Posts Tagged ‘narcotics withdrawal’

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.

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Exercising my buprenorphine waiver for the first times

January 29, 2014

With my patients I can make a pact

Per the modified Harrison Act

Buprenorphine,

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.