounge, and went to the other hospital. I talked with another FP. I listened while she discussed her practice and her children, and then I related my upcoming plans and how I learned to live with uncertainty.
I refuse to believe in my next job until I get my tickets; those arrived two days ago. So, except in the case of bad weather, I leave Iowa on New Year’s Day and arrive in Nome, Alaska the day afterwards. I can recover from jet lag for a couple of days and start orientation about 3 days later.
I read the Wikipedia article on my destination. I follow the blog from a doc who works there.
Yesterday I started putting together my gear; long underwear comes first. I have Arctic-grade overalls, mittens, and parka.
I dug out the aluminum wok I got at a garage sale during med school. It served me well in my 4th year, when I moved 6 times in 6 months. I moved less stuff every time, but that small, light, handy wok survived the odyssey.
Much remains to be purchased and even more assembled.
On this trip I would like to acquire more Inupiaq language than just vocabulary, and I contacted Rosetta Stone about a product they developed 7 years ago.
But throughout the day the tingling of anticipation coursed through my veins, more anticipation than just the holiday season brings. I wonder about the things I’ll see and the people I’ll meet. I enjoy the delicious sense of not knowing. If I knew, I couldn’t have any surprises. And I look forward to them.
After all, I’ve learned to live with uncertainty.

Going walkabout again

October 7, 2014

The thirty days that they require

Has now come right past the wire

I think that it’s fitting,

Not quite that I’m quitting,

I’m hoping someday for re-hire


Synopsis:  I’m a family practitioner from Sioux City, Iowa.  I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went for adventures working in out-of-the-way locations.  After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took a part-time position with a Community Health Center.  I did two short assignments in Petersburg, Alaska.  On Sept 2, I turned in my 30 days’ notice.

I finished up my most recent job this week.

I liked the position, I had wonderful nursing support, and our new CEO has gone a long way to improve the problems that her predecessor brought on.

I got the chance to speak a lot of Spanish. Opening up my patient panel brought in a flood of pediatrics and young people.

I got to see pathology I wouldn’t get to see elsewhere, because of our patient population. I took care of many schizophrenics, with a high prevalence of Type I Diabetes.  East and West Africans came with a whole range of unusual problems including TB and its late consequences.  Rarely a week went by when I didn’t declare, “Weight loss in Iowa in the 21st century is NOT NORMAL.”

I also got a waiver to prescribe buprenorphine, a narcotic used to treat narcotics addicts. By Federal law, a doctor can’t get that credential without 10 hours of Continuing Medical Education and taking a test.

I learned a lot about narcotics addiction by getting my name on the national list. Opiate withdrawal turns out to be a lot worse than I’d thought, and takes weeks to conclude.  I developed my own mnemonic, DANDY LIPPS (dysphoria, aching, nasal discharge, diarrhea, yawning, lacrimation, insomnia, piloerection, pupillary dilatation, salivation) to remember the features.  Diarrhea, sleeplessness, and pupillary dilatation resolve after all the other symptoms have disappeared.

I learned other lessons about the ugly process of addiction. My own narcotics prescription habits have gone from conservative to stingy to the point where I baulked at 15 hydrocodone for a patient with well documented kidney stones.

The corporate subculture of functional, mission-driven dynamics and support made the work day go well.

Why, if my job had so many positives, would I want to leave?

The answer comes down to one item, the electronic medical record (EMR) system. Poorly designed and badly installed, I found it barely tolerable till June.  The vendor sent us an update without beta-testing, and the system slowed down from snail to glacial.  Clicking on a button would not bring a response in less than 20 seconds.  Clicking on a particular, popular button would guarantee a freeze-up that could only be fixed by the System Administrator.  I found myself spending more than 8 hours weekly watching an unresponsive screen.

One day the system kicked me off 11 times, with each sign-on costing an average of 5 minutes. At the end, I finished my documentations and started in on the queue of 35 messages from the Billing Department.  The first one took 14 minutes to complete, most of it involving an hourglass that didn’t seem to move.

I gave my 30 days’ notice and I did my best to burn no bridges. I left eligible for rehire, on such good terms that I’ll cover the 12/25 holiday.

In the meantime, I’m going walkabout again.

