Office-based Opioid Addiction Treatment: Raising the One-hundred Patient Limit

aaaaaaaaaawait

The hearts of addiction medicine doctors nationwide are aflutter at rumors that the limit on office-based buprenorphine patients may be raised or lifted. As it is now, the DATA 2000 law says each doctor who prescribes buprenorphine from an office setting for the treatment of opioid addiction can have no more than one hundred patients at any one time.

DATA 2000 was a big deal. Until it passed, it was illegal for any doctor to prescribe any opioid to treat opioid addiction, unless they worked at a specially licensed opioid treatment program. In other words, doctors in an office setting had to refer opioid-addicted patients to opioid treatment centers for medication-assisted treatment. And the only medication available was methadone.

Then DATA 2000 allowed Schedule 3 opioids to be prescribed from physicians’ offices for the purpose of treating opioid addiction, as long as these medications were FDA-approved for this purpose. Thus far, buprenorphine is the only medication that meets the DATA 2000 requirements.

But the law had other limitations. For example, each physician had to get a special DEA number to prescribe buprenorphine. And as above, no physician could have any more than one hundred patients on buprenorphine at any one time.

My office gets multiple calls each week from people seeking treatment for opioid addiction in an office setting. These callers say they’ve already been to the websites that list doctors. (http://buprenorphine.samhsa.gov and http://suboxone.com . They’ve made multiple calls and discovered these doctors aren’t taking new patients because they’re already at their one hundred patient limit. This is happening all over the country; patients want treatment but can’t get it. For many such people, opioid treatment centers are geographically impractical, so that’s not an option either.

Since addiction is a devastating and potentially fatal disease, government officials feel pressure to do something to help our nation’s opioid addiction problem. Lifting the one- hundred patient limit has been suggested as one option to improve the situation. This would seem to be the best, easiest, and quickest way to get more people into treatment. At least, most Addiction Medicine doctors like me think it makes sense.

Not everyone agrees.

Opposition has come from some unexpected sources. I went to an opioid addiction treatment conference in a neighboring state lately and heard the president of AATOD (American Association for the Treatment of Opioid Dependence), Mark Parrino, MPA, speak against lifting the limit.

First let me say I admire Mr. Parrino immensely. He has been and continues to be a huge advocate for this field. He’s done more good in the field of opioid addiction treatment than most people I can think of, and has been doing this good work long before I ever even entered the field.

But that doesn’t mean I agree with him on everything.

When he spoke at the conference, he said he was opposed to expanded buprenorphine treatment in the office-based setting because patients don’t get the counseling that they need, so it really isn’t medication-assisted treatment, it’s just medication assistance. He says opioid treatment programs provide on-site counseling, drug testing, and other services that can help patients, and that most office-based programs don’t offer such comprehensive services. He also said diversion of buprenorphine from office-based practices is a huge problem, and that much of the black market use is actually abuse of the medication. He raised the uncomfortable issue of price gouging by some unscrupulous buprenorphine doctors who charge large fees and deliver little care.

You can read a statement on the AATOD website that fully describes their opposition – or at least call for caution – regarding raising the one hundred patient office based treatment limit:
http://www.aatod.org/policies/policy-statements/increasing-access-to-medication-to-treat-opioid-addiction-increasing-access-for-the-treatment-of-opioid-addiction-with-medications/

I don’t completely disagree with the points Mr. Parrino made at the conference, but I do think the same arguments can be made against OTPs if one were inclined to do so.

What about opioid treatment programs that pay lip service to the counseling needs of the patients? What about OTPs that hire people to be counselors with little or no experience in the counseling field? Just as Mr. Parrino can point to the worst examples of office-based buprenorphine treatment, I can point to OTPs who aren’t doing a great job. How can an OTP counselor provide Motivational Interviewing as a therapeutic technique if that counselor has never even heard of MI? Yet I’ve seen these problems at opioid treatment programs.

Don’t paint all office-based practices with the same brush. Many of us want to provide good treatment with adequate counseling. For example, my office has a therapist who is a Licensed Professional Counselor with a Master’s in Addiction Counseling. He does a great job, and as an added bonus has great legs. (He’s my fiancé, before you assume I’m sexually harassing him at the workplace).

