Any FP docs here who prescribe Suboxone?

[scharnhorst]

Hi
I was wondering if any FP docs here prescribe suboxone
can you share your experiences ? pros and cons
major pitfalls ?
What setting are you in ? Do you exclusively do addiction medicine or just as a part of your primary care practice ?
The major malpractice issues related to suboxone ?
Would you prefer it to the once daily methadone clinic ? Does anyone does that anymore i.e the once daily methadone clinic ?
Thanks

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[oscardagrouch]

I do not currently prescribe suboxone, but I did have a lot of experience with it during residency. A LOT. I was at an inner city program in NY, and we had a lot of patients on methadone and suboxone, and the residents were bombarded with seeing these patients.

I found that patients on suboxone were very needy as compared to methadone patients. Always calling or showing up to the clinic to be seen, mostly because they were not taking their medication as prescribed and starting to feel the consequences. Not all of them were like this. One of my favorite generic stories I would often hear from these patients is this: I need a 3 month refill because I just got a job at a glass/ nail/ bead/ (random object) factory out in (Insert Any Mid-West or Southern State), and I have to leave tomorrow.

Personally, I found the patients on methadone a lot more relaxed, took better care of themselves, and were in a better position in life in terms of work and family life etc.

Some of the pitfalls I remember include it not being a pleasant experience for the support staff as they did not like dealing with these patients. you are limited to 30 patients in the beginning and can eventually manage 100 patients at a time, so if you're considering adding suboxone to your practice to drive patients in, you may not get the yield you are looking for. The visits took up a lot of your time as well, as you spend a bulk of your time confronting them about their urine test results.

Both methadone and suboxone are great tools used to support patients with their addiction, but since I got out of residency I decided to stay away from suboxone as I had too many unpleasant experiences with dealing with the patients who take it.

 

[septoplasty]

+1 to the above.

Also, you need to be "licensed" to prescribe it.. i.e go through some CME stuff which is more $$ to see (poly)substance abuse and deal with the above.

I don't/wouldn't even if I got paid very very well for it (which is not the case).

 

[deleted87716]

I don't/wouldn't even if I got paid very very well for it (which is not the case).

Ditto that. We have one FP in our group who does it, but my understanding is that he got certified a few years ago primarily to help one of his patients. I don't think he's made a habit out of it.

That being said, there's a methadone/Suboxone clinic in my office park. The sketchy cast of characters that I see coming and going there on a daily basis has been more than enough to convince me that I'd never want to do that.

 

[SLC]

Took the course during intern year, can prescribe once I'm fully licenced.

But I don't plan to, for many of the same reasons highlighted above. After residency, I'm looking for a less socially complicated clientele, not more.

 

[simpler2]

I have been prescribing buprenorphine for medication assisted treatment (MAT) for about 7 years now (including 2 in residency). I have between 60-70 active patients most of the time (about 20-25% of my encounters). This is an atypically large panel for primary care with most providers staying under 20-30 patients. My practice is part of a multi site "community clinic" or FQHC. Even with the numbers I see for MAT, I find the visits mostly faster and less complex than non-MAT visits. As long as you set structure and clear expectations/consequences in providing MAT, the practice is very straightforward and I don't see it attract more "problem patients" (whatever this means) in my clinic or the clinics of other providers who I know provide MAT.

The only malpractice or legal issues that I have heard of specific to MAT are the consequences that for cash profit oriented sites face similar to issues faced by opiate/controlled substance "pill mills" deal with.

There are certainly differences both in policy and pharmacologically between methadone and buprenorphine (naltrexone as well) that are numerous and worth reading up on if interested. I recommend the ASAM 2015 guideline as a starting point:
http://www.asam.org/docs/default-so...am-national-practice-guideline-supplement.pdf
I don't see much merit in debating which is better or worse and simply see these as treatment options for the same disease of opioid dependence.
Methadone maintenance is alive and prevalent to some degree in almost all areas of the country. It can only be provided at specifically licensed methadone clinics and not in the primary care setting.

 

[FamilymedMD]

I've had a DEA waiver for a couple of years and started a small addiction group in my DPC practice a little over a year ago and also moonlight once a month at a cash based counseling plus bupeprenorphine network clinic.

Don't judge addiction medicine by the negative experiences we've all had with active addicts trying to lie or manipulate to get scripts from us in the ER or clinic. While some patients still lie, cheat on urines, etc., most patients who are actively working on their recovery are very different. Some of the most gratifying work in primary care is in addiction treatment.

Don't assume cash based practices are pill mills. By cutting out all the insurance crap we can make addiction care affordable to most working class patients. Do be careful and check out any addiction jobs carefully but overall I think the liability risk of addiction work is less than for hospitalist work.

Addiction medicine, like anything else, is best learned with a mentor, an experienced doc and counselor are invaluable. The eight hour DEA waiver course is just the beginning. However, it's less complex than many other parts of medicine that we've done like obstetrics or hospital care.

 

[simpler2]

[QUOTE="FamilymedMD, post: 18888462, member: 296532"
Don't assume cash based practices are pill mills. By cutting out all the insurance crap we can make addiction care affordable to most working class patients. Do be careful and check out any addiction jobs carefully but overall I think the liability risk of addiction work is less than for hospitalist work.
QUOTE]

Apologies for not being more specific. I did not mean to imply that all cash based practices treating addiction are pill mills. I was just trying to make the point that clinics who are operating like pill mills in their prescribing practices for MAT with buprenorphine are the only settings where I see increased liability in practice, but doing so unclearly/poorly.