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How many Folks here have been cared for by a Physician Assistant or Nurse Practitioner....???
Yes... I know what a PA or NP is and have been seen by one... 91%  91%  [ 21 ]
No... I don't know what a PA or NP is and have never been seen by one... 9%  9%  [ 2 ]
Total votes : 23
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PostPosted: Wed Dec 07, 2011 1:29 am 
*******
After some discussion with Dr Junig and the moderators, DocNusum, the guy who posted this, is no longer a member of this forum. His views in his posts do not & never did represent those of this board or the rank of 'medical expert'.

-tj
*******



MDs are NOT the only providers of Addiction Medicine.

Doctors of Osteopathy-DO
Physician Assistants-PA
Nurse Practitioners-NP
Medical Doctors-MD

ALL practice medicine to the SAME standard and all can practice addiction Medicine specifically.
All can be certified addiction medicine specialists
All have individual licenses by their respective states to practice clinical care in ALL medical specialties either independently or collaboratively.

All can own, manage, staff Suboxone clinics.
All can prescribe and/or dispense Buprenorphine using their own DEA numbers.
Only DOs/MDs can prescribe Buprenorphine for the express purpose of Opioid replacement therapy.

In my clinic...
I own the building and everything in it. I employ 2 MDs (Psychiatrists) and 1 DO (Family Practice).
Each has a Data 2000 waiver with 100 slots for Buprenorphine patients.
We currently have 125 patients with the capacity of seeing 300 Suboxone patients.
Right now, I see all of the patients Wed-Fri from 3pm-9pm and do ALL of the Inductions on Saturday mornings from 9am-2pm. I will expand the days and hours as the clinic grows and slowly relinquish days and hrs at my other two inpatient psych/internal medicine/detox jobs and decrease my teaching duties. currently, I refer all of the counseling out. The plan is to expand into "Pain Medicine" in 2013, and then add Internal Medicine "HouseCalls" in 2014. We may even bring the counseling peice in-house, with my wife as the lead... if she wants to do it.

The Family Practice physician is my "Medical Director" (Doctor of Osteopathy, Triple Board certified in FP, Addiction and Accupuncture)

I'm the Managing Member and the "Clinical Director" (Paramedic, Critical Care Nurse, Family Nurse Practitioner & Physician Assistant, Masters in Psychiatry/Behavioral Medicine with a special focus in Addiction Medicine)

My Wife is the "Operations Manager" (X-ray Tech, Radiation Therapist, Masters in Health Care Management, Masters in Counseling Psychology)

My eldest Daughter is the "Receptionist" (Medical assistant and nursing student)


[quote]
What is a Physician Assistant/Physician Associate...???

A physician assistant/associate (PA) is a healthcare professional trained and licensed to practice medicine with limited supervision by a physician.

A physician associate/assistant is concerned with preventing, maintaining, and treating human illness and injury by providing a broad range of health care services that were traditionally performed by a physician or medical practitioner.[citation needed] Physician associates/assistants conduct physical exams, diagnose and treat illnesses, order and interpret tests, counsel on preventive health care, assist in surgery, give medical orders and write prescriptions.[2]

Physician associates/assistants work in hospitals, clinics, and other types of health facilities, and exercise autonomy in medical decision making as determined by their supervising physician, surgeon or medical practitioner. The professional requirements typically include at least two years of post-graduate education.[citation needed] They are educated in the medical model designed to complement physician training, rather than in the nursing model as nurse practitioners are.[citation needed] Physician associates/assistants are not to be confused with medical assistants, who perform administrative and simple clinical tasks with limited postsecondary education under the direct supervision of physicians and other health professionals, or nursing assistants.[citation needed]

In the United States, the profession is represented by the American Academy of Physician Assistants. The equivalent type of provider may also go under different titles in different countries, such as clinical officer, clinical associate, assistant medical officer medical care practitioner or Feldsher.[3]


