Difficulty coming off Buprenorphine

[Anasazi23]

For those experienced with buprenorphine and opiate withdrawal syndromes in general...

I inherited a Suboxone patient (oxycontin, vicodin addiction) a number of weeks ago, who at the time, was taking 4mg PO QD. She had remained clean from exogenous opiates for a number of weeks, and was looking to come off the Suboxone. I slowly titrated it down to a dose of 2mg QD, and am having a hell of a time going lower. I've tried fractionating the doses, and have prescribed and recommended many supportive meds to deal with the severe stomach cramping, sweating, headaches, and nausea that she experiences when she drops to any dose below 2mg. We've even tried fractionating the pills in 1/8ths, to no avail, and have seemed to have hit the floor at the 2mg dose. Last visit, I started clonidine 0.1mg PO Q6h after taking her BP and pulse. I'm going to follow-up on that strategy tonight. An attending recommended splitting the dose BID. In this case, 1mg BID. But in only a couple of hours after the lowered dose, the withdrawal sets back in. She's unwilling to go to a higher dose than the 2mg, even for the short term.

So my question is....how would you help a patient (other than inpatient detox admit) get through an intolerable buprenorphine dose reduction, who has to go to work, and remain functional that's reasonable in an outpatient setting.

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[OldPsychDoc]

What's the hurry? It seems to me that the risk of relapse far outweighs the risks/costs of keeping her on 2 mg for a while (even months) longer. Or is there a reason not to consider maintenance for her? I like to see my patients REALLY stable in sobreity before I take them off.

For those experienced with buprenorphine and opiate withdrawal syndromes in general...

I inherited a Suboxone patient (oxycontin, vicodin addiction) a number of weeks ago, who at the time, was taking 4mg PO QD. She had remained clean from exogenous opiates for a number of weeks, and was looking to come off the Suboxone. I slowly titrated it down to a dose of 2mg QD, and am having a hell of a time going lower. I've tried fractionating the doses, and have prescribed and recommended many supportive meds to deal with the severe stomach cramping, sweating, headaches, and nausea that she experiences when she drops to any dose below 2mg. We've even tried fractionating the pills in 1/8ths, to no avail, and have seemed to have hit the floor at the 2mg dose. Last visit, I started clonidine 0.1mg PO Q6h after taking her BP and pulse. I'm going to follow-up on that strategy tonight. An attending recommended splitting the dose BID. In this case, 1mg BID. But in only a couple of hours after the lowered dose, the withdrawal sets back in. She's unwilling to go to a higher dose than the 2mg, even for the short term.

So my question is....how would you help a patient (other than inpatient detox admit) get through an intolerable buprenorphine dose reduction, who has to go to work, and remain functional that's reasonable in an outpatient setting.

 

[Anasazi23]

Right. Well, it's her request really. She's looking to come off all exogenous drugs, prescribed or otherwise.

 

[Doc Samson]

I agree with OPD... present her with the maintenance model of treatment, need to maintain her homeostasis, etc.

Therapeutically, I'd also question this flight into health of going from a vicodin and OC addict to needing to be off all meds, prescribed or otherwise. Sounds like the baby's going out with the bathwater, and you don't necessarily have to agree with it.

 

[OldPsychDoc]

I agree with OPD... present her with the maintenance model of treatment, need to maintain her homeostasis, etc.

Therapeutically, I'd also question this flight into health of going from a vicodin and OC addict to needing to be off all meds, prescribed or otherwise. Sounds like the baby's going out with the bathwater, and you don't necessarily have to agree with it.

"Two out of three mods recommend Suboxone for their patients who chew drugs"....

 

[whopper]

Well congratulations on having a substance addict that actually wants to get off of the habit. A very good but hard to find thing.

Here's what an attending told me what he would do in a similar situation and this is anectdotal and not evidence based.

1-antidepressant-he would choose duloxetine. Why? He claims that opioid dependent patients suffer from anxiety & increased sensitivity to pain. This med will help with both. I asked him about giving it to non-depressed/non anxiety DO pts and the problems with this. He said he still believed from his own anectdotal experience that it was worth it.

