Vomit in Vermont

It makes me sick. Vermont's medical board witch hunt continues to discourage buprenorphine treatment of opiate addiction while revealing gross failure to adhere to any kind of standard, including common sense. 

Physician and VT Board victim Jennifer FauntLeRoy, MD agreed to stipulations of the State of Vermont Board of Medical Practice in order to avoid even more draconian punishment in May of this year. The Board investigated her practice after a pharmacist accused her of "improperly prescribing Subutex." The Board failed to show that her conduct resulted in harm to any patient and accused her of "unacceptable patient care" in only three cases. Not surprisingly the board left us to guess at the number of cases reviewed and found acceptable.

Patient A

The Board faulted Dr. FauntLeRoy for failure to address drug screens showing presence of opiates, cocaine and marijuana but negative for prescribed clonazepam, suggesting that based on these laboratory results she should have stopped prescribing buprenorphine or referred the patient to a more intensive treatment setting.

The Board states (with characteristic ambiguity) that Patient A "repeatedly acknowledged use of cocaine and marijuana during treatment sessions." We can only hope and assume that the acknowledgement -- not the use -- occurred during those sessions. Ideally of course those of us who treat addiction hope that patients will achieve complete abstinence, but by definition no one who takes buprenorphine is completely abstinent. Use of cocaine and relapse with opiates suggests less than optimal outcome, but in the real world the pronouncement of treatment failure in this harm reduction approach must arise out of the physician's discretion in consultation with the patient, not rigid unthinking adherence to a guideline devised in an ivory tower. As for the clonazepam's absence this could easily be explained by irregular or as needed use, which in my opinion is preferable to regular use in combination with buprenorphine. One can easily imagine the Vermont Board faulting Dr. FauntLeRoy for drug screens positive for clonazepam or other benzodiazepine.

Patient B

In this case as in the case of Patient A the Board demonstrates failure of perspective in its concern over marijuana use in a patient treated for much more serious addiction to opiates. The Board's use of the trade names Subutex and Suboxone suggests failure to appreciate potential conflicts of interest in relation to pharmaceutical companies. Or perhaps the Board simply does not know of which generic drugs it speaks. Here the Board criticizes Dr. FauntLeRoy for failing to explain her decision to switch the patient from buprenorphine/naloxone to buprenorphine alone. The Board goes on to criticize the physician for allowing the patient refills "prematurely" but fails to specify how early the refills occurred and how much drug they involved. This suggests the Board fails to appreciate the reality that patients addicted to buprenorphine, in order to aviod painful withdrawal, naturally want to assure their supply, for example, over weekends, holidays, or other times when the prescribing physician might not be available. Patients do occasionally travel such that they may need refills prior to leaving on a trip. The physician must also exercise discretion in allowing the patient to vary the dose of medication within reasonable limits. In reality a physician prescribing any medication can never know with absolute certainty when or how much of that medication the patient takes, and it is unreasonable for the prescribing physician to document an explanation for each and every "premature" refill.

Patient C

Here we see evidence that whatever the physician does the Board may deem inadequate. The Board criticizes Dr. FauntLeRoy despite admitting that she documented discussion of same. We also see more sloppy writing. While the Board admits that she documented that "overuse of his medication was acknowledged and discussed" it accuses her of failing to document that she was "aware" of oversupply medication. Would the Board have us believe that the physician could document acknowledgments and discussion in the absence of awareness?

In this case we also see the Board's most outrageous attack. The Board faults Dr. FauntLeRoy for the failure to "document her observation of objective evidence of Patient C's subjective complaint or the occurrence and frequency of his claimed emesis." Vermont physicians must indeed be a rare breed if they can objectively observe nausea in their patients. Objective evidence of vomiting of course is a different story. Perhaps the Vermont Board expects Dr. FauntLeRoy's patients to bring her their vomit. One can only hope that the Board will not been criticize her for failing to confirm the source of the vomit (Those devious addicts will surely team up with bulimics in order to fool the doctors.), not to mention the exact time of each upchuck. We might wonder whether they expect Dr. FauntLeRoy to require her patients to vomit only during appointments with her. Add vomit monitoring to pill counting and drug screens for physicians to further delude themselves regarding their ability to determine the fate of prescription drugs.

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