Alternatively, if the patient prefers to do only 12-step meetings, I’m OK with that, so long as they provide me with a list of meetings they’ve attended each month. Or if they’re already working with a therapist, it’s OK with me if they want to continue, as long as they agree to allow me to speak with their therapist about issues directly relating to the treatment of their addiction.

Diversion of buprenorphine to the black market is a big problem. Not all office-based buprenorphine doctors are as careful as we should be. We will never be able to get rid of all diversion of any controlled substance that we prescribe, but all buprenorphine doctors should be doing drug screens and have diversion controls in place to limit the problem.

Not as much methadone is diverted, but only because of the very strict regulations on methadone take- home doses at the OTP. Many patients – and OTP personnel – feel present regulations on methadone take- home doses are overly strict and limit flexibility of treatment for patients who are doing well. Is the answer then to regulate take -home doses of buprenorphine as closely as methadone?

What about the predatory doctors who prescribe buprenorphine just for a quick buck, sensing they can charge exorbitant fees from desperate opioid addicts? I can’t say anything in their favor. They embarrass me. As with many things in life, the actions of a few give the rest of us a bad reputation. But I do think these doctors are in the minority.

And don’t believe everything you are told about office-based practices; I’m sometimes told by patients that I’m in it “for the money” though I charge the same for an office visit for a buprenorphine patient as I would for any other medical ailment. Some patients feel like their treatment should be free, but the U.S system of medical care is not usually free for any disease.

In short, though I recognize there’s some truth in many of Mr. Parrino’s statements, I still think most buprenorphine doctors try very hard to do things right so that they provide good care for opioid addicts who can’t or won’t go to an opioid treatment program. Expanding access by raising the one-hundred patient limit will allow more people to get addiction treatment.

Advertisements

17 responses to this post.

  1. Good subject!

    Reply

  2. Posted by Elizabeth on October 22, 2014 at 2:20 am

    Very well said Dr. Burson. I was recently having a discussion about this very topic wuth some people who are against raising the patient cap until buprenorphine treatment in an office setting is so overly regulated, that it will hinder some patient’s ability to receive treatment. I have a wonderful doctor who is very caring and requires UAs, and counseling, and doesn’t “hand out” a month’s worth of medication on the first visit, as many opponents claim is so common among buprenorphine prescribers. I’ve heard of less than great doctors, but I personally haven’t seen a doctor prescribe that much on day one. Even in the 1st program I attended, which I hated, and thought was a terrible program, only allowed a three day supply for my 1st prescription, then a week for my 2nd, and I had to be seen 2-3 times per week for the first three months in that particular program for groups/therapy/UAs etc. The doctor at that particular practice walked out on all 100 of his patients leaving us with no prescriber, and some relapsed.
    I did, however find a much better program, and much better doctor, and feel that the groups who are against raising or eliminating the patient cap are painting all addicts on buprenorphine, and their doctors with the same brush, which just isn’t fair. I’ve been reading the Internet talk about it all day, and in one breath, they say yeah there’s a few good doctors, and we’re not talking about making it as regulated as methadone, and in the next breath they’re saying how bupe patients should have to earn take home medications using the same guidelines as are used in methadone clinics. Yes, some practices need to do a better job, but to deny the many in need for the few who abuse the meds or the doctors who abuse their right to prescribe it, is just wrong! People are dying! Reading some of the comments I’ve read today, it almost seems like some methadone patients are envious that bupe patients don’t have to endure the same hassles that they do. but wasn’t part of the reasoning for Data 2000, to make office based treatment of opioid addiction possible for those who wanted the privacy and normalcy of being treated in a private office setting? To avoid the inconvenience and expense of inpatient treatment, and to avoid the inconvenience of daily clinic visits? I’m sorry that methadone is so overly regulated, but why should I, as a compliant patient, who never misses appointments, or have positive UAs, and consistently go to my counseling, above and beyond what my program requires of me actually, have to suffer for the bad apples? I even read the argument that if a dr isn’t “in it for the money”, they’d just apply to become an OTP, and not have to worry about the cap issue and treat as many people as they want. I find these arguments ridiculous and insulting. Ok, if they become an OTP, then buprenorphine is subject to many of the same regulations that methadone is subject to. I personally don’t want my doctor to have to become an OTP, I like the private office setting. I’m left shaking my head on this one Dr. Burson.