Scope of practice

PAs are medical professionals. They typically obtain medical histories, perform examinations and procedures, order treatments, diagnose illnesses, prescribe medication, order and interpret diagnostic tests, refer patients to specialists as required, and first or second-assist in surgery. Physician assistants' scope of practice is spelled out in their PA-Physician practice agreement. PAs are employed in primary care or in specialties in urban or rural regions, as well as in academic administration. PAs may practice in any medical or surgical specialty, and have the ability to move within and between different medical and surgical fields during their careers.[citation needed]

Physician assistants have their own medical licenses and do not work under a physician's license.[13] Each of the 50 states has different laws regarding the prescription of medications by mid-level practitioners (which include PAs) by State and the licensing authority granted to each category within that particular State through the Drug Enforcement Administration (DEA).[14] PAs in Florida, Kentucky, Puerto Rico and the U.S. Virgin Islands, are not allowed to prescribe, order, dispense, or administer any controlled substances.[15] Several other states place a limit on the type of controlled substance or the quantity that can be prescribed, dispensed, or administered by a PA.[15]

Depending upon the specific laws of any given state board of medicine, the PA must have a formal relationship on file with a collaborative physician supervisor. The physician collaborator must also be licensed in the state in which the PA is working, although he or she may physically be located elsewhere. Physician supervision can be in person, by telecommunication systems or by other reliable means (for example, availability for consultation). The physician supervision, in most cases, need not be direct or on-site, and many PAs practice alone in remote or under-served areas in satellite clinics.


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PostPosted: Wed Dec 07, 2011 2:59 am 
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I have been cared for by both PA's and NP's, as well as MD's, DO's, PhD's, MA's, ND's and whatever else.

During my addiction treatment I saw a Psychiatrist for my Sub scrip and I think both of my counselors were MSW's with a CDP lisence.

The PA's and NP's that I've seen have been just for non-addiction related medical stuff. I've been really impressed with the quality of care I've received from NP's...not so much from the PA's.

Which is not to slam PA's or anything. I'm sure there are some very good PA's who know what they are doing. The HMO cooperative where I get my healthcare has just switched to using a lot of PA's in the last few years and frankly, some of them are fucking idiots and it scares me that they have prescription pads. The NP's on the other hand are awesome, spend more time talking to me and for routine stuff are better than the doctors (who can't be bothered to listen to a damn thing I have to say).

DocNusum, it sounds like you have the makings of a great clinic. I noticed that your DO also does accupuncture - you guys should offer that as a service to your patients. When I was detoxing off Suboxone I got accupuncture and it was so helpful. I noticed that I slept much better if I'd had a treatment that day and I had more energy. Just a thought.

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PostPosted: Wed Dec 07, 2011 3:32 am 
Yeah...
We do use (pre and post tragal) accupuncture to decrease cravings.
The DO comes to the clinic every 2 weeks for a few hrs and does accupuncture by appointment.

I also do some limited addiction specific accupuncture during follow-up visits that he taught me during the sstabilization and follow up phase of treatment.


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PostPosted: Wed Dec 07, 2011 8:46 am 
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I've been treated by PAs and/or NPs on and off over the years and have always been treated great. In fact, I've actually found that I've gotten BETTER care from a PA or a NP than from an MD or DO. I don't know why, maybe it's something I imagined, or maybe it's because they don't get the respect they deserve from the medical community and they have to try harder to prove themselves. If that's the case, it really sucks for them.

Physician assistants and Nurse Practitioners are essential in the medical field and I for one am glad they are around. My sub doctor is my PCP and has a PA that he works with, so therefore I work with him, too. I have no issues with whom I deal with - either the DO or the PA....makes no difference to me. I treat them equally and according to how they treat me.

Glad you are around nusum.

HAT

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PostPosted: Wed Dec 07, 2011 11:57 pm 
Doc-

Just curious what your personal opinion/practice is regarding the prescribing of generic Subutex as a medical professional and director of a medical facility?

