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 Post subject: New doc
PostPosted: Sat Sep 24, 2016 9:11 am 
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Hi yall. I'm a physician practicing in Tampa, Fl. Worked part time as director of an OTP in New Mexico a few years back and I really miss it, thinking seriously about hanging out my shingle again here in Tampa.

My background is in neurology; been at it a quarter century. Very interested in psychology and spirituality, and how those things interact with biology. Happy to answer any brain questions if I can; just understand, way I look at it, anyone who thinks they have the human brain mastered is fooling himself. I look at it the way most neurologists do; I consider myself a student of the brain, not an expert.

With that in mind, lurking this forum has been a great learning experience. I've found, over the years, that I get quite a bit more mileage out of listening to patient experiences rather than marketing hype; if someone has BTDT, I think they deserve to be heard. Also I tend to read the "gripe" threads carefully. Is it cheesy to say "I hear you," or "you feelings count"? I dunno. I think we all need to hear that sometimes. If yall have any advice as I move forward with this thing, I am all ears. It'll come around to helping someone in need.

To those in recovery: you are magnificent. Anybody can mess up. Few have the courage to admit it, and the gumption to do something about it. To those who post here to help others: you are both magnificent and kind. I love that combination, but note with sadness such things seem rare in the recovery business. To the extent I can contribute to this discussion, I aspire to live up to that example.


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 Post subject: Re: New doc
PostPosted: Sat Sep 24, 2016 1:44 pm 
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Welcome DrDave,

Glad you are here and posted. Thanks.

Ya, the brain sure seems to be still a big unknown.

Some random thoughts/questions on the psyche side that I wrestle w. I pirated the black box concept from someone else who uses the airline industry's black box but applies it to everyday human failure. When a plane goes down, we search oceans or mountainsides for the black box to painstakingly examine what went wrong in the crash so that another crash never happens again. Yet for addicts why is it so hard, to look at what we did to bring us down and cause our crash -- so we avoid another one? Yet crashes repeat in spite of how painful they are... I realize addiction is an equal opportunist and can bite anyone in anyplace and certainly has biological components that we're starting to learn about and likely why its harder on some. I'm fascinated and disturbed - the lies, denial and self sabotage that come w addiction bc does not seem to come w most/all other maladies? That might be the toughest part of coming back into addiction patient care. I assume you support MAT for addiction? If so, is your possible interest more w opiate addicts or a full spectrum practice w the other substances/behaviors as well? Again thanks and wishing you my best, Pel

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Did well on Suboxone. Stopped May 2011.
Stopping went well -- its the staying stopped -- where the real work begins.
Coming here 'keeps recovery green'.


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 Post subject: Re: New doc
PostPosted: Sat Sep 24, 2016 3:59 pm 
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Thanks for your kind words, Pel.

I ran a guilt-free practice, easier on the patient and the doctor. Like I said, I miss it.

Definitely think meds can help. It's not the whole thing. I think the rule for psych meds in general is that we can expect them to get us into a state of mind where we can work on psychological and spiritual growth, but they aren't going to do the growth for us.

As for what other than suboxone treatment, well, what got me really thinking about this was a conversation I had with a guy who runs a medical cannabis clinic in Gunnison, CO. Smart guy, has a master's in psychology. He said the most rewarding thing about his business is working with vets with PTSD. They come into his shop all loaded up on umpteen psych meds, including opioids. Way he looks at it, those guys are lost, just wandering through life getting nowhere. He sees them get off all the pharms, helps em get hooked up with local support groups. Sees em start living again, instead of just existing in some kind of fugue state. I wanted to open an office right next door to the guy, that's how much he inspired me. Except Gunny is too doggone cold. But yeah, if I could do a little something special for vets with PTSD, that would be pretty cool.


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 Post subject: Re: New doc
PostPosted: Sat Sep 24, 2016 7:37 pm 
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Hi Dr. Dave, thank you so much for coming in here and offering your services to answer our questions, that is so nice. I have a million questions about my brain but I'll try to just ask a couple! {cute smiles}

So I was on opiates and hard core inhalants before I (thank goodness, hand to God) found this Suboxone treatment. I was inhaling dusters about 15 of them a day and coming down using heroin. My brain was all wacky. I feel sometimes I get shocks to my brain, is that from previous use or from the subs possibly?

