Uncharted Territory: Claims that a patient is selling Buprenorphine

[whopper]

So there's a bunch of data telling you to do things like do drug tests, make them show up more often etc.

There's nothing telling you what to do if someone calls your office claiming your patient is selling their Buprenorphine.

A problem with Buprenorphine is some people need more than the usual 16 mg daily. Add to that if the person is stable for an extended duration, often times more than several months (e.g. 1+ years) the person could figure out how to wean down to a lower dosage than they use, and sell the rest. This will then still allow them to pass a UDS showing a clean one except with Buprenorphine.

There's pretty much no standard on what to do about this should this happen. I've seen it happen about 5x with the most recent one today.

What to do? I don't know. I do tell people in general not to let others know they are on Buprenorphine unless they highly trust the person they are telling for this very reason among others. E.g. I've seen patients go clean then their former drug addict friends break in to their place to steal the Buprenorphine.

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[Sushirolls]

Consider the other formulations? i.e. SQ or the implant?

 

[calvnandhobbs68]

Random pill counts should nip that in the bud. Patients should sign an agreement at the beginning that they’ll be subject to random pill counts where they have to bring their bottles with meds in within 8 hours of the phone call (so basically gives them a business day but little time to try to buy some off a friend to make up the difference if they know it’s coming). As soon as you get wind of this they get a call that next week telling them to come in for their pill count and if they don’t do it they go down to weekly with a random count during the week.

you run into this same stuff with stimulants. Someone only really needs their Adderall XR during the week so sells all their weekend doses but will still be positive on your UDS. Pill count.

 

[Mad Jack]

So there's a bunch of data telling you to do things like do drug tests, make them show up more often etc.

There's nothing telling you what to do if someone calls your office claiming your patient is selling their Buprenorphine.

A problem with Buprenorphine is some people need more than the usual 16 mg daily. Add to that if the person is stable for an extended duration, often times more than several months (e.g. 1+ years) the person could figure out how to wean down to a lower dosage than they use, and sell the rest. This will then still allow them to pass a UDS showing a clean one except with Buprenorphine.

There's pretty much no standard on what to do about this should this happen. I've seen it happen about 5x with the most recent one today.

What to do? I don't know. I do tell people in general not to let others know they are on Buprenorphine unless they highly trust the person they are telling for this very reason among others. E.g. I've seen patients go clean then their former drug addict friends break in to their place to steal the Buprenorphine.

You can do quantitative norbup levels and cofrelate them with the patient's dose. Rotated at a clinic that would catch sellers this way, as they would often only have trace levels in their system that would fool a typical positive/negative test

 

[VA Hopeful Dr]

You can do quantitative norbup levels and cofrelate them with the patient's dose. Rotated at a clinic that would catch sellers this way, as they would often only have trace levels in their system that would fool a typical positive/negative test

Is this the standard LC/MS/MS or something beyond that?

 

[Mad Jack]

Is this the standard LC/MS/MS or something beyond that?

Pretty sure it was some variant of LC/MS but I honestly can't recall. Could ask the clinic director if you're curious. It was in a big integrated system clinic so test cost wasn't an issue since the addiction program, insurer, and lab were all owned by the same health system (setup similar to Kaiser)

 

[Old&InTheWay]

I wonder if this role is similar to that of forensic or disability evaluations, that is, when you adopt the role of detective, It seems as though one is stepping outside the role of treating physician and potentially risking damage to the therapeutic relationship. Particularly if one adopts a low-trust position with all patients, many of whom will be acting honestly/ethically and will resent the lack of trust.

From the perspective of whether we have a duty to police our patients, I think a utilitarian argument can be made that if a patient is remaining clean of other opioids and is selling some of the bup, you are still in a positive benefit/harm ratio. And given that the risk of overdose on buprenorphine is lower than with full agonist opioids, I'd rather have more bup/suboxone being used recreationally than heroin.

Also, how much weight, if any, should be actually given to unsolicited collateral as described in the OP?

**The above is not fully thought out...pretty much thinking out loud. Curious what others think**

 

[VA Hopeful Dr]

Pretty sure it was some variant of LC/MS but I honestly can't recall. Could ask the clinic director if you're curious. It was in a big integrated system clinic so test cost wasn't an issue since the addiction program, insurer, and lab were all owned by the same health system (setup similar to Kaiser)

Nah, its not that important just pure curiosity

 

[Mad Jack]

I wonder if this role is similar to that of forensic or disability evaluations, that is, when you adopt the role of detective, It seems as though one is stepping outside the role of treating physician and potentially risking damage to the therapeutic relationship. Particularly if one adopts a low-trust position with all patients, many of whom will be acting honestly/ethically and will resent the lack of trust.

From the perspective of whether we have a duty to police our patients, I think a utilitarian argument can be made that if a patient is remaining clean of other opioids and is selling some of the bup, you are still in a positive benefit/harm ratio. And given that the risk of overdose on buprenorphine is lower than with full agonist opioids, I'd rather have more bup/suboxone being used recreationally than heroin.

Also, how much weight, if any, should be actually given to unsolicited collateral as described in the OP?