Another last week

October 5, 2014

Quite early to work I did sneak
To start when no one would speak
I will sing and I’ll praise
These last final days
And be done at the end of the week

Synopsis: I’m a family practitioner from Sioux City, Iowa. I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went for adventures working in out-of-the-way locations. After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took a part-time position with a Community Health Center. I did two short assignments in Petersburg, Alaska. On Sept 2, I turned in my 30 days’ notice.
My last week with the Community Health Center started with a really fantastic Monday. Away from the clinic for ten days for a hunting vacation, I looked forward to patient contact, but dreaded the crunch that comes from being away. So I arrived an hour early, and attacked the 35 items that had accumulated on my electronic desk top, mostly expected normal lab and x-ray.
Three thyroid items came unexpectedly normal, a welcome set of results for a family with no resources and no insurance.
Four items had to do with one of my buprenorphine patients. I had to get a special license to be able to prescribe this narcotic to narcotics addicts, and this particular patient had done well with counselling and meetings for 7 months. Despite warnings to the contrary, the quartet of ER documents confirmed that the patient took an off-the-street benzodiazepine (the drug class that includes Xanax, Valium, Librium, alprazolam, lorazepam and diazepam) and lost the will to breathe, which in this case necessitated CPR and an ICU admission.
Two of my other buprenorphine patients came; they have done well with the medication and watching them maintain jobs and families encourages me. That medication, however, like any other in my profession, lacks 100% efficacy. In fact, if I hit 20% with this particular disease state I count myself lucky. No drug does any better. I had to arrange for subsequent care for both.
No-shows kept my patient flow well within reasonable limits; I kept up with my documentation along with the steady influx of results and reports that have to be personally reviewed by the doctor. Also the numerous emails that accompany the end of employment.
I flew down the stairs to Human Resources to sign papers and learn about my benefits. I spent most of my exit interview talking about the stuff I love about my job.
Then I enjoyed a rare luxury: lunch. I ate my sandwich, smoked salmon salad with fresh basil lovingly prepared by my wife. For twenty minutes I savored the goodness without trying to work at the same time.
One of my schizophrenic patients came in for the monthly Haldol injection, and expressed sadness that I’d be leaving; we share an interest in history and frequently we surprise each other with our details. Well children alternated with diabetics, depressives, and hypertensives, and the afternoon slipped into evening.
And just when I started to wallow in how reasonably the day had gone, to barely start to wonder about my decision to leave, the computer froze, and I remembered why I turned in my 30 day notice 27 days before. I fumed. I muttered bad Navajo words under my breath. I had fantasies of throwing my computer out the window.
I left the office before 800PM to go to the gym, with only 5 documents left undone.

Meditation at 12000 feet

September 30, 2014

Into the mountains I sneak

To  camp by a lake on a creek

The permit I bought

To be alone with my thought

And remember the important third week

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went for adventures working in out-of-the-way locations.  After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took a part-time position with a Community Health Center.  I did two short assignments in Petersburg, Alaska.  On Sept 2, I turned in my 30 days notice.

 I went elk hunting in Colorado with a friend from Iowa and two friends from Colorado.

Acclimatization to altitude comes as a huge barrier to flatlanders hunting, and we flew out two days early to spend a couple of nights at altitude. Where before I announced I would never spend the first night in camp over 10,000 feet, I compromised this time.  We spent three nights at 8500 feet and then pitched our tents at 11,500.

I felt every foot of that altitude more than I felt every year of my age, 24 more than any of my companions.

Knowing the physiology helps understand the process of getting used to low oxygen, but it does not speed the process. By this time we’ve all learned the importance of maintaining good hydration.  And we’ve all come to a phase in our careers where we can afford good gear.

Along the way I took care of one person with a sprained ankle, another with posterior tibial tendonitis. I gave good advice to a person who drinks more than he should.

While the younger guys ran around canyons and rim rock, I spent most of my days pretending to hunt and being alone with my thoughts. I would put the cap on the muzzle loader and walk 300 yards along the edge of the glacial lake to a spot overlooking an elk wallow.  With spires of fractured granite towering a thousand feet over me, I watched the tortured landscape and thought about my upcoming career move.

My job brings me much satisfaction. I speak a lot of Spanish and I get to do a lot of pediatrics.  I work under top-notch management with great coworkers and outstanding colleagues.

But I cannot abide an electronic medical record system that parasitizes 2 hours a day in gratuitous delays.

The more I thought the better I liked my decision.

After the 7 mile walk out (at 12000 feet), the first shower in a week, the celebratory meal at the swank restaurant, and a night in a bed, we sat in the airport in Durango and struck up a conversation with another Iowan.

He walked from Denver to Durango along the Colorado Trail.

I didn’t ask what he thought about during those 5 weeks, but we talked about wildlife. And after a little bit I asked what day he started walking; I added 21 days to that and said, “On September 6 you had the start of a health problem.  What was it?”

