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PostPosted: Tue May 03, 2016 3:50 pm 
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I live in a northern MN town that is big enough to have a hospital, Target, Home Depot, etc, but still no docs w/ DATA2000 waivers to prescribe Buprenorphine products for addiction. The first Suboxone doc I had when I moved to MN, was in the habit of firing patients after their second positive screen for opiates, saying "I'm not going to support their habits with Suboxone." She seemed to taking cues from the DEA agent who came to the office a week earlier about wrapper counts and only prescribing Buprenorphine w/ Naloxone. She also asked her therpist daughter to come and fill the roll of drug counselor. And so suddenly one day without notice, we were forced to meet with her monthly(and pay extra) for B.S. sessions using a pamplet provided by the Reckit Benkiser rep. Her main concerns were: my $350./month, keeping the DEA happy, and committing to prescribing only Suboxone brand Buprenorphine. The required "counseling" was just a wink and a nod to say she was legit, and not a pill mill. I told her she WAS a pill mill by virtue of charging so much. The new dr I found by calling the administrator of the local methadone clinic, is awesome but still a half hour away, and doesn't really advertize Yet. I told him about this site and at my next appt he quoted Dr Junig when answering a question I had. He loves this site and says his Suboxone patients are his favs because the positive reactions he's seeing to the treatment are so profound.
At my last appt. we dicussed the posibility of getting the word out to dr's in my area about this drug. I get the impression that the docs around here believe prescribing Suboxone would be like taking on more patients dependant on longterm agonists like Oxy or Fentanyl, and would inlcude issues typical of those drugs like increasing tolerance, poor pain control, running out early etc. The DEA doesn't make things any easier by intimidating everyone they come into contact with.
I spoke to several pharmacists about where the Suboxone prescriptions they fill are coming from. Not one mentioned my new doc 1/2 hour away, all were from Deluth or Minneapolis, 2 1/2-3 hours away, most likely from doctors charging $300 and up for eaach visit. One local psychiatrist who advertizes a specialty in addiction medicine, including opiates, has no immediate plans to prescribe Suboxone. Meanwhile the methodone clinic here has a waiting list. One dr I spoke with yesterday said she thought of Suboxone as 'office based methadone' and felt that as an internal medicine specialist she wasn't qualified to manage those patients.' She does however, feel qualified to prescribe 250 mgs of Oxy to my friend who is her patient, who by the way has hit that wall of tolerance where her pain is not managed by her current dose. I don't want to under-rate her concern, empathy, and best intentions, AND was glad to hear she would agree to read anything I sent her about this game changing medication. She might be one of the 'good ones.'
So I was thinking I could call an acquantance, A doc(GP) who just retired one year ago, (his wife is a local nurse practicioner) and arrange to stop by his house to discuss the benefits of Buprenorphine, and getting some of his old colleagues to play a bigger role in stopping the deaths associated w/ this huge opiate epidemic. He is heavy into social justice and is well known and respected in the town so I think people would listen to him! (He is also a member of the church were my wife is the minister.)
To properly inform and educate someone with a strong medical backround, what materials would I bring to best make the case? How could I demonstrate to him that Buprnorphine is safe, effective, and not the diversion nightmare the DEA is making it out to be. I really believe he has the clout to make an impression on these other docs keeping MAT at arms length. The need is obviously huge- people are getting arrested here for diversion and use of prescripiton agonists and heroin left and right. My Suboxone doc has also agreed to talk to anyone who will listen, so I will have him give this retired MD a call to share his experience.
I wish it were as simple as just referring these local practicioners to Dr J and this site, but I think it's going to take more pushing and prodding than that. Somehow I need to impress upon them what an enormous impact they could have on this and surrounding communities by makng Buprenorphine available to one of the most medically underserved populations.
I did ask three pharmacists about getting word to the existing 'long commute' Suboxone patients about the great doctor thirty min's away, and am waiting to hear back. Maybe I could get permission to post some flyers advertizing this closer and ethical prescriber.
Any other ideas greatly appreciated. Thanks, Mike


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PostPosted: Tue May 03, 2016 4:28 pm 
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That's a great thing you are suggesting, and I wish you success. I would be happy to speak with any docs who might be on the fence, either by email or phone.

I went through the audit process a few years ago; I don't know if it has changed, but at that time the DEA agents made it very clear that they had no interest in practice patterns like the time between visits and the drug prescribed. They were focused on the number of patients, and the handling of stocked medications. They said several times, when I started to talk about when I decided to discharge patients for example, that 'we don't have a say in medical practice-- that is YOUR decision.'

In light of that, I think that much of the fear-mongering out there takes place because doctors are looking for someone to blame for their own garbage behaviors. I know a number of docs who see stable patients every 3 months-- and that is how it SHOULD be. After all, that's the frequency most docs see patients on schedule II meds-- and bupe is schedule III. Of course scheduling isn't the only issue-- but stable buprenorphine/Suboxone patients are about the easiest patients one could ask for. They don't START that way, but they usually get there within 6-12 months-- especially if some effort is made to find the patients who are truly ready for help. For example, I decided years ago that I won't take any patient whose mom calls for him. If a patient isn't mature or desperate enough to call himself, he is not ready for buprenorphine treatment.