**The above is not fully thought out...pretty much thinking out loud. Curious what others think**

This was actually a discussion I had with the clinic director. It was a pure addiction medicine service, not addiction psych, and everyone in the clinic was tested the same way. He said that while this was the way their clinic was established, there was an argument to be made for diversion not being the worst thing, as patients getting diverted buprenorphine would be less likely to overdose than on other opioids. From a community outcomes perspective, no one knows whether a high adherence model or a more trust-based model would be better for outcomes. With regard to the therapeutic alliance, his patients seemed to have a great deal of respect for him because he wasn't being taken advantage of as many other physicians would allow. This seemed to strengthen the therapeutic alliance with those that actually wanted to get help, as he showed a real investment in their care and adherence to it, while many others would just take their money and give them their films. Kicking someone out of the clinic for poor adherence was a rarity, as most would improve compliance after abnormalities were noted.

I am always skeptical of claims about patients selling medication made by others, there are often complicated dynamics at play that aren't my place to investigate or get involved in

 

[Old&InTheWay]

With regard to the therapeutic alliance, his patients seemed to have a great deal of respect for him because he wasn't being taken advantage of as many other physicians would allow. This seemed to strengthen the therapeutic alliance with those that actually wanted to get help, as he showed a real investment in their care and adherence to it, while many others would just take their money and give them their films.

This is very interesting, and a dynamic I had not previously considered.

 

[dl2dp2]

Nothing to do. You are not the police. You are not to either confirm nor deny that this person that whoever called you is either your patient or not, let alone that this person is or isn't committing a potential federal crime.

Whoever calls you should be referred to law enforcement.

In the meantime, you can disclose to your patient that someone called, and as per the confidentiality agreement nothing has been disclosed. You are to treat your patient to take whatever he reports at face value and document as such, including your assessment as to whether he's compliant with his medication. Whether someone told you that he sold your prescribed medication stays off the chart.

 

[Pomacentridae]

Nothing to do. You are not the police. You are not to either confirm nor deny that this person that whoever called you is either your patient or not, let alone that this person is or isn't committing a potential federal crime.

Whoever calls you should be referred to law enforcement.

In the meantime, you can disclose to your patient that someone called, and as per the confidentiality agreement nothing has been disclosed. You are to treat your patient to take whatever he reports at face value and document as such, including your assessment as to whether he's compliant with his medication. Whether someone told you that he sold your prescribed medication stays off the chart.

Hi Sluox,

Just wondering but do you mind PMing me? I have a question I wanted to ask you but the system doesn't allow me to message you directly.

 

[calvnandhobbs68]

You can do quantitative norbup levels and cofrelate them with the patient's dose. Rotated at a clinic that would catch sellers this way, as they would often only have trace levels in their system that would fool a typical positive/negative test

Yeah but I assume this method would only catch those who are selling the majority of the script, not those who are getting 16mg a day and selling 8mg of that.

I still think pill counts are a much easier and less expensive way to get this info. However, this isn’t something you can just spring on someone without any mention of it ahead of time. It needs to be clearly stated upfront at intake that you can be asked to bring in your medication at anytime for a pill count, just like random UDS or observed UDS. That way this doesn't turn into a "why is this a new rule now" when something like this comes up.

I agree with the posts above that people who are calling accusing patients of various activities usually have ulterior motives for these calls. However, having an established policy of objective ways to measure adherence that can be put into place at any time (random UDS, pill counts) helps totally resolve any personal discomfort with the situation. Bring them in for a pill count, it's all good, awesome carry on as usual. Bring them in for a pill count, count is off by 10, now it's time to have a discussion about what's going on here and if this is a problem with overuse/misuse of the medication or selling it, along with closer monitoring and followup.

It is your DEA number that's being used to authorize dispensing of these controlled substances after all....they aren't given out OTC at the pharmacy for a reason.

 

[Mad Jack]

Yeah but I assume this method would only catch those who are selling the majority of the script, not those who are getting 16mg a day and selling 8mg of that.

I still think pill counts are a much easier and less expensive way to get this info.

He would also do film counts with accounting for lot numbers in some patients, depended on the situation. Everyone got quantitative bup screens at every visit along with testing for other drugs. Ones with repeated issues with low norbup levels would have progressively increased visits (2x weekly) with film counts and levels that were gradually dialed back as adherence improved. As we could easily trend bup/norbup levels and ratios, it was pretty easy to tell who was adherent and who wasn't

Mind you, this was very involved and a 100% addiction clinic. It's really not something that would be easy to do in a general practice where you've just got a few patients on buprenorphine

 

[calvnandhobbs68]

This was actually a discussion I had with the clinic director. It was a pure addiction medicine service, not addiction psych, and everyone in the clinic was tested the same way. He said that while this was the way their clinic was established, there was an argument to be made for diversion not being the worst thing, as patients getting diverted buprenorphine would be less likely to overdose than on other opioids. From a community outcomes perspective, no one knows whether a high adherence model or a more trust-based model would be better for outcomes.