I explained the three week rule, the summation of microtraumas accumulated in the course of accommodating to a new level of fitness.

And I thought about how I’ll have to watch out for the 21st day after I leave my job.

Schizophrenia should not be a death sentence

May 1, 2014

Even the worst of the cynics
Support the function of clinics
It’s a seasonal flow
They come and they go
The homeless bipolar schizophrenics

Synopsis: I’m a family practitioner from Sioux City, Iowa. I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went for adventures working in out-of-the-way locations. After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took a part-time position with a Community Health Center. I just returned from my second locums trip to Petersburg, Alaska.
The young man I talked to in the clinic recently brought a distressingly familiar story; because so many have similar tales I can talk about the non-unique elements. From out of town, he couldn’t give me a good reason he had landed in Sioux City; he had no work or money and the word “tenuous” described his housing arrangements. As we talked the contradictions in the history started to add up, but I carefully avoided bringing inconsistencies to his attention.
I won’t discuss his “admission ticket,” the physical illness he described came second to his main problem.
A long, involved medical history with improbable descriptions of other health care facilities, led me to conclude that he maintained an uncertain relationship with reality, and, eventually, he mentioned his history of schizophrenia.
My 22 years as a co-owner of an upscale clinic brought me little contact with schizophrenics, but my current position has. Our facility cares for most of the schizophrenics in the city.
I have learned that schizophrenia, bipolar disease, and substance abuse overlap each other with terrible frequency. Most schizophrenics smoke, and trying to get them to stop ranks with trying to stop the tides. The majority of schizophrenics have difficult-to-control diabetes.
We have drugs to treat the bipolar, the diabetes, and the smoking. Yet we lack good, effective treatment for the basic disease process, where a person’s thoughts loses touch with reality.
(One very effective drug, clozaril, shows dramatic improvements not only in symptoms but functionality; the worst side effect, occasional and unpredictable bone marrow shut down, makes it too toxic for all but the most severe cases.)
Our society has failed our mentally ill. A Republican President with bipartisan support closed the mental hospitals and dumped the patients onto the streets. They form a disproportionate percentage of our prison and jail population and a majority of the homeless. Unable to cope with the real world, they can’t hold jobs, manage money or maintain interpersonal relationships.
If someone in our town stumbles out from under a bridge and into a clinic, they stumble into our clinic. They truly can’t afford to pay for their services.
The most conservative, fiscally stingy, small-government supporters I know agree that schizophrenia should not be a death sentence.
Some of my schizophrenics can maintain a semblance of a normal existence with regular medication; a few can manage part-time employment. But many just keep drifting, north in the summer, south in the winter.
I do what I can for them, recognizing the fleeting nature of the relationship.

Dead doctors and AAA batteries

April 9, 2014

This one’s about a dead cell
That leaked, and corroded as well
I got over that quirk,
And made the thing work
After only a very short spell

Synopsis: I’m a family practitioner from Sioux City, Iowa. I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went to have adventures and work in out-of-the-way locations. After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took up a part-time position with a Community Health Center. I have just returned from a one month locums assignment in Petersburg, Alaska.
In 1989, my then-partner said, “Well, it’s like when you make rounds on Christmas. You start early, you put a Dictaphone in your pocket and you go like mad.”
Sitting at a stoplight on the way home I thought about what he’d said and decided to round as efficiently as possible every day. Later on, when I started doing the hospital work for my group, I started to carry a dictating machine to save time. The alternative required finding a telephone, and entering the following digitally: physician number, dictation type (progress note, discharge summary, etc.), and patient medical record number. As years passed each hospital required more info and developed more pauses before dictation could actually start. Both hospitals shift their equipment every 2-3 years, requiring purchase of a new dictating machine, generally for about $600. With every passing year that purchase brings an increased efficiency over phone documentation.
The last of the handwritten progress notes died two years ago. By then I had figured out how to dictate while walking from patient to patient.
This morning I slipped my hospital-specific digital recorder in my pocket and started rounds at 7:00AM, finding the machine would not turn on. As always, I looked to battery replacement as the first fix, and the pediatric head nurse brought me two new AAA cells, but to no avail. While I grumbled, she took the batteries to the recycling bin, commenting that, as one had leaked, much time must have passed since last I used the machine.
New in mid-January, those batteries saw scant use till late February and no use after; I thought neither period qualified as a long time. I removed the new cells and spotted corrosion on one of the terminals. I went to work with a pencil eraser, cleaning the metal to shininess. I recalled how, in previous years, I repaired so many tiny tapes with scalpel, forceps, and Scotch tape I almost wrote an article, Microsurgery for Microcassettes.
I know batteries go bad, but I have never seen a battery go from new to leaking in less than three months.
Then, with the digital recorder working well, I started on rounds.
At lunch in the Doctors’ lounge, I sat down to a conversation in full swing on the subject of death. One of our ophthalmologists passed away a couple of weeks ago without warning. Then we all remembered the cardiologist who died young on a treadmill, and the orthopedist who died, gratuitously, of colon cancer. In short order we shifted the topic to nature vs. nurture in the realm of colon cancer, heart attacks, alcoholism and cirrhosis.
While the other docs talked, I ate hospital chicken and rice, and thought about batteries leaking and corroding after premature failure. And I rejoiced in the time I’ve spent doing locum tenens.
Carpe diem.