Some things to put on a list of selling points for your docs:
- most patients are very grateful.
- most patients do well (the exception being people under 25, which is a broad generalization with some truth behind it)
- worried about the DEA? your chance of killing someone, or being a link in the diversion of drugs that kill people, are much higher if you prescribe agonists than if you prescribe buprenorphine. I changed all patients on schedule II agonists to schedule III buprenorphine-- and I sleep MUCH easier at night. And most of the patients feel much better on buprenorphine!
- If you are worried about retirement some day, consider being able to keep a group of stable buprenorphine/suboxone patients after you leave your busy practice. You could work without dealing with insurance. As an example, my stable patients pay $200 to see me every 3 months. It is a reasonable deal for them-- less than $70 per month-- and because I'm no heavily discounting, I can see each patient for a full 30 minutes. Patients like having 30 minutes and always starting right on time, and I like knowing exactly when my day will end.

I think a lot of docs get an image of chaos dealing with people with addictions. My practice is just the opposite. Patients don't have any wait, so my office has one person in the waiting room at a time. I have a small fridge with water and soda, nice music, and some comfy chairs. One thing I tell new docs: the best thing about being an addiction doc is that patients are used to being treated like criminals by rude docs and staff. It is VERY easy to be 'the nice guy'-- because the other doctors are so rude!!

Finally, tell the docs that they will develop many long-term relationships with interesting, often-bright people. I learn so much from my patients-- again, talking about the people who are stable and doing well. I hear how cheese is made, or how engines can be taken apart, or what the newest Navy ships look like-- from the people who build them up in Manitowoc. I hear how the recording industry works (from a guy who owns a studio), how to blow glass, how to keep bees and produce honey, and the difference between cows and heifers. I've learned that you can cut the floor out of the back seat of a chevy suburban, plug it with a piece of wood, and use it for ice fishing. I'm just running through a few patients, and I could come up with a much longer list...

Time for my next patient. I'm honest about having them contact me though--- it is also a great way to start an independent practice, and Lord knows we need a lot MORE of that!


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PostPosted: Tue May 03, 2016 4:39 pm 
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That sounds like a wonderful experience for patients, gosh I wish that all doctors did that! A personal relationship with each patient and actually taking the time to get to know a little about them would definitely make so much difference. I'm so very grateful to just have a dr but feeling appreciated for being a trustworthy long term patient has to be awesome.

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PostPosted: Tue May 03, 2016 5:08 pm 
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I was thinking the exact same thing when I read Dr J''s post. I am fairly certain (only been a couple of visits) that I have a pretty good Dr. but he still lacks in some areas. Wouldn't it be awesome if there was more like Dr J ! :D

Willow


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PostPosted: Tue May 03, 2016 5:36 pm 
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The doctor that my husband sees is trying to drum up business. His patients are typically Coors employees because his office is in one of the Coors office buildings. My husband works at Coors. I have gotten very close to contacting him and asking him to become certified to prescribe bupe for opiate addicts. I don't know if he would go for it, but it would certainly be helpful in this area.

I have actually heard a little gossip that Colorado has lots of bupe doctors, but I'm not sure if that's true. My sub doctor is a half hour away with no traffic, but he also lets me have two video appointments in between office visits. So I see him 4 times a year. But my husband's doctor is only 10 minutes away, so I would consider changing practices.

Here's a question to the doctors or anyone else who might have insight. Say one of your patients who was in the process of becoming an addiction counselor wanted to start a suboxone support group, especially for patients newly on sub. Would you be open to that as long as you had confidence in the new counselor? And what would need to happen from a HIPAA and 42 CFR Part 2 standpoint? Would patients have to sign a waiver?

Amy

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PostPosted: Tue May 03, 2016 8:43 pm 
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This is a very interesting topic to me. I know I've mentioned it at least a few times in the past as well. As individuals, we really can't do much, other than wait, for the patient cap to be raised. However we could make a difference in increasing the number of certified docs. It really Does come down to marketing. If only I had more time. It's no different than a salesperson meeting with a doc to prescribe a new drug. You would think the bup manufacturers would get involved as it could very much effect their bottom line. I just know if more docs could meet and talk with us, they would give getting the waiver a try. Yeah, sometimes they would want to hear from their peers but if we could get organized and reach out to more GPs especially, I know we could increase the numbers. The Challenge is just doing it.

If the OP has that ability I'm certain it will work. Now will each doc you meet with do it? Hell no. You never make a sale every time. But I know you can get more to sign up. It's about 1) educating them on the need 2) convincing them to give it A try 3) holding their hand through it. By that I mean how to take the course, help in starting, etc.

It's sales. It's lobbying. It's how things are done. I wish you luck if you are willing to try.