    Reply

  3. Well said and until I read your article I was all for raising the 100 patient limit. I use the medication Suboxone and my life is wonderful. I am a strong advocate of Medication Assisted Treatment and do my best to help spread the word that MAT does work in conjunction with some type of support group. I feel ther is too much bad press by uneducated and unqualified writers regarding this subject.

    Reply

  4. Posted by Amy Jamez on October 22, 2014 at 6:59 pm

    Zac Talbott, aren’t you of the opinion that buprenorphine should be treated just like methadone? That bupeprenorphine patients should have to earn take-homes, and start out by visiting a treatment center daily? Isn’t that what you advocate in your Facebook group, while deleting respectful, but differing opinions? You seem very balanced and fair while addressing a respected member of the medical community, but your views are much more extreme than what you present here.

    I am a complying buprenorphine patient who sees a doctor who takes insurance, performs urine tests, requires counseling or 12 step meetings, and who is available to his patients when they need him. I was required to go through a 48 hour withdrawal before I was induced in my doctor’s office. I was there for 3 hours while we figured out the correct dose. I left the office and noticed right away that I was no longer obsessing over pills. I felt like a normal functioning person and my pill obsession was gone.

    However, that doesn’t mean I was suddenly cured or fixed. That is why I see an addiction counselor every other week. I am active in an online suboxone support group. There isn’t a day that goes by that I don’t think about my addiction and its consequences.

    When you, Zac, advocate for tighter regulations on buprenorphine providers and patients, and suggest that buprenorphine patients be treated exactly the same as methadone patients, you are ignoring the very real fact that buprenorphine and methadone are two very different medications.

    Methadone does not take away a patient/client’s urge to use. Buprenorphine does. Methadone does not keep a client from being high, and depending on the dose, can get a client high. Buprenorphine does not make an active user high. Buprenorphine binds strongly enough to the opiate receptors in the brain that a patient could take heroin and not get high. The reason that buprenorphine is appropriate for a doctor’s office while methadone is better suited for a clinic setting has everything to do with their chemical formulations.

    I don’t think that buprenorphine is a miracle drug, despite the fact that it has been a miracle for me. It only works as it should when the addict truly wants recovery. It is a tool in the fight against opiate addiction, not a cure. There will always be people who misuse buprenorphine and those who divert it. The regulations that are necessary should focus on the providers who are basically dealers. I abhor the thought of “doctors” prescribing buprenorphine from their cars without any follow up care. Regulate the fly by night providers, by all means! Require routine urine test and counseling for every patient! But don’t throw the baby out with the bath water!

    If you take away the ability for patients to be treated at a doctor’s office with 30 day prescriptions, the consequences will ultimately hurt addicts, not help them. I know addicts who travel 2 1/2 hours to get to their buprenorphine doctor. What would happen to them if they had to get to their provider every day? They would be left without treatment. Only wealthy people would be able to handle that kind of barrier.

    The problem that exists right now is that there are not enough buprenorphine providers for the number of addicts who need treatment, especially for the addicts in rural areas of this country. That’s why we need to be lifting the patient caps of good, compliant, doctors, not making it harder for addicts who are seeking treatment.

    Because access to treatment should be made more available to addicts, not less,

    Amy Jamez

    Reply

    • Amy, having been a client at a methadone maintenance clinic for just over twenty years, I feel qualified to comment on your letter. Methadone does, in fact, remove an addicts’ urge to use. It does not, in my case, get me “high”. I’ve been up to 170mg/day, and have been at 130mg for the past eight years. Methadone certainly does block the effects of other opiods. Early in treatment, at 80mg, I tried it out, as many do, for myself. Absolutely blocked! It does bind with the opiate receptors as you say buprenorphine does, to at least a comparable degree. After 20 years, I have not had a positive urine screen in the last 19 and a half years. Until federal regs changed, I was getting 30 takehomes at a time for several years.The medication has indeed been a Godsend for me. I have been able to be the parent my children needed, in all ways. Of course, this is my experience, but it makes me believe that others can, if properly motivated and counseled, succeed in a methadone clinic setting. Congratulations for your success and best wishes in the future. Jon

      Reply

  5. Posted by Amy Jamez on October 23, 2014 at 5:30 am

    Sorry Zac, I was referring to the closed facebook group that you help administrate. The people that I know who joined your facebook group were saying that anyone who differed with your opinion in a comment was quickly deleted.