I am educated and i feel now more than ever back to my intellectual self, I think this has to do with subs, if and when I ween off am I still going to feel this way? I feel motivated and really into books, curious, motivated to get my life right and just BE GOOD. I am nervous to get tapered off. I have been on subs for two months now. I've quit everything right down to drinking, actually not everything, I still smoke cigarettes, a lot more actually, I think it's a hand to mouth thing I don't know. But ever since I've been on subs I do smoke more.

Being on subs, I don't feel messed up at all, I am on 1.5 mg a day. Am I messed up? What are the subs doing to my brain specifically?

Thanks for any advice you can give me!

Jess_vox.pop


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 Post subject: Re: New doc
PostPosted: Sat Sep 24, 2016 11:03 pm 
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Jess --

When I ramble on about dopamine receptors and NMDA receptors, which I'm sometimes prone to do, I'm really talking about capacity to enjoy normal life, and the ability to think. But it's not even precisely that. I'm talking about hope, and coming up with a narrative about the self, and the meaning of life, that makes sense. Faith, in the sense of believing something to be true even if we can't prove it, plays a role in those narratives. Your hope for the future, and your growing faith in yourself are real things. No medicine can do that. You're doing that. Ain't easy, is it? In fact it's damn hard work. I think it's OK to take credit for that.

I know that doesn't specifically answer your question. All I know is, I've seen some people who took some pretty bad hits to the brain and fought their way back. Nobody can know if you've taken any permanent hits from any drug you've taken. Maybe not; if you like reading that much, that's a pretty darn good sign. But maybe that's not even the point. Maybe the point is, you're betting on yourself moving forward. Sounds like a good bet to me. Take heroin often enough and long enough, it'll affect how your brain works. Say "I know I can do this" often and long enough, that'll affect how your brain works too, so there.


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 Post subject: Re: New doc
PostPosted: Tue Sep 27, 2016 7:56 am 
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A little more on where I'm coming from.

The docs who come here to teach are providing a great service to people struggling with addiction, and also to doctors who want to do a better job of working with addicts.

I count myself in the second category. I'm here to learn. When I was doing addictions, I'd say about half what I learned came from my mentors, and about half from my patients. Perhaps you can see, then, why I find this forum so valuable.

I love to teach, but I feel like I should limit my comments to things I either know something about, or at least have a decent theory about. I'm not planning to give advice about how to use buprenorphine; I don't know that two years of experience two years ago is enough to make me an expert on that. I think not.

Here's what I can do.

1. Have general questions about neurology? Ask away. If you have a comorbidity like epilepsy or MS or traumatic brain injury, I'm glad to share.
2. I have a deep interest in the intersection between the brain and the mind. Neurologists are expected to know something about psychology; about a third of our boards is mental health. I took that very seriously in training, and have since. Originally I was very interested in the correlation between psychoanalytic theory and behavioral neurology, and recently I've been very interested in how spirituality interacts with those two things.

My current project is, I'm writing a book on spirituality from that perspective. On the links between spirituality, psychoanalytic theory, and behavioral neurology. I say "a book"; it's actually several:

- a monograph, which I'm told is unreadable
- a couple of self-help books, one applying my thoughts to addiction. One, to dealing with end-of-life issues.
- a novel
- a short story.

The short story actually got honorable mention is a writing contest, so maybe I'm on to something eh. If any of that stuff seems interesting, I'll talk your ear off. (And may talk your ear off even if you don't find it interesting, so feel free to say "enough already," believe me you won't be the first.)

I re-found this forum because I'm kind of fed up with "working for the man," thinking about going into business myself again. I don't know that I'll do that, or if I'll devote a part of my time to addictions. I think I'd like to, though. The brief time I worked in addictions was one of the most meaningful and rewarding things I ever did. It was humbling. At first it was really cool; buprenorphine is a great tool, and that comes from the perspective of a so-called "therapeutic nihilist." A lot of neurologists are that way; we question whether any drug every does anything. So there was this brief period of feeling a certain shamanic power, the idea I could prescribe something that could really change lives. But that was quickly followed by awe. I saw the human spirit unfolding. People who know and understand down to their very core how bad life sucks, and yet they wake up one day and choose life. I saw what a difficult path that actually is, how much courage and faith it takes to walk down that path. There is something special about being a human. Something magnificent, and meaningful, and beautiful.

