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Monday Apr 22, 2019

How Many Chances Should We Give Patients? It Depends

I recently was discussing a thought-provoking article in The New York Times(www.nytimes.com) with a family member who works for a prosthetic cardiac valve company. The story chronicles the care of a patient with drug-related endocarditis and also offers the perspective of a cardiothoracic surgeon who has started refusing to operate on such patients because of the high costs and their likelihood of continued drug use.

[recovery painted on road]

The headline raised a blunt question: "How Many Second Chances Should a User Get?" For me, it raised another question: Is it ever acceptable to withhold potentially life-saving treatment from high-risk patients?

My simple response to these complicated questions is, "Well, it depends."

In a truly free-market health care system, the patient would receive as many interventions or treatments as they were willing and able to pay for. Unfortunately, the cost of health care is often prohibitive and complicated.

We live in an unprecedented time of modern medical miracles that our patients have come to expect as routine care. However, such care does not come without high cost. Cash-paying and Medicaid patients are particularly disadvantaged. Substance-dependent patients often find themselves in this unfortunate category and fall through the cracks in our health care system. So, the question should not be how often or how thoroughly we should treat them, but how we can find ways to provide them the high-level care they need.

Patients who have substance use disorders are often unlikely to seek health care because of the terrible demands of their substance use and also because they are aware of the stigma that has historically followed those who suffer from these disorders. The patient in the New York Times article couldn't find a primary care physician because of her past drug use, and she isn't alone. Many physicians will not agree to take such patients after seeing a history of drug use on their charts, and they are frequently fired by clinicians when they relapse.

Of course, it is reasonable to expect that patients be held to some degree of accountability for their health, but those with substance use disorder are often beyond the point of controlling their impulses and actions. We must take this limitation into account when we make medical decisions regarding their care.

The key to caring for patients with substance use disorders is to provide them a judgment-free zone and to make as many drug treatment options available to them as possible. It does such individuals a disservice when medication-free addiction support groups or rehabilitation programs impose their biases on patients receiving medication-assisted treatment (MAT) by accusing them of not "being clean" because they are on opioid replacement therapy with methadone or buprenorphine. Such drugs can be life-savers and help promote harm reduction by keeping patients off the streets and away from illegal activity and by helping them reduce risky behaviors such as unprotected sex and IV drug use.

When dealing with such complex patients, it is important to address areas of medical noncompliance and to make sure that they are in some sort of drug rehabilitation program, ideally, one that employs the three pillars of addiction recovery: peer support, cognitive behavioral therapy and MAT.

Many health care systems in Missouri, where I practice, are going to a medication-first model(static1.squarespace.com) of addiction treatment based on research(www.ncbi.nlm.nih.gov) that has shown that starting patients on MAT early can reduce the risk of life-threatening relapse and potentially lethal overdose. The Missouri Department of Mental Health is leading two related projects(missouriopioidstr.org) intended to expand access to prevention, treatment and recovery support services for individuals with opioid use disorder.

I am a strong believer in the medication-first model, not only because of my personal experience providing addiction care for my patients but also because a couple of years ago, tragedy struck close to home when dear friends of mine lost their 25-year-old son to an opioid overdose. He was a decorated officer and pilot in the Air Force who had been honorably discharged. He was suffering from posttraumatic stress disorder, which he attempted to manage by self-medicating with opioids. Unfortunately, he was unable to maintain routine psychiatric care. His parents paid multiple times for him to receive addiction care. Following his final 30-day, medication-free inpatient drug rehab program, this young man was given an address and an appointment for an outpatient opioid treatment program where he was supposed to begin MAT.

He never made it. He was found a week later, dead in his car with a heroin needle in his arm. Having lost his opioid tolerance during his monthlong period of drying out, his body could no longer handle the physiological effects of his drug of choice at the dose he was used to taking. Additionally, the drug was laced with fentanyl. If he had received his first medication dose while he was in rehab, he might still be alive.

As with the carbohydrate-dependent patient with type 2 diabetes who develops insulin resistance through diet-related obesity, we should not allow the substance of abuse to define the patient before us. As medical professionals, we need to look at the whole patient, treating all their health care needs without allowing bias to cloud our judgment. Call it the "Golden Rule" or the "Good Samaritan principle." We should do unto others as we would have done to us, and we should not withhold treatment from someone just because we think they don't deserve it.

This is not to say that a clinician does not have the prerogative to refuse a patient who they think may put their medical license in jeopardy. A physician may indeed choose not to accept certain high-risk patients or decline to perform a risky or costly procedure if they think the risks outweigh the benefits. However, such decisions must be made after all criteria, options and goals have been presented to the patient, adequate time has been given for the patient to reach the required threshold for care, and a full benefit-risk analysis has been carried out in a nonbiased manner.

Another obstacle to care of high-risk patients is the third-party payer system, which functions on a cost-to-benefit model that stratifies patients according to risk. This is done in a cold, calculated way that approaches the patient as a faceless dataset or problem list without considering the individual's particular psychosocial circumstances or their best intentions to recover. This middleman mediating health care decisions between the patient and the clinician often presents a significant barrier to care and puts patients' well-being at risk by frequently delaying or denying care. Clinicians do not have the time or energy to fight with an insurance carrier who sends us multiple forms to fill out justifying a particular device or treatment, only to have it denied or requiring another time-consuming peer-to-peer phone encounter with some remote physician who then passes final judgment on our care plans.

As health care professionals, we need to work to minimize red tape and reduce barriers to care. We need to reduce the unnecessary and cumbersome presence of middlemen who demand more of our time and attention than most patients. We, the physicians caring for the patients, should be the ultimate arbitrators of health care delivery who decide whether a medical device, treatment or service is warranted.

Health care should be about a relationship between a patient and physician or other medical care provider. It is in the face-to-face, relational dynamic of the exam room that motivational interviewing occurs, patient-centered conversations transpire and optimal management plans are negotiated. Only by protecting, prioritizing and optimizing the doctor-patient relationship can we deliver the type of best-practice health care that we envision and our patients expect.

Finally, medical professionals need to improve our education and comfort in diagnosing and treating or referring patients who have substance use disorders. Simply using the Screening, Brief Intervention and Referral to Treatment(www.integration.samhsa.gov) (SBIRT) questionnaire can go a long way toward this goal. Acquiring a waiver under the Drug Addiction Treatment Act enables physicians to provide essential opioid replacement medications for MAT. In doing so, we can give our substance-dependent patients the second chances they need to reclaim their health and well-being. If we take charge of our exam rooms and practice at the top of our licenses, our patients will thank us, and they will receive the optimized health care they deserve.

Kurt Bravata, M.D., is a family physician who practices primary care, geriatric medicine and addiction recovery in rural southwest Missouri.

Read other posts by this blogger.  

Posted at 02:22PM Apr 22, 2019 by Kurt Bravata, M.D.

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