    The people that I know who are in your facebook group have said that you are in complete agreement with those that want very harsh restrictions on buprenorphine administration, including the patients having to visit a clinic every day until they earn take-homes. You may have never said these things outside of that closed facebook group, but within the auspices of that group your opinions are more extreme than what you present here.

    I would be happy to view the scientific evidence you have that buprenorphine does not take away the urge to use or that you can get high on it if you come from a place of active addiction. Most addicts who take buprenorphine try to take a little extra at first to see if they can get high from it, but are quickly disappointed. (We are addicts after all.) The only way people get high from buprenorphine is if they are opiate naive and take a dose, or if they stop taking it for a time to make sure they feel an effect when they do take it.

    I am speaking from personal experience that the urge to use goes away almost immediately after being induced on buprenorphine. And I’ve never gotten high from it either. Where do you derive your information about what buprenorphine is or isn’t? Buprenorphine has a ceiling limit that limits the potential for abuse and overdose. Methadone doesn’t.

    If you have scientific evidence that delineates that buprenorphine is no different from methadone, I’d love to see it. And if you do believe they have differences, what are they in your opinion? From my perspective, office based treatment would never have started if medical professionals and scientists did not see the differences in how buprenorphine functions in the brains of addicts.

    Reply

    • Posted by Elizabeth on October 23, 2014 at 9:30 pm

      I don’t think the above poster to this blog is personally attacking you or insulting you. She’s simply asking you questions about your views on lifting or raising the patient cap on buprenorphine practices and presenting her own views as well. I think it’s important to hear all sides of this discussion, and not take it personally when someone is in disagreement with you. I think it’s very reasonable to ask for credible studies showing that buprenorphine and methadone are so much alike that they should be similarly regulated by the federal government.
      Everything credible that I’ve read, shows that in stable and compliant buprenorphine patients, mandated counseling and UAs, make little to no difference in treatment outcomes. Some addicts are sicker than others, and the highly regulated and more rigid environment of an OTP perhaps would be more suited to their needs, but in more stable patients, for whom office based treatment was originally intended, the cap presents a significant barrier to treatment to those in need. You did agree with many comments in methadone discussion that said things like (paraphrasing here), “buprenorphine take home doses should be subject to the same regulations for earning methadone take homes”, and “we should be working together to get this into a clinic setting” even if you didn’t make those exact comments yourself. Again, I’m not attacking anyone either, but rather, I am trying to engage in intelligent discussion of this topic, which often does produce differences of opinion. The fact that we are all here and discussing it in the 1st place, shows that we all care very much. I believe all our voices should be heard.

      Reply

    • Posted by Amy Jamez on October 24, 2014 at 8:12 pm

      The last thing I want to do is to get into a debate about whether methadone or buprenorpine is better. I think that those of us in MAT need to support each other since the stigma of addiction and MAT treatment is weighing us all down. I support the availability of both and I know of addicts who are stable and doing well on each medication.

      My only goal in the statement you quoted was to get you to acknowledge that buprenorphine and methadone are two different medications and that they function differently. Please tell me the ways in which you believe the medications are different. Perhaps that would allow me to understand what you believe about buprenorphine. I may be getting some things about methadone wrong and I acknowledge that, but my point was not to malign methadone. It was to highlight the differences between the medications.

      My assertion is that the unique nature of buprenorphine makes some of the restrictions that are necessary for methadone patients, unnecessary for buprenorphine patients.

      I’m very grateful for Dr. Burson’s blog and for her bringing the struggle to raise the patient cap for buprenorphine providers to the forefront. However, Zac, your opinion against lifting the patient cap without putting new regulation in place is the tip of the iceberg of what you, and the number of people who are like-minded, want buprenorphine regulation to look like. I appreciate that Dr. Burson is giving me some latitude to express my dismay in this public forum.

      [********I have deleted the portion of this comment that refers to another closed discussion group, at the request of an administrator of that group. ********
      Jana Burson]

      My contention is that the differences in chemical structure between methadone and buprenorphine and their effects on addicts indicate that different practices are necessary for treating methadone patients and buprenorphine patients. I am not contending that one treatment or one medication is better than the other. Just that they require different treatment practices.

