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?