CIII Filling (Specifically Suboxone)

[darkenwulven]

A patient on Suboxone, prescribed by a Pain Management Specialist with a Buprenorphine Waiver, who doesnt fall into the normal box and has a complex medical history, meaning quitting all other substances with dependency potential is not an option, has landed in a difficult situation.

The MD was prescribing Suboxone and Percocet (Yes I know, that is counterintuitive, but that's not the focus of this question). Other MDs have been prescribing Phenobarbital, Fiorocet, Lunesta, Diastat, all MDs fully aware of each other's prescriptions, and the patient has been compliant, demonstrated by PDMPs and UAs.

The MD very unfortunately had an accident, rendering him unable to come into the office. The patient was referred to a psychiatrist who agreed to cover his Suboxone patients, but because of the other prescriptions, refused to prescribe the Suboxone, which of course is totally understandable. The patient was and is willing to cease taking the Percocet and deal with more pain, to prevent the specific objection of Suboxone and Percocet together, and to hand the MD the bottle, but understandably, the psychiatrist was still uncomfortable and wouldn't prescribe and told him to call the office of his Pain Management doctor for advice.

The patient has legitimate severe chronic pain, epilepsy, intractable insomnia and migraines unresponsive to other therapies, has worked hard in counselling, has massively improved and very stable. The MD with the waiver agreed, if he came in and saw a partner (Who doesn't have a buprenorphine waiver) and UA'd appropriate and had appropriate PDMPs, to write prescriptions for his Suboxone, then have his partner come to his house and pick them up, and give them to the patient. His partner wrote the Percocet prescriptions with the other physician's knowledge.

The patient received the Suboxone scripts for 2 months, and they were filled (i.e. a total of a 60 day supply, two 30 day supplies.).
Just to qualify, these prescriptions were hand written on each occassion.

The MD with the buprenorphine waiver, has said he can't do it any more because its not legal. As far as I am aware, as Suboxone is a CIII, there is nothing preventing him from continuing to do this five times in a 180 day period, or even just calling in refills on his last prescription for the next 120 days once a month so long as he doesn't exceed five fills in 180 days, and is taking precautions to ensure compliance.

Can someone help me out on clarifying whether it is legal for the MD to continue either hand writing the scripts, or refilling his last one? The state is Colorado, if it makes a difference. I think its very unlikely that the patient is going to find another MD with a buprenorphine waiver willing to prescribe with the other medications. I naturally can't do anything about whether the MD prescribes, but I am getting the impression he wants to help, and may help if he was reassured regarding the law, if I am correct.

Thanks,

Dr K

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[zelman]

A patient on Suboxone, prescribed by a Pain Management Specialist with a Buprenorphine Waiver, who doesnt fall into the normal box and has a complex medical history, meaning quitting all other substances with dependency potential is not an option, has landed in a difficult situation.

The MD was prescribing Suboxone and Percocet (Yes I know, that is counterintuitive, but that's not the focus of this question). Other MDs have been prescribing Phenobarbital, Fiorocet, Lunesta, all MDs fully aware of each other's prescriptions, and the patient has been compliant, demonstrated by PDMPs and UAs.

The MD very unfortunately had an accident, rendering him unable to come into the office. The patient was referred to a psychiatrist who agreed to cover his Suboxone patients, but because of the other prescriptions, refused to prescribe the Suboxone, which of course is totally understandable. The patient was and is willing to cease taking the Percocet and deal with more pain, to prevent the specific objection of Suboxone and Percocet together, and to hand the MD the bottle, but understandably, the psychiatrist was still uncomfortable and wouldn't prescribe and told him to call the office of his Pain Management doctor for advice.

The patient has legitimate severe chronic pain, epilepsy, intractable insomnia and migraines unresponsive to other therapies, has worked hard in counselling, has massively improved and very stable. The MD with the waiver agreed, if he came in and saw a partner (Who doesn't have a buprenorphine waiver) and UA'd appropriate and had appropriate PDMPs, to write prescriptions for his Suboxone, then have his partner come to his house and pick them up, and give them to the patient. His partner wrote the Percocet prescriptions with the other physician's knowledge.