-Travis


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PostPosted: Thu Dec 08, 2011 12:23 am 
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DocNusum,I too had a NP and like DOQ said she spent alot more time with me. I aslo had my children see a NP and she was wonderful also. With Doctor's office so full and having to wait so long to make an appointment to see the dr I think we should have more of them. It really works on my nerves when I have an appointment to see the Dr. and have to seat for 2 or 3 hours. I pay to see them not them paying me and I feel they should have more respect of my time. So I'm all for it more help in the office means less time I have to sit and wait.
Mel :wink:

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PostPosted: Thu Dec 08, 2011 1:57 am 
travispnorton wrote:
Doc-

Just curious what your personal opinion/practice is regarding the prescribing of generic Subutex as a medical professional and director of a medical facility?

-Travis


As I stated in a previous post...

We use it in "rare" instances... mostly for pregnant females unable to get to methadone clinic.

As far as we are concerned... if this is simply about cost and using long acting opioids... versus reducing diversion, temptation and harm reduction... then there is a methadone clinic down the road.

Another often overlooked issue is that we need to be able to withstand the scrutiny of the DEA inspectors and that of the the local medical community... IF we plan to keep our practice open, hassle free and available for patients.

YMMV


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PostPosted: Thu Dec 08, 2011 8:43 pm 
docnusum wrote:
As I stated in a previous post...

We use it in "rare" instances... mostly for pregnant females unable to get to methadone clinic.

As far as we are concerned... if this is simply about cost and using long acting opioids... versus reducing diversion, temptation and harm reduction... then there is a methadone clinic down the road.

Another often overlooked issue is that we need to be able to withstand the scrutiny of the DEA inspectors and that of the the local medical community... IF we plan to keep our practice open, hassle free and available for patients.

YMMV


Sorry if I'm causing you to repeat yourself, I didn't see the previous post in which you went into detail about your typical practice regarding prescribing Subutex...

I'm curious what DEA scrutiny or hassle might look like in this case? Is there a real possibility of losing licensure by prescribing buprenorphine minus naloxone? It would seem to me that the abuse potential is about equal for both medications. What's your take on this? Suboxone is sought out as a drug of abuse to the same extent Subutex is in my experience and opinion. It is buprenorphine that causes precipitated withdrawal, as it is a potent partial-agonist, right? If this were the case, Suboxone and Subutex would cause identical precipitated withdrawal in individuals tolerant to opioid agonists. How do you personally feel about the potential of naloxone to deter abuse or diversion of Suboxone? What I've seen is that in populations who are abusing buprenorphine products the naloxone has no deterrent qualities and ultimately no active effect. I understand that the manufacturer of Suboxone and Subutex have created an atmosphere in which Suboxone is seen as having less abuse and diversion potential than buprenorphine preparations without naloxone, some people are almost under the misguided notion that Suboxone is an antagonist that has no mood altering qualities due to the presence of naloxone and because Subutex is buprenorphine alone it is euphoric and mood altering. Anyone who has taken Suboxone and Subutex understands that this is not a true and I would like to believe that anyone with an even elementary understanding of pharmacology understands this as well. It seems to me that in this case the DEA and many DATA waiver physicians are allowing pharmaceutical company propaganda to guide their prescribing practices and that for me is frustrating.

-Travis


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PostPosted: Thu Dec 08, 2011 11:30 pm 
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I have had the discussion with my Dr. about the Subutex/Suboxone difference, and Travis is correct, there is none. My Dr. has been prescribing me buprenorphine for over 2 years and has had no contact with the DEA. The naloxone is practically inert when administered sublingually, coupled with the fact that buprenorphine has a stronger binding affinity with the Mu receptor then naloxone, there is no reason not to prescribe generic Subutex and help patients with the cost of this treatment. Steve


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PostPosted: Fri Dec 09, 2011 1:05 am 
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docnusum wrote:
travispnorton wrote:
Doc-

Just curious what your personal opinion/practice is regarding the prescribing of generic Subutex as a medical professional and director of a medical facility?