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PostPosted: Tue May 03, 2016 10:19 pm 
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You would think the bup manufacturers would get involved as it could very much effect their bottom line. I haven't seen or heard from the Suboxone Rep in over two years, last time was before the change to Indiviodor or whatever they are now. Never have had a Bunavail or Zubsolv rep stop by. Haven't seen a rep at any conference lately either.
Amy, for referrals to a specific counselor or service I give the patient the contact information. No HIPIA violation if they make the contact. Alternatively, a release of information will suffice. At least according to our compliance officers.
And yes, I would refer to a counselor that is taking Suboxone. I couldn't imagine a better resource. We have alcoholics and addicts serving after a period of sobriety, so I would support a counselor that has been stable on Sub for a similar period of time.
I have posted about the DEA before. The process of getting the waiver and then upgrading a year later to see 100 patients is quite painless. Actually less paper work than my original CII-CV DEA. The only communication I have ever had from them was the registration and renewals. No letters, no 'policy changes,' no warnings to do such and such. With our EHR and the excel spread sheet that lists all my current patients, and another that lists former, I am not to concerned about an audit.


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PostPosted: Wed May 04, 2016 1:29 am 
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This is all such good news. I especially like hearing that the credentialing(waver) process is fairly simple/painless, and that the DEA is behaving much better than I was led to believe. I'm hoping that this is also true of you docs having the freedom to write for the most affordable Bupernorphine products regardless of whether or not they contain Naloxone. I'm assuming my old doctor from the twin cities was on the Reckitt payroll, ie having her name on their physician locator list (list of shame) in exchange for prescribing Suboxone brand buprenorphine only. She even tried to get me to use a smart phone app from R. Benkiser, where you scan the barcode of the Suboxone wrapper with your phone every time you take a strip. Waaaay to big brother for me with all the access to my data the app requires.
Thank you for this support everyone, and Dr J. I will figure out the best way to take you up on your offer to communicate with would be prescribers! The idea of marketing is also such a good one and so I will get in touch with a rep from either Reckit or the maker of Zubsolv to acquire some assistance. I would think you're right- they should be thrilled to do anything which might increase their sales. If nothing else, they always have good visual aids, perhaps they'll be willing to share them with me.
My goal is to meet with this retired doctor and impress him so much with success stories, evidence based medical facts about Buprnorphine, testimony from current Suboxone docs to quell myths and demonstrate how fulfilling we Buprnorphine patients are. I'll also tell my own o/d story when I couldn't get Suboxone, and of course how well I'm doing after sixteen months of treatment WITH Suboxone. I'll bring my wife for pastoral support, and so she can tell my story of near death and eventual success with Suboxone MAT from her perspective. I am only alive today because of my beautiful wife and her willingness to learn everything about my illness!
If this works the way I hope, this ret'd doc will agree to help me organize either an individual or group presentation to convince our area physicians to join this good fight. A church friend has agreed to put me in touch with a nearby hospital coordinator friend of hers to discuss a community presentation at her facilty. A retired pastor and his wife who attend our church recently suffered the tragic loss of their 23y/o grandson to an opiate overdose. They are extremely social justice oriented and have offered to be involved with any effort to reduce harm among opiate addicts in the community. As a team I think we can get this done, as long as I can impress upon our taget audience that we are not immune from this opiate crisis, and recovery from opiates without Suboxone is much more difficult and extremely danagerous. I really agree with the notion that anyone who regularly prescribes complete agonists, also has an ethical responsability to offer treatment with Suboxone too.
I'm also not going to rule out the posibilty of talking this retired physicain into becoming a Suboxone doc himself, even if it's until others can take over for him. I'll continue posting with my progress and look forward to any new ideas! Thank you again everyone, Mike


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PostPosted: Mon May 09, 2016 10:13 am 
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Conversations at the end of last week and the weekend with several different folks have been helpful. I spoke with the doctor and will be meeting with him this thursday. I spoke with a man who is a local judge presiding over several courts including drug court, where MAT is permitted and Suboxone could if it was available, make a big difference with the long term outcomes of defendants working through opiate addiction. Fortunately, keeping people alive and out of jail seems to be a concept embraced by prosecutors and defence attorneys too. I also spoke with a local newspaper reporter at a forum for 'Adverse Childhood Experiences (ACE's) and Incarceration' who expressed an interest in getting a story out about the opiate epidemic here and why none of the doctors are willing and waivered to prescribe Suboxone. I have no experiences with reporters and want to be careful about the possibility of her writing something with a negative slant, instead of presenting a cogent and fact based explanation of the positive impact Buprenorphine containing medications are having with opiate dependent persons. I don't want to make any assumptions about her ideology and end up setting things back even further. I know for sure there are many people here who just don't want to understand this problem, and refuse to agree on MAT despite the overwhelming evidence supporting it. If she is supportive, this could be a very good way to raise awareness and change the minds of would be prescribers.
I've also arranged to meet with an RN who works for a large local health corporation as director of continuing education to get further information about their future intentions to push practitioners closer to prescribing Suboxone for patients who need it. Unfortunately, when I spoke with her on the phone, she was sure that at least a few docs were taking this on already. She was very surprised when I told her the truth, and may not have believed me, since opiate dependency was definitely "an enormous issue we[they] are working on."


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