The patient received the Suboxone scripts for 2 months, and they were filled (i.e. a total of a 60 day supply, two 30 day supplies.).
Just to qualify, these prescriptions were hand written on each occassion.

The MD with the buprenorphine waiver, has said he can't do it any more because its not legal. As far as I am aware, as Suboxone is a CIII, there is nothing preventing him from continuing to do this five times in a 180 day period, or even just calling in refills on his last prescription for the next 120 days once a month so long as he doesn't exceed five fills in 180 days, and is taking precautions to ensure compliance.

Can someone help me out on clarifying whether it is legal for the MD to continue either hand writing the scripts, or refilling his last one? The state is Colorado, if it makes a difference. I think its very unlikely that the patient is going to find another MD with a buprenorphine waiver willing to prescribe with the other medications. I naturally can't do anything about whether the MD prescribes, but I am getting the impression he wants to help, and may help if he was reassured regarding the law, if I am correct.

Thanks,

Dr K

What is the indication for the suboxone?

 

[darkenwulven]

Opioid Dependency is whats coded on the script, but there is genuine severe chronic pain from various diagnoses. The patient has been evaluated by med schools and Mayo for other possible interventions without any positive suggestions. Basically the patient was on a crapload of prescribed narcs (TM), self referred to detox and was stable on Suboxone alone with his pain managed by that, Xanaflex and Lidoderm patches, until an auto accident. He was prescribed Percocet 10/325 BID PRN for additional relief as trial with success, and gets regular nerve blocks and physical therapy. Yes, prescribing the Percocet in addition is controversial but seems to work for him, and its baby aspirin compared to what he was on. As previously stated, he's willing to quit that if it will help the issue. However I don't see any MD outside of (maybe) another Pain Management specialist, prescribing given the Lunesta, Phenobarbital, Diastat and Fioricet, prescribing Suboxone, and there aren't others within any reasonable, or unreasonable distance, the only options are psychiatrists.

 

[SRCorp]

as long as suboxone is for pain and not detox, I believe it's treated as regular C III. Dr no need to register to suboxone program. Must say for PAIN on the script though.

 

[darkenwulven]

as long as suboxone is for pain and not detox, I believe it's treated as regular C III. Dr no need to register to suboxone program. Must say for PAIN on the script though.

Thank you for that thought. The patient is somewhat in both boxes, he is on Suboxone maintenance, and the prior authorisation for insurance (and medical records) have it coded as opioid dependence (Which bluntly was accurate). But he has serious pain too. Given it is Medicaid, I suspect they'd deny Suboxone for pain, and would be paying for it out of pocket. But that's maybe an avenue we can explore with the partner of his normal Pain Management Doctor, or his PCP, if its denied, if he'd prescribe generic buprenorphine to keep the cost down a bit. I guess it'll all depend on their comfort level.

 

[Mao263]

Thank you for that thought. The patient is somewhat in both boxes, he is on Suboxone maintenance, and the prior authorisation for insurance (and medical records) have it coded as opioid dependence (Which bluntly was accurate). But he has serious pain too. Given it is Medicaid, I suspect they'd deny Suboxone for pain, and would be paying for it out of pocket. But that's maybe an avenue we can explore with the partner of his normal Pain Management Doctor, or his PCP, if its denied, if he'd prescribe generic buprenorphine to keep the cost down a bit. I guess it'll all depend on their comfort level.

Medicaid wouldn't deny suboxone. They require Prior auth every 3 month with using a special form for it, not a universal form. Along with that patient has do urine test too to support PRior auth. Medicaid can deny Films, because they are more expensive to cover, and suggest pills.
Prob patient didn't present to other Doctor urine test or smth. I know one of our patient get suboxone from one doctor. And doc wasn't available and patient didn't come on time, other doc refused to give a script cause he didn't want to take responsibilities

 

[zelman]

The doc who is actually practicing should either write a suboxone Rx for pain, write an Rx for butrans, or switch to methadone for pain (in order of my personal preference).