      I agree that there needs to be strict oversight of these “fly by night” buprenorphine providers! I agree that buprenorphine patients should be receiving counseling on a regular basis and even that it be mandated. I think the regulation of urinalysis tests is fine if they’re not excessive. (Say…one every visit until the 6 month mark, and then once every 3 to 6 months.) I agree that there should be closer monitoring of a new buprenorphine patients for the first month.

      My doctor was available by phone within minutes during my first two weeks on buprenorphine. I was given a 2 week supply of buprenorphine after I was inducted and had a follow up appointment after the two weeks. It worked perfectly for me. I think I had a urinalysis after the first month and then it dropped to once every 6 months.

      These are my questions for you, Zac. (And I’m not picking on you. I am acknowledging that you represent a viewpoint that has many proponents. You are the one who lists the acronyms and organizations you represent.)

      1. What are the differences between methadone and buprenorphine as you understand them, or do you believe that they are essentially the same medication?

      2. Tell me what regulations you think are necessary to place on buprenorphine providers and patients and why they should be different or the same as methadone providers and patients.

      3. Do you believe that the approach laid out by Liz **** ***** is correct? Where does your opinion differ from hers? Or do you fully agree with her?

      If you are not willing to answer these questions it should be very telling to all of us that you do not wish to be fully transparent about your opinions. If you believe you have a valid opinion there is no reason not to share it here.

      Because, otherwise, it just smacks of methadone patients thinking that buprenorphine patients should be required to go through the same protocols as methadone patients. Not because it is necessary, but because the grapes taste so sour.

      Amy

      Reply

  6. I came here to leave a comment about this blog, and I will do so. However, I first want to say that Zac Talbott is a fair, generous, kind and knowledgable man, both in person and in the Methadone Discussion group, of which he is an administrator, not an owner. I have made comments in this group that are in disagreement with Zac’s opinions and he has not deleted them. The comments that are deleted are those that are blatantly false and those that are rude or unsupportive of medication assisted treatment. I also did not see anywhere in this blog where he said buprenorphine did not stop cravings or keep patients from getting high, as was said by Amy Jamez regarding methadone. I resent the statements made about methadone. Patients on the correct dose of methadone do not get high from illicit opiates and do not have cravings. Finally, if everyone is taking their buprenorphine properly, where is all the illicit buprenorphine on the black market coming from? I agree that it is a wonderful medication, but let’s not paint it as perfect.

    Now, for my comment:

    I feel that patient limits for doctors prescribing buprenorphine should not be raised until a better system of rules and regulations is put into place. If we were able to treat ourselves with no counseling or accountability, there would be no need for anything more than a “magic pill or liquid” to cure us. Sadly, after failing to be able to self-regulate pain medication or heroin, it is foolish to believe that when first entering into treatment, we will immediately be able to control our buprenorphine intake without regulations and counseling. It is also foolish to believe that we can resist selling some of it to try to repair some of the financial mess we usually find ourselves in when we first go into MAT. Take home doses should only be available to patients who have demonstrated that they can properly manage them, not handed out in a 30-day supply on the first day of treatment.

    Inadequate regulation presents a variety of problems. First and foremost, it decreases the probability that MAT will be successful in patients who feel ready for treatment. They are given/sold an incomplete tool kit to fight their disease if there is no counseling and accountability early in the treatment process. Secondly, it puts society at risk when black market buprenorphine is available to anyone who wants to try it, whether to get high or to temporarily stop using and later return to it when it’s more convenient. Finally, it adds to stigma. People fail to notice the many patients who have turned their lives around with buprenorphine. They only hear about the ones who abuse and sell it. This gives anti-MAT crusaders ammunition for their battle to ban buprenorphine and methadone altogether.

    I think we need to make buprenorphine available through more than just a handful of doctors and clinics. Any doctor who presently prescribes it responsibly should be given the opportunity to show proof of that fact, along with future plans for continuing responsible prescribing behavior. After doing that, he/she should be among the first to be approved for more patients. Drug screens and verified participation in counseling should be mandatory. The ability to earn take home doses and to keep them should follow similar guidelines to those used at methadone clinics. Just as I do not believe a patient should be handed a 30-day prescription at the beginning of treatment, I do not believe he/she should be required to come in on a daily basis after he/she becomes stable and demonstrates responsibility with take home medication. Creating and implementing guidelines for prescribing buprenorphine should be a priority so patient caps can be raised responsibly and greater availability can become a reality.