I do appreciate the argument that most suboxone is sold to prevent withdrawal symptoms or people who are trying to get off heroin/fentanyl on their own. That's why I'm very willing to prescribe suboxone to people who are buying suboxone from others but now want to engage in treatment (in contrast to people who come in with the "I took my friends Adderall and my ADHD is all better" or "My mom's Klonopin really helps my anxiety doc!"....). A lot of people are worried that if they come to a substance use program they'll get kicked out or will pee dirty and now have no source of suboxone to stave off terrible withdrawal sx. Positive UDS is always just a discussion initially and closer monitoring, not automatically kicking someone out. Pill counts being off are the same way, closer followup and possible reduction in dose but we're not cutting anyone off. We're not the police but you also want to stay on top of things...people selling suboxone to others likely means they're still around people who are using heroin/fentanyl which means that their social network is not ideal and a risk for relapse. That's also a discussion.

I agree that patients do give you more respect when you actually act like you give a crap about them. I've been talking to one patient about going gradually down from 24mg of suboxone hopefully to 16mg for months now (we're working down slowly, he's doing just fine) and he made the comment that I'm the first person actually even mentioned that he could go lower or even cared...everyone else he had been to just filled the script and carried on.

 

[whopper]

I am always skeptical of claims about patients selling medication made by others, there are often complicated dynamics at play that aren't my place to investigate or get involved in

The problem being that the accuser could be faking the accusation and have their own agenda. Like what was mentioned above a physician is not the police.

Pill counts? That's a good idea although this too can easily be defeated. E.g. let's say someone's on 24 mg, weans down to 16 mg a day, and you force them to come to the office for a pill count. They just need to keep as many in the bottle that corresponds to 16 mg a day.

 

[PikminOC]

This is very interesting, and a dynamic I had not previously considered.

Thats funny because most of the drug seekers I see stomp off in a jiffy and write a bad review

 

[Ceke2002]

Can you put them back, or on, daily chemist pick ups? No takeaways, they have to pick their dose up from a pharmacy every time until they are deemed trust worthy enough to be allowed limited take home doses? That's how both the Bupe and Methadone system works here.

 

[SourceOfDenial]

In reference to the above description of lab work—there is no way with UDS to correlate to dose—except in the absence of any norbup(I.e. haven’t been taking and just started). There are so many factors that go into determining how much of a substance shows up in UDS that it really should only be used to say something is there or not.

In reference to selling and getting a call—my job is not to investigate the patient. If you trust the patient you keep doing what you’re doing. If you have concerns bring them up, but I don’t get the impulse that other psychiatrists sometimes feel to suddenly change the treatment plan based on one datapoint. If there’s a trend it will likely show up again.
Add to that, there being extra bup floating around outside prescribing doesn’t alarm me at all. I’d rather there be a safe drug supply than whatever is currently available in most situations.

 

[Liquid8]

It's a tricky situation. In most cases I will take a patient at face value, unless the source is someone reputable - in that case I am obliged to discuss the allegations with them and gauge their response accordingly.

Have a current patient who I had suspicions about selling medications about due to recent family concerns and past history of large amounts of medications suddenly disappearing (although nothing proven then). Although illicit drug use was denied, the implausibility of recent explanations for certain behaviours and actions had be wondering eg. a crackpipe in the house (supposedly a memento from an ex partner) and heavy use of scented candles (likely to mask any drug odours).

The initial request for a UDS elicited a very borderline/hostile response towards the family and talking about changing all their healthcare providers. 3 months later it still hasn't happened - supposedly missing or kept by their parents which made no sense as they were in favour of it. During that time no further scripts have been written, and while a repeat pathology request was sent out, I've still yet to see anything. There's been some recent events with implausible and dubious explanations - last week was speaking to another of their other health providers who had similar concerns, but the good news is that they are thinking about changing doctors which would be no loss to me.

 

[whopper]

Can you put them back, or on, daily chemist pick ups? No takeaways, they have to pick their dose up from a pharmacy every time until they are deemed trust worthy enough to be allowed limited take home doses? That's how both the Bupe and Methadone system works here.

Yes you can and likely it will not work.

Why?

The way many pharmacies price, the price is not by the pill. E.g. 1 pill might cost someone $30, but 30 pills $120. I never got an explanation from a pharmacist but I figure some of it is the time going into putting the pills in the bottle.

So if you did say 2 pills a day and they had to go to the pharmacist every day, you'll get 1 angry patient, 1 angry pharmacist, it'll be a pain in the butt for the prescriber, the patient will end up paying a lot more money, and the patient can still use less than what they're being prescribed and sell the rest.

There are various things that can be done but none of them will 100% solve the problem leaving a lot of risk of punishing someone where the evidence against them is based on hearsay. Let's be frank. Lots of former drug addicts have scumbags they know willing to ruin their lives. A pill count can be defeated. One could force Suboxone only and force the patient to provide the wrappers. The problem where is Suboxone is much more expensive and many insurances won't pay for it and some patients who are innocent will be forced to pay higher prices that might not be able to afford them. You could do daily prescribing and the problems are mentioned above.

Add to this I've only had a small handful of patients get accused in the first place.