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.

How Long Should I Take Suboxone?

The length of time a person stays on Suboxone, i.e. buprenorphine treatment, has become a needlessly-heated issue.  Readers of my blog, SuboxoneTalkZone, likely know my opinions on the topic.

I recently met with the parents of one of my buprenorphine patients who were frustrated over their son’s ‘lack of progress.’  They complained that he has been on Suboxone for three years, and wondered when I would finally get him off the medication.  They pointed out how sick he gets when he forgets to have the medication refilled, saying that he is just as ‘dependent’ as he was when he was taking heroin.

I am glad, at such times, that I don’t have to search my conscience to determine whether my treatment plan has a financial incentive.  In short, it doesn’t.  If anything, my financial incentive would be to get everyone off buprenorphine as quickly as possible.  I have a long waiting list of people who are hoping for a spot in treatment.  And since new patients usually need a higher level of care, bringing in new patients results in more ‘business.’  Because of the 100-patient cap, the portion of my practice taken up by people on Suboxone has become a small, relatively-stable group of patients.

But I know the statistics for people who suffer from opioid dependence, before or after residential treatment.  The rate of relapse is high, as is the fatality rate. Everyone— doctors, patients, and family members alike– wishes that spending a certain amount of time on Suboxone would somehow reduce the rate of relapse.  But the facts suggest otherwise;  that regardless of the length of time a person takes Suboxone or buprenorphine, the risk of relapse after stopping the medication remains high.

The frustration over the relapsing nature of the illness is unique to addiction. Nobody would expect a diabetic to cease needing insulin after several years.  Nobody expects coronary disease, hypertention, or elevated cholesterol to simply ‘go away’ after a few years of medication.  Even other psychiatric conditions, such as bipolar illness or depression, are not expected to resolve after a couple years on mood stabilizers or SSRIs.  And the unfortunate truth is that addictive illnesses are similar to non-addictive illnesses.  Most illnesses, including addiction, tend to recur over time.

I shared my thoughts with the parents of my patient, explaining that I am always willing to take a fresh look at the treatment options.  The chance of long-term sobriety after other treatments, for example residential treatment costing 50-100 times more than a year if his current treatment approach, is low– on the order of 5%.  And the rate of complications during active heroin addiction, including felony charges, brain damage, hepatitis, and death, is frighteningly high.  If they know of a better approach at this point, I’m all ears– and ready to make the referral.

I didn’t share the other thought in the back of my mind– that their son was pretty darn lucky, to have access to a medication that probably played a major role in keeping him alive and out of prison for the past three years.