You know at the end of the day, we all want a life that is meaningful. We want to do meaningful work. Right now, about 30% of my time is highly meaningful. The rest of the time I'm the world's most expensive click farm (could somebody please write an EMR program that actually works?) That's what I miss about addictions. It's about 90% meaningful work, and I tell you, it strikes right at the heart of the matter. If you look for example at the Buddhist formulation of the problem of life, and have a holistic view of addiction (that you can be addicted to sex, or base-jumping, or money), then in some respects, addiction itself is the core problem of life.

I'm not like most doctors. I'm tangoing with questions that do not have simple declarative answers and to the extent I'm wrapping my head around any of these things, boiling it down into something logical and useful has been an interesting endeavor to say the least. Not clear to me at this point that I have anything useful to say.

Love this forum though. More doctors should come here to learn imho.


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 Post subject: Re: New doc
PostPosted: Wed Sep 28, 2016 2:23 am 
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DrD,
Wowo, yes yes, glad to have you here. You are a cerebral deep thinker and can help.

So this is my half a penny, which is not worth much as I am a newbie, aka 'NU B', which - in my corporate world, is code for -- Nearly Useless Being.

I had look up stuff to figure out what you meant. Looked up OTP. My prior response to you meant I thought OTP = OuT Patient. which is why I thought you were in a mixed OuT Patient neuro/psyche program and might be unaware of how hard it is to work w addicts. So. I looked up working in an OTP = and it meant Opiate Therapy Program. So then I got it.

And therapeutic nihilism --- yep had to look it up too, per wiki, therapeutic nihilist = many "cures" do more harm than good, and that one should instead encourage the body to heal itself. Yep, also had to look up shamanic power = The ability to perceive, contact, and bargain or control the spiritual world.

I'm truly a nobody here and a NUB and often, not of help and can be blunt bc I do not have the time or patience but I think you can be helpful here, for others AND and for YOU. So I'm mentioning to you what I remind myself -- folks come here - sick - some really sick -- and might not look up all and understand what you mean...

I'm 5 yrs off bup, doing great and came here - on a whim -- and learned forgiveness for myself and others -- a fabulous unexpected outcome --- and I will remain ever ever so grateful. Hoping YOU find what YOU need and want here as well. Wishing you my best, P

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Did well on Suboxone. Stopped May 2011.
Stopping went well -- its the staying stopped -- where the real work begins.
Coming here 'keeps recovery green'.


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 Post subject: Re: New doc
PostPosted: Tue Oct 04, 2016 9:25 pm 
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Welcome Dr. Dave. I am so glad to have a person such as yourself to be a part of this forum. I just joined today but have been lurking around here for a few months now. A lot of good information here as well as support.


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 Post subject: Re: New doc
PostPosted: Tue Oct 04, 2016 9:32 pm 
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Pelican, thanks for looking all that up on Dr. D post. I thought he was talking about outpatient as well. 5 yrs off sub? Congrads!!!
Sorry for taking over your post there for a minute Doc. lol


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 Post subject: Re: Thanks and update
PostPosted: Thu Aug 10, 2017 10:31 am 
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I've decided to return to addictions.

Abandoned the idea of starting a solo cash practice, I'm re-joining the clinic where I got my start (and some excellent mentoring). They are now accepting insurance, they do take medicaid for both methadone and buprenorphine.

I was there at the beginning, and evidently they partially blame me for their success. I'm not so sure sure about that, but I'll take it. I'll be coming back as medical director, which is exciting. They've more than doubled in size since I last worked there and have plans to grow some more. I'll be treating patients and helping to recruit and train doctors for a program that emphasizes treating the patients with empathy and respect.

I'm not ready to announce where I'll be, that feels too much like shilling (I'll suggest my employer support this website if he wants that kind of publicity). But I do want to thank everyone for their feedback and words of support. Karma points for everyone; this clinic is doing important work and they are going about their work ethically, with kindness.


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 Post subject: Re: New doc
PostPosted: Thu Aug 10, 2017 11:35 am 
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Welcome Back DrDave,

Please do post your clinic here. We try to give out as much useful information as possible to help those in need. We don't care if you're advertising or not. Addicts need to know where the doctors who prescribe Suboxone are.

