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.

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?

‘Here to Help’ Not Helping

I am removing the link to the ‘Here to Help’ program, a thinly-veiled piece of Reckitt Benckiser propaganda that does much more to harm the lives of opioid addicts than to improve them. The connection isn’t real complicated, but might take a moment or two of your concentration to understand.

I’ve written in the past about how RB profits from the misunderstandings about the value (or lack thereof) of naloxone, a chemical that turns generic buprenorphine at $0.25 per mg into the identically-acting drug Suboxone at $1 per mg.  I’ve written about RB’s mad rush to promote Suboxone film, to replace the profits expected to disappear as generic buprenorphine/naloxone enters the market. And I’ve written about the latest stunt by RB of declaring their own tablets unsafe shortly after their patent expired, essentially eliminating the ‘risk’ that affordable generic ‘Suboxone’ will ever reach suffering addicts.

The impact of RB’s actions extend beyond raising the price of their signature product– an action that by itself costs untold lives.  The hyped concern over the safety of buprenorphine also strongly impacts the debate over raising the 100-patient limit faced by current providers.  That means the doctors like me, with a waiting list of 80 people, must reconcile the wait list with obituaries as they appear in the paper each week– rather than treat those in need.  But to RB, the most important thing isn’t to open more doors to treatment, but rather that the film be successful.

The National Alliance of Advocates for Buprenorphine Treatment has never been publicly critical of Reckitt Benckiser, even as they release a report on the reasons to increase the 100-patient cap on buprenorphine treatment.  In fact, it is hard to find anyone critical of RB these days– SAMHSA, CSAT, NIDA… pick the initials.  I guess it helps sometimes to be the 400-pound gorilla– especially when the zookeepers appear to be 90-pound weaklings. Or maybe there are only so many bananas to go around these days.

As if I needed more to write about, I happened across the RB web page and their ‘doctor-finder.’  I wondered, with all of the nice things I’ve had to say, whether I was listed– and in fairness I was, number 15 out of 100 listed for Wisconsin in the section marked ‘SAMHSA Physicians.’  But I was not listed at all in the default search section, where ‘Here to Help Certified Providers’ are listed.  I read about what it took to become a member of that distinguished group, and found that the providers had to do all the same things that any buprenorphine-certified physician had to do, but one thing more– to promise to prescribe ONLY Suboxone film to patients.

That’s right; to be classified as ‘Here to Help’, I would have to promise Reckitt Benckiser that I will ignore patients who complain of headaches and ask to try buprenorphine tablets.  I would have to ignore patients who simply preferred a tablet over the film– such as patients who complain about hiding all those little wrappers that tell employers about their medications, or who tire of their medication blowing away in the breeze when they try to take it, or who have lived a sufficient number of years that it is difficult for them to see and crease the tiny dotted line, that allows for at least a fighting chance at opening the wrapper.

Can’t tolerate the taste of the film without vomiting?  Want the option for a generic, lower-cost alternative?  No children in your home, so you’d prefer the non-child-proof option?  Sorry– I’m from ‘Here to Help!