Why So Few Suboxone Doctors?

Some parts of the country report a shortage of physicians who are DATA-2000 certified, i.e. able to prescribe Suboxone and other buprenorphine products. The shortage of buprenorphine-certified doctors parallels shortages of mental health practitioners in general, including psychiatrists and addictionologists. Larger cities and areas near the east and west coasts are less likely to have shortages of doctors than are smaller and more-rural parts of the country, particularly across the Midwest.

The shortage of Suboxone doctors is caused by a number of factors.  All doctors train in medical schools, which are primarily located in larger cities.  So by the end of training. most doctors have spent several years living in larger cities, establishing friends and business partners and sending their children to area school districts.  As with members of any profession, doctors are more likely to choose positions in areas they know than to move to unknown areas, unless the area holds special attractions like morning sunrises over the ocean or mountain views.  Even doctors who grew up in rural areas find it hard to move back, after living in more urban areas during the 12 years of college, medical school, and residency.

Beyond the regionalization pressures, doctors are discouraged from becoming certified to treat opioid dependence using buprenorphine.  The coursework is limited by medical school standards, and the cost for buprenorphine training and registration is relatively minor.  But to become buprenorphine-certified, doctors must sign an agreement that allows random inspections by the DEA without cause.  Other doctors enjoy privacy rights similar to other businessmen, where search of the premises and review of records would require probable cause and issuance of a warrant by a judge.  But in order to treat with Suboxone or buprenorphine, doctors must waive that right of privacy and allow inspections with no notice, even if such inspections require closing the clinic doors for the day.

The requirement to allow random inspections has an effect on individual doctors, especially since the 100-patient limit (30 patients the first year) guarantees that buprenorphine-prescribing will not support a practice without a significant number of non-buprenorphine patients.  And now that most doctors are employees of large health systems, the requirement for inspections is a greater hindrance.  Most major health systems are not as interested in treating addiction— an area of medicine with low reimbursement rates, and patients who are more likely to be impoverished by their illness– as in attracting orthopedic or heart patients, the ‘cash cows’ of modern medicine.  If you were CEO of a multi-physician network, would you permit random DEA inspections of your physicians’ offices in exchange for the ability to treat more patients addicted to drugs including opioids?

I can’t blame those CEOs and physicians for the decisions they make.  The result is a shortage of buprenorphine-certified doctors, and the attraction of businessmen-doctors who find a way to turn buprenorphine treatment into a profitable enterprise, by signing doctors to increase their patient-limit, and seeing as many patients in as short a time as possible.  Other doctors tend to be physicians who enjoy working in the field of addiction because of their own experiences with addiction and recovery.  To those physicians, treating a fatal disease, in a disrespected and stigmatized patients, can be very a very rewarding way to practice medicine.

There are calls to raise the patient cap, or to find other ways to reduce the stigma over opioid dependence that discourages doctors from entering the field of addiction treatment.  But now as more and more states are writing regulations of their own, sometimes through well-motivated but misguided efforts to reduce ‘diversion’, I’m not holding my breath that the shortage will end soon.   And since much diversion consists of people using Suboxone on their own after failing to find a physician, don’t expect state regulations to move the diversion problem in the right direction!

Find Suboxone doctor locators here.

How to Use This Site

If you are searching for a doctor certified to prescribe buprenorphine, click on the third selection in the menu above– or simply click here, for ‘Doctor Directories.’  You will be taken to a page that lists a number of buprenorphine-certified doctor databases with comments about each database.  People are encouraged to list any database not mentioned here in the ‘comments’ section (as one reader has already done).

Again, the information is at Suboxone Doctor Locators

The menu contains links to several other resources.   Bupetube, for example, is a collection of YouTube videos about addiction and the use of buprenorphine to treat opioid dependence.  The link ‘Google-Results’ is a destination page for searches related to Suboxone .   To use the search on web sites about buprenorphine, opioid dependence, or addiction, simply enter your search term in the box at the right of the header labeled ‘Google Custom Search’ and click on ‘Search’.  If you leave the page that contains your search results, you can return to it by clicking on the link to ‘Google Results.’

The menu item ‘SuboxSearch‘ connects to a new feature where one can search either SuboxForum or Suboxone Talk Zone–independently– about topics related to buprenorphine and addiction.  For example, someone seeking information about buprenorphine and pregnancy can find thousands of comments related to buprenorphine and pregnancy, or about one small aspect of buprenorphine and pregnancy, from buprenorphine patients themselves, answering each others’ questions on SuboxForum. Or the person can search for information on the specific topic of choice from the archives of Suboxone Talk Zone, from posts that were written over the past seven years.

I wish you success with your search for an appropriate physician, and I encourage you to use the search functions and view the informational videos.  I have done my best to provide information that is free of commercial bias, based on the science behind buprenorphine and addiction.

Why Limit Care?

My personal practice receives several calls per week by people asking for help in treating their addiction to pain medications or heroin, or often both.  As people seeking treatment usually discover, each physician is capped at the total number of patients who can be treated with buprenorphine at any one time.  During the first year of buprenorphine certification, physicians can have up to 30 patients under treatment at one time.  After a year, a physician can apply to have the number increased to 100.

I have been at 100 patients for years, and I have relatively slow turnover, since I am an advocate for long-term treatment using buprenorphine.  My wait-list has about 60 names, although when a spot opens up and I start calling people on the list, many of the numbers have been disconnected.  Opioid dependence tends to do that to telephone accounts, either through poverty or death.

Why would we limit the treatment spots for such a lethal condition?  I know HOW it happened, but I’ve no idea WHY.   In order to allow for maintenance treatment for opioid dependence, Congress had to pass a law called DATA 2000 to make an exception to the Harrison Act– an old rule that forbids prescribing opioids for opioid dependence.  Congress through in the patient cap, assumedly out of caution, but in part, I know, because they COULD.  Lawmakers have no ability to control the amount of oxycodone that prescribers release into a community, but since buprenorphine required their permission, they made certain that their permission carried strings.

Proponents for the cap claim that one physician can adequately treat only 100 patients at one time, a ridiculous claim.  Most of my patients are entirely stable, going about their lives in stable jobs and relationships.  Many are by far the easiest patients to manage in my psychiatric practice.  Beyond that, there is no cap on the number of patients that a doctor can have on hydrocodone, oxycodone, oxymorphone, alprazolam, clonazepam….  does anyone really think that patients on buprenorphine are MORE difficlut to manage than THOSE patients?!

The cynic in me wonders if those behind residential treatment programs make up part of the push against increasing the cap.  I have no evidence for that being the case, but I know that successful management of opioid dependence using buprenorphine reduces the number of patients who attend $50,000 per month programs with very low success rates.  I hope my cynicism is wrongly-placed, as everyone in the treatment world should have an interest in keeping people with addictions alive.

There are many reasons to eliminate the cap.  But the one reason is simple:  people are dying because they can’t find a doctor.  Isn’t that reason enough?