At the very least, make sure your name and or clinic is listed in the directory for people to find.

What's the patient cap going to be at the new place? I'm curious to hear from those who do the 250 cap and see how hard the jumping through hoops is.

rule

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 Post subject: Re: New doc
PostPosted: Thu Aug 10, 2017 11:48 am 
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Rule,
My colleague is an addictionologist so he was able to go the 275 limit without any hoops except notifying SAMHSA. My situation doesn't meet the requirements so I sit at 100. Ironic, we share a hallway and staff.
If I understand DrD situation he will be in a OTP and they operate under a different set of federal rules, cap doesn't apply but those on buprenorphine are treated similarly to methadone.
Welcome back Dr. Dave, my understanding is that you are in one on the hotspots of the current 'epidemic.'


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 Post subject: Re: New doc
PostPosted: Thu Aug 10, 2017 11:56 am 
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Thanks for the info docm2. Why the rules are so hard is beyond me. I understand we have people who don't really get how addiction works but it seems the laws they pass hurt more good people than bad.

r

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 Post subject: Re: New doc
PostPosted: Thu Aug 10, 2017 2:18 pm 
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Welcome back Dr. Dave! :D I'm thrilled to hear that you're back helping with this serious crisis that our country now find ourselves in. You stated in your initial posts that you were 90% happy doing this kind of work. I see much happiness in your future.

Are you back in New Mexico? Ever skied Siera Blanca in Ruidoso? My family, then my husband & I owned a cabin there for 30+ years so NM is very close to my heart.

I hope that you'll continue to post as you take on your new position. We have 2 great Dr.'s here that help us all so much. A 3rd is like manna from Heaven.

I'm also a NUB. Been on Suboxone since April 14, 2017 (Good Friday). Thought that was apropos.

Well, just wanted to Welcome you back and wish you the best of luck with your new position!

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 Post subject: Re: New doc
PostPosted: Thu Aug 10, 2017 7:54 pm 
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I'm re-joining Albuquerque Health Partners.

The 275 patient cap requires a certain amount of infrastructure, among other things it requires that the clinic accept insurance. That figured prominently in my decision, heck of a lot easier to join a firm that already has that infrastructure in place.

DeeKay: thanks for the kind words. Do most of my skiing at Taos, which is a monster. So glad to hear that you've opened a new chapter in your life. Hope is a precious thing, isn't it?

Yeah New Mexico is really suffering. When I worked there before the market was awash in oxycodone, it was everywhere. I remember I got called on the carpet once by a hospital administrator because I refused to prescribe 300 oxy's to some lady who came in with a minor injury. She filed a customer satisfaction complaint, there was an investigation... I was thinking, no wonder there's an addiction epidemic. Not sure things have changed all that much since then.


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 Post subject: Re: New doc
PostPosted: Thu Aug 10, 2017 8:26 pm 
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Dr Dave,

Nice to hear from you and big congrats on your new med director position! Happy that patients will get the good care they need and deserve. Hope we continue to hear from you and agree w DeeKay's statement "A 3rd is like manna from Heaven"! The strong medical - science aspect, clearly sets this site apart. Wishing you so very well and again congrats for making the decision to accept this big new challenge. We need good Dr's helping us. Best always, Peli

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Did well on Suboxone. Stopped May 2011.
Stopping went well -- its the staying stopped -- where the real work begins.
Coming here 'keeps recovery green'.


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 Post subject: Re: New doc
PostPosted: Thu Aug 10, 2017 10:02 pm 
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Dr. Dave,
Little off subject, but do you think the President's declaration today will help us poor souls? Do you think more doctors will help with MAT? I think it's ridiculous for our family doctors to be able to prescribe things like OxyContin and fentanyl and have to jump through hoops to write Suboxone. Have you noticed people are beginning to understand that addiction is a disease and should be treated as such? Thanks Detective Mike


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 Post subject: Re: New doc
PostPosted: Fri Aug 11, 2017 5:05 pm 
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Dr. Dave! I'm so glad you came back to update us!!

It is stellar that you'll be directing the clinic! I have a question about your clinic. Do you have addiction therapists on staff there? How do you make sure that your patients are receiving some sort of therapy?

Amy

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