-Travis


As I stated in a previous post...

We use it in "rare" instances... mostly for pregnant females unable to get to methadone clinic.

As far as we are concerned... if this is simply about cost and using long acting opioids... versus reducing diversion, temptation and harm reduction... then there is a methadone clinic down the road.

Another often overlooked issue is that we need to be able to withstand the scrutiny of the DEA inspectors and that of the the local medical community... IF we plan to keep our practice open, hassle free and available for patients.

YMMV


Maybe it's just the medium of the internet, but this sentiment (what I bolded above) reeks of a lack of compassion.

Shouldn't removing barriers to treatment be a goal of providers who treat addicts? Especially when we all know that there's no reduction in diversion, temptation or harm reduction provided by Suboxone vs. generic Subutex. Both can be insulffated, and it is well known that the amount of naloxone in Suboxone is not enough to produce an effect when someone habituated to buprenorphine injects it. The cold fact of the matter is that naloxone HAD to be added to the Suboxone preparation for political reasons. Because it is a sublingual preparation, it has to be water-soluble. To make this fact easier to stomach, naloxone was added as a "deterrent" to IV drug abusers so the drug could be approved. But it really doesn't deter anything.

So maybe there is a methadone clinic down the street, and people too poor to pay for brand name Suboxone should just go there. Fair enough, it's your clinic with your name on the door. But you're lying to yourself if you think that that policy hasn't kept addicts out of treatment or barred them from accessing a treatment that might be more optimal for them than methadone.

By the way - I googled the name of your clinic and couldn't find it in Washington, Oregon or Idaho. I also looked on several of the listing sites for Suboxone providers and couldn't find it. You might want to look into that.

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PostPosted: Fri Dec 09, 2011 2:25 am 
It "reeks of a lack of compassion" because you have a preconceived notion based upon YOUR understanding of how you THINK this medication should be prescrbed by those of us able to provide it. I could be uber "compasssionate" and simply prescribe opiates to those dependent on them... or marinol for our THc users and Benzos for our Benzo dependents. Don't need a Data waiver for that.

Addiction medicine isn't a popular specialty. Why...??? Probably because the majority of addicts aren't the most reasonable, respectful, appreciative, enjoyable patients to be around. So I'd consider that those of us who do practice addition medicine ARE minimizing barriers to access to care for substance abusers. But in typical addict fashion.... nothing we do will be enough.

I always find it interesting when those NOT trained to practice medicine... with no experience with the DEA or the state licensing and regulatory agencies start pre-supposing, and opinionating about how those with these things should practice or what the standards of care should be.

Nowhere in any of my previous responses did I state that I actually BELIEVE adding naloxone to buprenorphine actually stops a determined addict from doing anything...

My experience with the drug doesn't bear that out.

The subtle piece you guys are missing is that YES many of us "overstand" that RB manipulated the political environment to get Suboxone approved and the preferred office-based opiate replacement. But that is what It is... THE PREFERRED DRUG whether users or providers like it or not.

To soothe the hackles of the anti-drug, abstinence crowd... Suboxone was promoted as "safe from diversion, misuse due to its fomulation" to move mantinence treatment from methadone clinics to private offices.

Prior to Suboxone (excluding LAAM), the only way to get "maintanance" treatment was/is methadone. The "puritans" were happy or shall I say tolerant of that situation and did everything they could to prevent maintanence treatment outside of that controlled environment.

Hell.... Subutex had been around for a while prior to this... so why do YOU think they didn't simply promote subutex as the replacement drug. Could it have been that the "puritan" simply weren't gonna go for it..???
Could it have been ... In order to convince the law makers to allow office based treatment... the compromise was made.

What many folks don't get is that the Data 2000 rules are purposefully TEMPORARY and can be recinded... which would then have EVERYONE back to methadone clinics.