    Reply

    • Posted by Elizabeth on October 25, 2014 at 2:41 pm

      I resent comments that say is foolish to believe buprenorphine patients won’t sell some of our medication to repair the financial damage done by our addictions! I know many patients prescribed thirty day supplies of their meds that HAVE NEVER diverted their medication! Nor have I ever done so. If methadone patients don’t want to all be painted with the same brush, they shouldn’t paint all bupe patients with it either! I’m in agreement with the poster, Amy…. sour grapes!

      Reply

      • Posted by Elizabeth on October 25, 2014 at 3:01 pm

        Dr. Burson,

        I understand why you deleted a portion of another poster’s comment, but I hope that it was read by at least some people. I think people who are pushing for what many call radical changes to the way data 2000 allows buprenorphine patients to receive care, should have the exact nature of what they are calling for laid out so we all may see. Why not be transparent in what they are calling for? It reeks of envy of the way even good doctors, like yourself and compliant patients, are able to provide and receive quality addiction treatment without the tight, noose like restraints that are required of patients who must attend an OTP. The kind of restrictions being called for by some, are far more stringent than what is being represented here for public view. If, god forbid, changes like those are actually implemented, it puts addiction treatment out of the reach of many.

  7. Posted by Jeff on October 25, 2014 at 9:29 pm

    I have no idea who this Zak person is. Never heard of him or read anything he’s written until today. I do find it really interesting and perhaps telling that in every post he made here, he stated he WAS NOT going to debate this or hijack someone else’s thread – then went on to do exactly that, then return a day or two later to say he would not do it again right befor, you guessed it, doing it again. Very telling. I tended to pay much more attention to what people actually do rather than what they say. People very often say one thing then do another. Just an observation.

    As to raising the cap, I’m seeing comments and concerns for rules, regulations, diversion, doctors not requiring this or that. Hello??? People are dying EVERY DAY from opiate overdose. Do you get that? Again, I’m paying attention to what you are really saying here. You are saying, until we can better fix diversion, until we can put more rules and laws in place, until we can provide what we think is the very best, top level of care – until we can do all of this, some more people are just going to have to die. It’s better to have rules in place and pay attention to those rules than to save a life. That is what you are really saying. Unless we can give EVERYONE on Bup. The top level of care, they are just better off dying from their disease than getting “substandard” treatment.

    That is what people against raising the cap are saying. If I am wrong please tell me how. You are saying that unless Bup can be prescribed with every I dotted and every T crossed, the patient is better off not getting any Bup treatment. Tell me how I am wrong.

    Wake the hell up people! We have an epidemic here with more people dying every year from overdose than car crashes. We have a medication proven to work and clearly at the very least not making patients worse yet you are willing to not let people get it, you are willing to let them die until the Cadillac treatment can be provided. This is the same as having everyone live in poverty rather than allow some to be filthy rich. It comes from that same crowd and same line of thinking. Perhaps I’ve really hit on something here.

    For Gods sake, please, let’s get this treatment available to the thousands if not millions on waiting lists with no treatment at all. That has to be job one. Perhaps then we can look into improving it. Saying it has to be the best or nothing – put another way, saying doing nothing is better than anything less than the best – is crazy. Far too many have NOTHING right now. A poor Bup treatment program is better than no Bup treatment at all. Sadly far to many having nothing right now. Please try to get that. Please?

    Some Addiction treatment is better than none – and certainly better than death!