 

[CetiAlphaFive]

A patient on Suboxone, prescribed by a Pain Management Specialist with a Buprenorphine Waiver, who doesnt fall into the normal box and has a complex medical history, meaning quitting all other substances with dependency potential is not an option, has landed in a difficult situation.

The MD was prescribing Suboxone and Percocet (Yes I know, that is counterintuitive, but that's not the focus of this question). Other MDs have been prescribing Phenobarbital, Fiorocet, Lunesta, Diastat, all MDs fully aware of each other's prescriptions, and the patient has been compliant, demonstrated by PDMPs and UAs.

The MD very unfortunately had an accident, rendering him unable to come into the office. The patient was referred to a psychiatrist who agreed to cover his Suboxone patients, but because of the other prescriptions, refused to prescribe the Suboxone, which of course is totally understandable. The patient was and is willing to cease taking the Percocet and deal with more pain, to prevent the specific objection of Suboxone and Percocet together, and to hand the MD the bottle, but understandably, the psychiatrist was still uncomfortable and wouldn't prescribe and told him to call the office of his Pain Management doctor for advice.

The patient has legitimate severe chronic pain, epilepsy, intractable insomnia and migraines unresponsive to other therapies, has worked hard in counselling, has massively improved and very stable. The MD with the waiver agreed, if he came in and saw a partner (Who doesn't have a buprenorphine waiver) and UA'd appropriate and had appropriate PDMPs, to write prescriptions for his Suboxone, then have his partner come to his house and pick them up, and give them to the patient. His partner wrote the Percocet prescriptions with the other physician's knowledge.

The patient received the Suboxone scripts for 2 months, and they were filled (i.e. a total of a 60 day supply, two 30 day supplies.).
Just to qualify, these prescriptions were hand written on each occassion.

The MD with the buprenorphine waiver, has said he can't do it any more because its not legal. As far as I am aware, as Suboxone is a CIII, there is nothing preventing him from continuing to do this five times in a 180 day period, or even just calling in refills on his last prescription for the next 120 days once a month so long as he doesn't exceed five fills in 180 days, and is taking precautions to ensure compliance.

Can someone help me out on clarifying whether it is legal for the MD to continue either hand writing the scripts, or refilling his last one? The state is Colorado, if it makes a difference. I think its very unlikely that the patient is going to find another MD with a buprenorphine waiver willing to prescribe with the other medications. I naturally can't do anything about whether the MD prescribes, but I am getting the impression he wants to help, and may help if he was reassured regarding the law, if I am correct.

Thanks,

Dr K

Did you try asking your M.D.s for a referral for your prescriptions?

I really doubt your M.D. Will care if it's actually legal. He's basically just letting you know he no longer believes the benefits outweigh the risks.

 

[ldiot]

If the script is being used for pain have them code it for pain on the script. Then the prescriber doesn't need a waiver anyways.

 

[darkenwulven]

Medicaid wouldn't deny suboxone. They require Prior with every 3 month using a special form for it, not a universal form. Along with that patient has do urine blood test. Medicaid can deny Films, because they are more expensive to cover.
Prob patient didn't present to other Doctor urine test or smth. I know one of our patient get suboxone from one doctor. And doc wasn't available and patient didn't come on time, other doc refused to give a script cause he didn't want to take responsibilities

- I go with him to all his appointments for accountability and to help support him. The Psychiatrist with the he was sent to, had been faxed his entire medical record from that doctor, including UAs. The specific problem was the fact he was on the other medications.

Did you try asking your M.D.s for a referral for your prescriptions?

I really doubt your M.D. Will care if it's actually legal. He's basically just letting you know he no longer believes the benefits outweigh the risks.

They referred to an MD, a psychiatrist, and the issue explained by him was that their practice had a policy that all patients receiving suboxone receive no other controlled substances other than from that practice (Currently neurologist and the Pain Management doctor's partner), and particularly took issue with the Percocet (Which I understand why, and that was/is willing to be stopped, and has been stopped for now to show willing.). The issue is not about a lack of willingness to help on the original MDs part, its that he's physically unable to get into the office, as stated earlier, he had an accident, then when in hospital got a blood clot, and is concerned about the legalities. His partner is attempting to negotiate with the MD referred to if he will prescribe for just a few months until the pain doc returns. But as his partner is generally only in the OR as an anaesthesiologist and doesn't have a buprenorphine waiver, he may not even be aware that he can write it for pain.

 

[ldiot]

Doesn't buprenorphine bind with a much higher affinity than oxycodone anyways? I'm suprised the Percocet helps much. It's doesn't really matter what is legal or not you really can't force the MD to do anything or write a script a certain way. Seems to me the easiest thing is to indicate Suboxone for pain or go off the Percocet but it's really their decision.

 

[Ackj]

Doesn't buprenorphine bind with a much higher affinity than oxycodone anyways? I'm suprised the Percocet helps much. It's doesn't really matter what is legal or not you really can't force the MD to do anything or write a script a certain way. Seems to me the easiest thing is to indicate Suboxone for pain or go off the Percocet but it's really their decision.

This is my thought. If the buprenorphine is for opiate detox, that means it's being used to replace the opioids and ideally taper off of them. Since that's not the case, the indication isn't accurate. If it's being used for pain, it's higher affinity than the oxycodone and the oxycodone isn't really necessary. Maybe adjust dose/frequency slightly of buprenorphine to compensate for the d/c of the oxy, but that may not be needed.

Seeing as it's hard to find docs to prescribe, they might need to stop the buprenorphine altogether and go on the standard chronic pain long acting + breakthrough opioid combo.

 

[RxPreceptor]

Doesn't buprenorphine bind with a much higher affinity than oxycodone anyways? I'm suprised the Percocet helps much. It's doesn't really matter what is legal or not you really can't force the MD to do anything or write a script a certain way. Seems to me the easiest thing is to indicate Suboxone for pain or go off the Percocet but it's really their decision.

Yes, buprenorphine's affinity for Mu opioid receptor is greater than Oxycodone but only has partial Agonism (ceiling for analgesia and supposidly less respiratory depression) vs. Oxycodone (Ceiling for APAP toxicity though). Other main difference is buprenorphine's kappa antagonism (more so with reversing pyschotomimetic effects of opioids, some effect on analgesia reversal too though). MD is being very indecisive...

 

[BidingMyTime]

Pretty much what everyone else has said. If the Suboxone is being used for pain, then no waiver is needed. If it's being used for addiction, then it's hard to justify prescribing it at the same time the pt is getting narcotics. I'm surprised the original doctor even started this mess of prescription, and not surprised that no other doctor will carry it on. It's asking to have the DEA breathing down one's neck, by prescribing Suboxone for both pain and addiction.

Best bet for your friend, 1) stop Suboxone 2) adjust/change other pain medicines as necessary for optimal pain control 3) use other methods to deal with addiction (ie have doctor only give 1 week supply of medications at a time, if this isn't reasonable due to copays, have pt put a family member in charge of patient's medications who can dole out a week supply at a time to the patient, be active and have support friends in NA or other addiction group, add on non-controlled medication for cravings such as bupropion.

 

[ldiot]

Pretty much what everyone else has said. If the Suboxone is being used for pain, then no waiver is needed. If it's being used for addiction, then it's hard to justify prescribing it at the same time the pt is getting narcotics. I'm surprised the original doctor even started this mess of prescription, and not surprised that no other doctor will carry it on. It's asking to have the DEA breathing down one's neck, by prescribing Suboxone for both pain and addiction.

Best bet for your friend, 1) stop Suboxone 2) adjust/change other pain medicines as necessary for optimal pain control 3) use other methods to deal with addiction (ie have doctor only give 1 week supply of medications at a time, if this isn't reasonable due to copays, have pt put a family member in charge of patient's medications who can dole out a week supply at a time to the patient, be active and have support friends in NA or other addiction group, add on non-controlled medication for cravings such as bupropion.

Yeah honestly I agree. You could also just ditch the Percocet and do the reverse if the Suboxone works better for the pain. Even if the patient isn't abusing the meds it still doesn't mean that the combo is appropriate in my opinion.