As a matter of discussion... there is currently a rapidly growing voice, pointing to the increasing levels of buprenorphine diversion, seeking to have the data 2000 rules cancelled.

[hr]
Folks with DEA numbers and licenses to practice medicine CAN'T just write scripts for anything they want... for any reason they want. As should be evident by studying the ibogaine issue.

I can't simply prescribe anything I want and expect to keep my license to practice.
So PLEASE tell me why a person who spent $100k+, 8-10-12 yrs post bachelors in school/training should risk their livelyhood to meet the ill-informed definition of "compassion" of a current or potential patient....?

Research "standards of care" ... as it pertains to licensed, certified healthcare providers... then come back and lets finish this discussion.


Last edited by docnusum on Fri Dec 09, 2011 3:45 am, edited 2 times in total.

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PostPosted: Fri Dec 09, 2011 3:21 am 
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docnusum wrote:
I always find it interesting when those NOT trained to practice medicine... with no experience with the DEA or the state licensing and regulatory agencies start pre-supposing, and opinionating about how those with these things should practice.


You're saying that the consumer has no right to have an opinion on the subject of their medical care? You've stated that you run a prison clinic attached to juvenile detention. But unlike those under your care, people on this forum still have the right to express their opinion be heard. Members here are free to say what they want. You don't have to talk like a screw in here.

Quote:
As a matter of discussion... there is currently a rapidly growing voice, pointing to the increasing levels of buprenorphine diversion, seeking to have the data 2000 rules cancelled.


That's not the fault of people like DoaQ expressing their opinion. That's the fault of careless prescribing practices by doctors and their clinics. I believe the right to get a 30 day take-home supply should be earned.

Quote:
Prior to Suboxone (excluding LAAM), the only way to get "maintanance" treatment was/is methadone.


That's not true DocNusum. Subutex was prescribed to treat opioid addiction years before Suboxone. Naltrexone maintenance was around some time before Suboxone as well.

Perhaps you should do some reading up on the history of addiction pharmacotherapy. :wink:


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PostPosted: Fri Dec 09, 2011 3:39 am 
tearj3rker wrote:
You've stated that you run a prison clinic attached to juvenile detention. But unlike those under your care, people on this forum still have the right to express their opinion be heard. Members here are free to say what they want. You don't have to talk like a screw in here.


Ummm.... are YOU high... ????
I do not and have never stated that I "run a prison clinic attached to juvenile detention."
Folks can express any opinion they want. I wrote that "I always find it interesting."


DocNusum wrote:
Prior to Suboxone (excluding LAAM), the only way to get "maintanance" treatment was/is methadone.


tearj3rker wrote:
That's not true DocNusum. Subutex was prescribed to treat opioid addiction years before Suboxone. Naltrexone maintenance was around some time before Suboxone as well.

Perhaps you should do some reading up on the history of addiction pharmacotherapy. :wink:


HA... ha.... You are funny,

Naltrexone isn't OPIATE REPLACEMENT Therapy.... it BLOCKS opiates... does NOT replace them.

Quote:
In October 2002, the Food and Drug Administration (FDA) approved buprenorphine monotherapy product, Subutex®, and a buprenorphine/naloxone combination product, Suboxone®, for use in opioid addiction treatment. The combination product is designed to decrease the potential for abuse by injection. Subutex® and Suboxone® are currently the only Schedule III, IV, or V medications to have received FDA approval for this indication.

Subutex and Suboxone are the first narcotic drugs available for the treatment of opiate dependence that can be prescribed in an office setting under the Drug Addiction Treatment Act (DATA) of 2000. Until recently, opiate dependence treatments in Schedule II, like methadone, could be dispensed in a very limited number of clinics that specialize in addiction treatment. As a consequence, there have not been enough addiction treatment centers to accommodate all patients desiring therapy. Under this new law, medications for the treatment of opiate dependence that are subject to less restrictive controls than those of Schedule II can be prescribed in a doctor's office by specially trained physicians. This change is expected to provide patients greater access to needed treatment.