    Reply

    • Posted by Elizabeth on October 26, 2014 at 12:07 am

      I think you’ve hit the nail right on the head, Jeff. I don’t know how insisting that so many regulations are in place that it hinders addicts ability to receive treatment, before considering raising the patient cap is going to help anyone or save anyone’s life. What’s being suggested as “commonsense” rules and regulations on buprenorphine practices are actually going to make getting treatment more difficult to obtain if they are made law before or after raising or lifting the 100 patient cap. I agree with trying to improve patient care, but certainly not to the extent that 1000s more people have to die 1st, and not to the extent that buprenorphine is similarly regulated as methadone is. Adding more rules and regulations to bupe treatment before lifting the cap only serves to delay treatment to those who are desperately waiting for a spot to open up. Not only that, but if the same guidelines that I’ve read being suggested are ever implemented, Data 2000, which allows for office based treatment with buprenorphine will no longer be. Over regulation may even cause some data 2000 providers to get out of the practice of prescribing buprenorphine, especially regulation to the extent of which I’ve been reading.
      Some people are calling for different phases of treatment for buprenorphine patients for example, upon entry to treatment patients would need to present daily for dosing for thirty days with mandatory weekly counseling and UAs. The next phase would call for Monday through Friday attendance with mandated counseling and UAs /and weekend take homes for thirty more days provided all UAs are negative and all counseling is attended.
      Next Monday, Wednesday, and Friday attendance. ……I could go on with this, but you get the picture of what’s being called for, for office based treatment, by many who are against raising or eliminating the patient cap until such guidelines are in place……how are these considered commonsense or reasonable to ask of physicians in private practice? Or of patients? At this rate it would be many months or more before a patient even gets a week’s worth of medication, even if they’re doing well! How would one even maintain employment?
      How many private doctor’s offices are going to do this?
      This is why I believe not lifting the cap, and calling for even stricter regulations governing buprenorphine, will cost more lives. Not only will it delay treatment, but it will also make it unattainable for many.

      Reply

  8. There is no sour taste in my mouth. I go to my clinic twice a month. The availability of buprenorphine has no effect on my take home doses of methadone. All I want is to see the availability of buprenorphine go forward responsibly. Buprenorphine is the most widely abused drug in my state of Ohio. I don’t want to see buprenorphine patients handicapped with the same rules imposed on methadone patients. Creating more opportunity for leakage of buprenorphine into the black market won’t help to expand availability. All I am saying is that a reasonable plan for regulation should be adopted prior to expansion of patient caps.

    Reply

  9. Posted by Danielle on October 27, 2014 at 9:23 pm

    I have mixed feelings on the subject. I do think that more counseling needs to be mandated for suboxone patients. It is a very very important part of recovery. I know many people who have been prescribed suboxone and after a few months end up selling part of their prescription and then go back to using here and there. A big part of addiction is the lifestyle & mindset that go along with it. And most addicts can not change those things without the help of counseling. They need to learn life skills that most never learned in the first place because they started using in high school and the users lifestyle is all they know. Such as how to cope with problems in life without using drugs to numb the brain so you just forget about it. I see that the dr who wrote this says that they requires their patients to so proof that they are receiving counseling and that they offer it at their office. Sadly I do not think this the norm. I would love to see more people with addiction issues be able to receive treatment for it. But I do not think that just raising the cap is going to work. Just because someone is one suboxone doesn’t mean they are receiving treatment. Addiction is a very complicated disease. I think there needs to be more requirements that new patients need to meet such as counseling. I have been through it. I know that without the counseling requirements that I had to fulfill in the first 2 years of treatment their is no way I would be where I am today, 5 years later. Many of the people I know on suboxone still have an addicts mindset. They may not use opiates anymore but they still use other substances. Many still don’t have jobs to support themselves & their family. In comparison with methadone clinics I think the clinics work better at treating addiction. But I also do not see any reason why suboxone patients can’t have required counseling. It can be done in the privacy of a drs office just like the prescription process. I also think that suboxone is sold on the street & a used much much more then the medical community is aware of. It’s one of the easiest things to get your hands on these days. If anything that should speak to reasoning as to why it needs more regulation. So to sum up , I would love to see the cap raised but only if it comes with more regulation & more requirements for patients to fulfill. It’s s greatt resource that can help so many people. If it’s done right.

    Reply

  10. Posted by Solarc on January 29, 2015 at 10:14 pm

    I agree with you. I have a lot of respect for Parrilo but I think more problems exist in methadone treatment programs than they do in Bupernorphine. At least I see my doctor once a month. When I was on methadone I always so some level of incompetency from people who never read anything about methadone or had any incline to do so. People with less than a high school degree which only skill was that they have been able or do not use drugs at all. I learned a long time that One Addict helping another is without parallel is all bull rubbish. Although it should be so, most addicts are incompetent when it comes to guidance and counseling. And strongly believe everyone should recover the way he/she did.

    Reply

  11. This is a very thoughtful piece by Dr. Jana Burson. I would also like to make the point that most insurer’s in our area, in order to cover the Suboxone, require both proof of counseling and results of urine screens insuring that office based providers are in fact requiring the patients to comply with the program. On this issue, the insurance company got it right.

    Reply

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

%d bloggers like this: