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Suboxone training

Discussion in 'Psychiatry' started by TexasPhysician, 07.30.11.

  1. TexasPhysician

    TexasPhysician Moderator

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    I am attempting to figure out how to prescribe suboxone and I found http://www.buppractice.com/ online. It is by ASAM.

    What else would I need to do besides this 9 hour online course? Seems simple enough to me. Why don't most psychiatrists do this?
     
  2. Doctor Bagel

    Doctor Bagel so cheap and juicy Moderator Emeritus

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    I would guess they don't want to deal with that population. From what I've heard it is easy, and I'm planning on getting the license once I'm fully licensed.

    BTW, it's such a ridiculous requirement. Indicative of how backwards we are about substance abuse treatment, I guess.
     
  3. OldPsychDoc

    OldPsychDoc Senior Curmudgeon Moderator Emeritus SDN Advisor

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    Kudos to both of you.

    Crazy that any yahoo with a DEA# can prescibe as much Percocet as they want, but we have to jump through hoops to prescibe a life-saving medication...
     
  4. Sneezing

    Sneezing Even Bears do it!

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  5. whopper

    whopper Former jolly good fellow

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    As far as I know the APA training is no longer free for residents but it's way cheaper than doing it as an attending.

    I prescribe Suboxone. I have gotten several people off of opioids successfully that have maintained remission for at least several months now.

    A problem, however, is at least per several of my patients, several are giving it out inappropriately. When you got one patient tell you something, whatever. When you got several, and none of them know each other, and they say all the same thing about the same doctor, I suspect something is going on. E.g. one doctor, so they claim, won't reduce the dosage even if the patient wants it reduced, and they give it out in dosages not recommended by the manufacturer (e.g. 24/6 mg).

    If you prescribe Suboxone, you got to play bad cop at times with patients. Frequent drug screens, monitoring the court websites and police reports to make sure they weren't arrested, and sometimes telling a guy upfront in an office with no security that you're not going to give it to them anymore because their drug screen is positive.

    I don't know why more psychiatrists don't do this but my suspicions are 1) lack of training in their residency program 2) not wanting to deal with a drug abusing patient population 3) risks associated with the population 4) not knowing what to expect in something that's likely new for them.
     
  6. firedoor

    firedoor let it bleed

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    When I had taken the APA online buprenorphine course this past June it was still offered free to resident APA members.
     
    Last edited: 08.01.11
  7. siked

    siked

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    I am a resident who has the opportunity to take the on-site course, but I do not yet have my medical license. Does anyone know if completing the course now will allow me to prescribe Suboxone in the future (once I've obtained my license). Thank you.
     
  8. nitemagi

    nitemagi Senior Member

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    Yes, it will. You need to complete the hours, apply for an XDEA # when you're independently licensed. I've prescribed suboxone mainly for detox on an inpatient unit.
     
  9. DebDynamite

    DebDynamite Attending

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    Bumping this thread to see if anyone has taken the course as a resident (free or inexpensively) lately.
    I would like to take it before I graduate in June. The SAMHSA link currently states that there are no training dates scheduled, but I thought it was an online course available all the time?

    (http://buprenorphine.samhsa.gov/pls/bwns/training)
     
  10. nitemagi

    nitemagi Senior Member

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    You can also train via the AAAP(Amer Acad of Addiction Psychiatry), which is I think is a $150 course fee. Not too bad.
     
  11. F0nzie

    F0nzie

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    AAAP annual conference offered free Suboxone training for residents last year.
     
  12. OldPsychDoc

    OldPsychDoc Senior Curmudgeon Moderator Emeritus SDN Advisor

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    Web-based via AAAP
     
  13. flash

    flash Senior Member

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  14. ghost dog

    ghost dog

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    This does not seem like an adequate manner in which to ensure quality assurance ; an online prescriber course for Buprenorphine?

    It took me quite a long time to learn how to prescribe opioids for chronic pain. This took place in person, by way of mentorship. It took a considerable amount of time.

    I understand methadone occurs by much the same way. I fail to see how methadone and Buprenorphine are that dramatically different.
     
  15. OldPsychDoc

    OldPsychDoc Senior Curmudgeon Moderator Emeritus SDN Advisor

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    Then perhaps you should take the course...
     
  16. mgdsh

    mgdsh

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  17. ghost dog

    ghost dog

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    I think you misunderstand, as it is my impression that prescribing Methadone requires an in-person apprenticeship in order to obtain a methadone license.

    How is bup substantially different ?

    The argument could be made that bup is somewhat harder to overdose someone on ( versus methadone), but this line of reasoning makes me very uneasy.

    Psychiatrists are ideally suited for managing the biopsychosocial component of addiction, but merely having an " online course " ( with no inperson mentoring experience) for managing the pharm component makes me uneasy.

    This population is manipulative to the extreme.

    Agree or disagree with this line of thought ?
     
  18. IAmAUser

    IAmAUser Member

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    .
     
    Last edited: 06.20.12
  19. OldPsychDoc

    OldPsychDoc Senior Curmudgeon Moderator Emeritus SDN Advisor

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    Disagree--that's why I suggested you take the course--so you'd learn the difference.
    Bup is a partial agonist, not a full agonist like methadone.
    I (and the FDA for that matter) agree it needs to be part of an "inperson" experience related to an overall intergrated treatment of the addiction (e.g. not just pushing a pill), and yes, opiate addicts do have a tendency to manipulate--but buprenorphine is intrinsically a lower risk substance than methadone.
     
  20. DebDynamite

    DebDynamite Attending

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    Thanks for all of the links. I am going to try and do the APA training before graduation this summer. I have worked with addicts for years . Before med school as the manager of a halfway house, then of course in residency (addictions), and finally as a moonlighter. Much more than an 8 or 9 hour online course would be overkill at this point. Thanks for the links!
     
  21. firedoor

    firedoor let it bleed

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    Because the DEA shows up at my office unannounced, flashing badges, looking into patient charts, treating me like a criminal.
     
    Last edited: 04.04.12
  22. ghost dog

    ghost dog

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    I agree with you 100% in regards to the local family MD scripting opioids when they are i) not indicated, or ii) prescribing inappropriately ( which in my consulting experience , unfortunately, is extremely common).

    Thus my reasoning - it would make sense from a quality assurance point of view to have a required inperson component in order to obtain a bup license ( to see how the old pros manage such patients - always a good idea). There are the typical case studies when it comes to addiction medicine - and then there is the real world. This population , as stated previously , can be very manipulative.

    Of course, this would be a different ball game if the person applying already has a fellowship in addiction medicine. However, I would think this would be part of the training in the fellowship.

    I see a relatively small portion of addicted patients in my practice ( admittedly in the precontemplative phase of addiction) - whoa boy. I have a lot of respect for the addictionologists. Lots of patience to manage this population.
     
    Last edited: 04.04.12
  23. whopper

    whopper Former jolly good fellow

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    A major difference between Suboxone and Methadone is if on Suboxone, it blocks other opioids. So if someone is on it, and tries to take another opioid, it won't work. Methadone can be mixed with other opioids. Another thing about Suboxone is the medication is designed so that tampering with the medication will likely destroy the opioid. Many treatments for opioids like Methadone could be played around with in a chemistry set to make it something more abusive.

    The company that makes it is also trying to move away from the existing tablet (and they claim they're going to get rid of it eventually), and move to films only that are even harder to abuse. There is some data that some people abuse Suboxone by crushing and snorting it though from my own anectdotal experience (data given to me by patients) that this is rare because they know the high from another opioid such as Percocet would get them a better effect.

    I'm fine with going away from the tablets but I do have a minority of patients (<10%) where I actually think they should be on the tablets instead of the films. For example, I have one guy with terrible tremor and you got to place the films under the tongue. His hands shake so much that he has trouble doing that, and when doing so, he accidently has the films touch his inner cheeks, gums or tongue, causing it to dissolve in the wrong place in his mouth.

    On Internet forums for drug addicts, the talk of abusing Suboxone is more along the lines of people who no longer need it, weaning themselves off of it, but telling their doctors they still need it and selling it, and people buying it not because they want to get high but because they want to get off of their own opioid dependence. As mentioned above, it's a partial agonist, not an agonist of the the u opioid receptor, hence the possible euphoria associated with it is less vs other opioids.
     
    Last edited: 04.04.12
  24. DebDynamite

    DebDynamite Attending

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    I'm obtaining the X # simply for the sake of my moonlighting job. Which I suspect the M-F docs appreciate- -having someone cover their inpatients over the weekend. So, I think the online course is overall a very good thing.
     
  25. markglt

    markglt

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    as a family medicine resident going for an adiction medicine fellowship, can i do this as well...or do i need to be a member of the APA?
     
  26. OldPsychDoc

    OldPsychDoc Senior Curmudgeon Moderator Emeritus SDN Advisor

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    Anyone with a DEA number can do it.
     
  27. whopper

    whopper Former jolly good fellow

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    I've noticed two doctors with FP residencies and an addiction fellowship are giving it out in a manner very different than the way I do.

    For example the manufacturer does not recommend it at dosages higher than 16/4 mg a day though they say 24/6 mg is appropriate only under extreme circumstances. The 2 FPs I've encountered had quite a few patients on 32/8 mg a day. The only patient I ever had on more than 16/4 mg a day for more than 6 months was 450 lbs. Every other patient I told them we're getting them to 16/4 mg and gave them a taper down schedule to get them there within a few weeks to months tops.

    This has been frustrating for me because I took over one of these doctor's 30 patients, and about 1/3 of them were being given Suboxone under circumstances I found very questionable. E.g. this doctor also gave them benzos, and even though the withdrawal was under control, she raised their Suboxone to dosages such as 24/6 mg or even 32/8 mg simply based on the patient's request because they were still having triggers to use drugs. I highly suspect these patients are using their Suboxone but being able to have excess they could sell off, or in these patient's minds, being somewhat buzzed is the "norm" for them.

    I've pretty much only given out Suboxone under the manufacturer's guidelines with very few problems so I don't know why these doctors are practicing in that manner. I'm not trying to say they're wrong because I haven't talked to them at length as to why they're going it their way. Maybe they know more than me, but they are not in tune with the manufacturer's guidelines. As for that doctor whose patient's I've taken over, she was doing a lot of things whacky (e.g. she'd dump the patient's urine from the drug tests in the sink where people use for drinking water).

    I have, however, found some of the manufacturer's guidelines to not work in clinical practice. For example, in some of their guides, they've recommended that a patient could be weaned off of Suboxone at a rate of up to 4/1 mg at a time and more than half the patients I've had where I've done this encountered pretty bad withdrawal. Another thing I've noticed is when I get patients off Suboxone they need to be weaned to dosages very much under what the manufacturer recommended. E.g. I've had patients on only 1/0.25 mg, stop from there, and still get bad withdrawal. I've had to have them go to 0.5/0.125 mg a day for about a week, then cut that to every other day, then even give clonidine and antihistamines.
     
    Last edited: 04.09.12
  28. ghost dog

    ghost dog

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    I think you make a pretty darned good point for an apprentice style / in person period of training prior to scripting Bup , whopper.

    Benzos + Bup ? That sounds pretty stupid to me. Asking for trouble.
     
  29. OldPsychDoc

    OldPsychDoc Senior Curmudgeon Moderator Emeritus SDN Advisor

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    Well it IS officially contraindicated...:rolleyes:
     
  30. whopper

    whopper Former jolly good fellow

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    Yeah I know. It's really annoying. When you tell a patient from the beginning you can't mix both--that's one thing but when another doctor told them it's alright, and put them on it, they freak out when you try to get them off the benzo.
     
  31. aphenomenon

    aphenomenon

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    Exactly - such a ridiculous dichotomy. And the limiting of the number of patients a provider can prescribe bup/nx to (is it still 100 everywhere?)
     
  32. aphenomenon

    aphenomenon

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    When you talk to patients, though, some do prefer suboxone because its easier to "skip a day" and then get high, higher. Which, in general, i view addiction more from a you're cutting down, thats good - and relapse isnt a failure perspective. But its also good to know thats one (of many reasons) why some pts choose bup. Unfortunately, this also contributes to some increases in overdose as well...
     
  33. kumar28

    kumar28 Senior Member

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    How long does it take to get ur suboxone license after the training?
     
  34. F0nzie

    F0nzie

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    2 months
     

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