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PostPosted: Fri Dec 09, 2011 4:20 am 
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Yeah, because there's no middle ground between "presribing opiates to people who are dependant on them" and "only prescribing generic subutex in rare instances like pregnancy."

Like maybe having a policy where compliant patients who have had clean UA's for a certain length of time can switch to the cheaper medication?

Because that's what my Suboxone doctor's policy is. And he doesn't have any problems with the DEA. He also accepts insurance, medicaid, and offers a sliding scale based on income. He never in the 2 years that I was his patient talked down to me the way you just did either. He was willing to listen and learn from the experience of his patients. I was one of his first patients to successfully taper off of Suboxone and he told me that he subsequently passed on some of my tapering advice & methods to other patients. He was all about reducing barriers to treatment...and not just by deigning to come down from his elevated status as a medical professional and treat the deeply unpleasant, disrespectful, unreasonable and unenjoyable class of patients who came to him for help.

I also know several other people who have or had similar arrangements with their doctors. One was willing to prescribe generic bupe if the patient didn't have a history with IV use and had been stable with clean UA's for 6 months. Another decided on a case by case basis taking financial need into account. So obviously, it is possible.

But I'm just an ignorant patient, so what do I know?

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PostPosted: Fri Dec 09, 2011 4:26 am 
Sounds like a great provider... !!!
Maybe you should refer everyone here to him...


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PostPosted: Fri Dec 09, 2011 4:36 am 
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Quote:
Prior to Suboxone (excluding LAAM), the only way to get "maintanance" treatment was/is methadone.


That's what you said. Maintenance can refer to any medicine.

Quote:
Naltrexone isn't OPIATE REPLACEMENT Therapy.... it BLOCKS opiates... does NOT replace them.


Naltrexone was a maintenance treatment, as was Subutex, years before Suboxone.

DocNusum, I really don't understand how a professional in the field of addiction treatment could say something like "your addict shit is showing". As Diary of a Quitter alluded to, it shows a lack of compassion and understanding of your clientele. Addiction is a disease. When an epileptic has a seizure, do you point to them and say "Your epileptic shit is showing?"

Quote:
Addiction medicine isn't a popular specialty. Why...??? Probably because the majority of addicts aren't the most reasonable, respectful, appreciative, enjoyable patients to be around.


Tell me you're joking, docnusum. That is one of the most ignorant statements I've heard on this board for some time. It's a shame your experience with your clients has distorted your opinion. Maybe all the reasonable and respectful ones go elsewhere?


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PostPosted: Fri Dec 09, 2011 10:53 am 
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I see you have open slots at your clinic, my cousin is in your area and is looking to start recovery with the help of Suboxone. He has had trouble finding a provider without waiting lists. I would really appreciate if you could give me your clinics contact info, you can pm it to me if you prefer to not post it publicly. Thanks in advance!


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PostPosted: Fri Dec 09, 2011 11:36 am 
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Are you an addict, docnusum?


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PostPosted: Fri Dec 09, 2011 12:08 pm 
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Lilly -

I asked the same question in his other thread and he said he is not but comes from a family affected by addiction.

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PostPosted: Fri Dec 09, 2011 7:15 pm 
The content of this post was moved to the moderator forum because it was rude and offensive.

If you really want to read it, PM me or another moderator.

docnusum,

Regardless of your level of education or your occupation, you still have to follow the forum rules if you want to participate here.

You've already stated that you are not here to help others or give advice or information. You have stated that you are not a recovering addict yourself. You have made it clear that you do not like addicts or have much compassion for us.

You have posted your clinic info, though you have stated that you're not really wanting new patients at this time.

I'm not sure why you are here, but if you are going to be here you will stop insulting the mental health and general disposition of our members and addicts in general.

This is an official warning.


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