Syphilis and gold: finding what you look for

April 2, 2014

Across the car park I strolled
In the rain and the wind and the cold
The thing I did find
Brought hope to my mind
And turned out to be real gold.

Synopsis: I’m a family practitioner from Sioux City, Iowa. I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went to have adventures and work in out-of-the-way locations. After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took up a part-time position with a Community Health Center. I just returned from my second locums trip to Petersburg, Alaska.

On my first Monday back from Alaska I went into the office to catch up on the miscellany that accumulated in my absence. I found 320 clinical items on my electronic desktop along with 78 administrative emails. In the quiet of the early morning, when my body clock should have screamed for sleep, I dug in and started plowing through the items one by one.

About half had to do with bad things that had happened to my patients, requiring hospitalization, while I vacationed. Every admission generated an ER note, a history and physical, progress notes, lab and x-ray reports, and a discharge summary. I could not determine the importance of each item without reading it.

I ran into some surprises.

Three patients received malignant diagnoses, and I judged each cancer gratuitous. None of them did anything to deserve their tumor.

One person’s syphilis tests came up positive. I followed the communications; saw that my partners had done the right thing through the health department notification, the lumbar puncture, and the penicillin injections. I look forward to seeing if the patient’s symptoms improve.

When my father attended medical school, his professors would lecture, “Know syphilis and know medicine,” but since then the frequency diminished to the point where we rarely think about it, and sometime we forget to look for it. Lyme disease brought a resurgence in testing because searching for one justifies testing for the other.

I left the clinic at 1230 to go home for lunch, and as I got into the car, I saw a faint gleam of yellow on the pavement. Smaller than a dime, when I picked it up I saw it had suffered from passing car tires grinding it into the gravel. But it had a milled edge, which marked it as a coin.
At age 9 I found a dollar bill in the street in front of our house, a powerful experience at the time, and even more so because of the large purchasing power it represented in 1959. I started looking for more. One finds things that one looks for.

During med school, the Michigan State school paper published a piece by a student who also found money and who kept track of it; he commented that as inflation eroded the value of money he found more and more. Perhaps because of its lower worth, and perhaps because I keep getting better at spotting it, I find a lot more money than I used to.

When I came back to the office, I stopped in at the pawn shop across the street, and asked my friends there to check the tiny item for gold content, which came, to the surprise of all, as 22 karat; I accepted the spot gold price and walked out a happier man.

I worked through till 530, when I cleared out the last of my electronic communications, thinking about how one find things that one looks for.

Exercising my buprenorphine waiver but going back to Alaska

February 26, 2014

I wonder if this is the way

With all the things I could say

I’m away and I’m off, To the Island Metkoff.  

I’m taking vacation today

SYNOPSIS:  I’m a family doctor from Sioux City, Iowa who danced back from the brink of burnout in 2010.   Honoring a 1-year noncompete clause, I did short term medical work in Keosauqua, Iowa, Grand Island, Nebraska, Barrow, Alaska and New Zealand.  I came back to work in a part-time position with a Community Health Center, and I’m now down to 40 hours a week.  I’m taking a month to work in Petersburg, Alaska, 

For the last week I’ve warned my patients  that I’ll take a month of vacation for March.  I’ll work in the same clinic in Southeast Alaska where I worked for 2 weeks in August.

My addictionology practice has grown by leaps and bounds in the last month, and the news of my upcoming time off has been particularly hard on my opiate addicted patients.

The narcotic or opiate group of drugs includes morphine, opium, heroin, hydrocodone, hydromorphone, meperidine, fentanyl, codeine, and others.   The epidemic of addiction to these drugs has started to strangle the country, until deaths from overdoses of legal narcotics surpassed deaths from motor vehicles in 2012.  Already, the US uses more narcotic pain killers than the rest of the world put together.

Some attribute this surge in dependency to a government agency’s decision to make pain the 5th vital sign, and to sanction doctors who failed to address a patient’s pain level that exceeded 5 on a 10 point scale.  In fact the opiate use started to grow logarithmically that year.

The problem usually starts when a person has a legitimate injury, such as a broken leg, and gets a prescription for a pain reliever, then gets hooked by taking a friend’s leftover pills.  Abuse escalates in short order, many start onto heroin because it’s cheaper than the prescription stuff, they lose their job/house/spouse/car/assets/family and when they find themselves with absolutely nothing they realize they have a problem.  Then they come to see me.

If I wait till they’re in full-blown withdrawal (yawning, tearing,  diarrhea, insomnia, aching) I can prescribe buprenorphine, but only because I have a special license to do so.

The requisite education, done online, only cost me 9 hours; I got the waiver last summer  to back up one of my partners while he had medical problems.  I didn’t write my first prescription for it for 6 months.

The medication blocks them from getting high, and can stop a lot of pain.  Success demands close monitoring and frequent blood tests.

Patients don’t seek help until chaos dominates their lives.  I don’t get to retell the dramatic , ironic stories because of confidentiality.  The temptation to judgementalism runs strong in my business, but especially in addictionology, yet I know I will finish my day with more energy if I approach each patient with an attitude that acknowledges the mistakes of the past and emphasizes the need to move on.  And really, the patients do the best when they take control of their lives.

But they have a lot of emotional needs and tend to bond tightly to people who listen without judging.

Fortunately I have a partner with more experience with that drug than I have.

Exercising my buprenorphine waiver for the first times

January 29, 2014

With my patients I can make a pact

Per the modified Harrison Act


A blocker of morphine

Can help, and that is a fact.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went to have adventures and work in out-of-the-way locations.  After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took up a part-time position with a Community Health Center; I’m now down to 40 hours a week.

In 1914, the Harrison Act mandated that physicians could not prescribe narcotics to treat narcotic addiction, which, at the time, seemed a pretty good idea.  Using morphine to get someone off heroin, or vice versa, didn’t make much sense. Yet 3000 doctors went to jail for defying the Act.

Time marched on, and scientists discovered compounds that could counteract morphine and its cousins, giving rise to a new class of chemicals, narcotic antagonists.  The novel drug naloxone (trade name, Narcan) came during my time in med school, and quickly became a staple in ERs all over the country.  If someone came in OD’d on heroin, you could just inject a vial or two and save a life.

Further chemical sophistication led to drugs with mixed effects; in some ways like a narcotic blocker, and in some ways like a narcotic.  In residency, when confronted with a drug-seeking patient, I learned to offer one of these narcotic agonist-antagonists, warn the patient of withdrawal if they were addicts, and watch them storm out of the ER.

As time went on, methadone showed its utility to block narcotic’s euphoria or high and squelch craving for narcotics.  Because of the 1914 law a doc could use methadone to treat pain, but could only use it to treat addiction in a licensed methadone treatment center.

Buprenorphine, a compound available since 1980, eventually established itself as a useful agent in treating addiction.  Again any doctor with a DEA number could use it for pain, but only those with a special waiver could use it to treat addiction.  But that treatment could be based in a physician’s office.

In our quadrant of the state, only 3 doctors have that waiver, though it takes a mere 9 hours of education to qualify.  I got mine over the summer so I could fill in for one of my partners.  In the time since the only methadone program in a hundred mile radius shut down.  And for months, the only patients who showed interest would not have fit the entrance criteria.

In the last two weeks, three patients have requested entrance into the program.  I confer with my more experienced partner on each one.  He tells me his buprenorphine practice brings him tremendous satisfaction.

I have cared for one of those three patients since I arrived at my current position, and writing that first prescription came as a relief.

Confidentiality limits what I can say about the patients, but it doesn’t limit what I say about myself.  I have lots of first-hand experience with chronic pain, and today ranked as one of the worst since the summer.  I try to walk normally, and I try not to grunt or grimace when I sit down or stand up.  I focus on the patient, but I also tell my story.  Those who want to score drugs for remarketing show themselves with stridency, those who listen usually end up demonstrating a real desire to get on with their lives.

Once, a patient revealed that the pain had completely gone, obviating my tale.  That happened only once, and the story brought light to my day.