Rest is stuff I've read & used-successfully.
2-antihistamine (e.g. vistaril). antihistamines when given with opioids can potentiate the euphoria of that opioid. This is documented in Kaplan & Sadock and is one of the theories as to why seroquel has street value--because opioid addicts want to potentiate their high with it. Several patients with chronic pain on opioids I've noticed often ask for a benadryl when they're given pain meds in the E.R. I told the ER doc about the antihistamine/opioid interaction and he was like, "Oh so that's why they do that!"

Be careful though in presenting this data. Should the person relapse, their new knowledge of mixing antihistamines with opioids can end up hurting them.

3-space the meds out on a non-daily basis. E.g. start using dosages every 36 hrs or at least an interval that can over the long term space the dosages apart that doesn't have to be daily, and have the patient try to time their dosage so that when the med wears off, the patient will be asleep--and sleep through their problems.

I like OPD's advice. Make sure they're stable before you go the next step.

 

[OldPsychDoc]

Well congratulations on having a substance addict that actually wants to get off of the habit. A very good but hard to find thing.
...

<sigh> If there's a stigma with being mentally ill, there's an even worse stigma with being an addict...

Really, whopper, I know that you're coming from a place of frustration with urban opiate addicts, but it truly is NOT that hard to find an addict that wants to quit. Like you, however, they are just completely conditioned to believe that it's not possible for them ever to do so.

I applaud you and your attending for looking at options (you mention 3 out of many) for treating this condition medically. To respond in particular to your first suggestion--I have yet to meet an addict without at least some degree of depression (regarding the impact of the disease on their life) and anxiety (regarding the scary changes needed to achieve sobreity). An antidepressant is hardly a panacea, but it may make enough difference that it buys some time to begin establishing a sober lifestyle. It is not "enabling" to relieve symptoms in early sobreity! The more we can do this, the more likely we are to see addicts fulfill their hopes of getting off their habits.

To come back to Sazi's patient, does it bother anyone that we're essentially saying "You still have symptoms? You're not better yet? Well, we'd better get you off this medication that's relieving the symptoms!" What other disease would you treat this way? "What? Still having angina? Better get you off that nitroglycerin then!!!" "Ankles swollen? Stop taking your lasix! You'll feel better for it."

OK--someone else can have the soapbox now...

 

[whopper]

If there's a stigma with being mentally ill, there's an even worse stigma with being an addict...

I don't know if you interpreted my statement right.

There's the saying that is true-"it has to get worse before it gets better" for most to want to stop their substance abuse.

Yes there are people who want to sincerely get off of a substance, and that's actually something I look forward to seeing-that's why I gave the congratulations. Its a nice thing to have. Yes--I do admit that substance abusers that don't seem to want to kick the habit bug me--but that makes treating those that do want help all the more enjoyable.

In regards to the antidepressant use-I have read some literature that backs it up as a theory-but its sparse--very sparse. I don't see too much research in this area. The greenbook's booklet on treatment of substance abuse & dependence is very comprehensive & well written. I don't remember it mentioning antidepressants showing strong data as a tool for helping patients get off of a substance. (last read it about 1 year ago).

To come back to Sazi's patient, does it bother anyone that we're essentially saying "You still have symptoms? You're not better yet? Well, we'd better get you off this medication that's relieving the symptoms!"

Substance dependence is a long road with several triggers. CBT is a good tool to fight that. It could be that the patient is still experiencing triggers to use opioids, and maybe using the suboxone to fight off those triggers that could be inducing episodes of craving.

I wouldn't push too hard for an "intolerable" dose reduction. Pushing someone too hard, too fast could cause them to fall off that difficult mountain climb they spent months to get where they are at. If the patient is pushing to get off the suboxone more quickly than you think is safe-this shows strong motivation on her part which is a good sign, but let the patient know the pitfalls and that in this area where usually aren't any quick solutions.

I think what I'd do is still give her the suboxone but try to have her space it out as much as she can--telling her if she has to, its still there for emergency use. Have her document how often she is taking it and trying to work with her on gradually decreasing it on her own whlie identifying any triggers that could be causing an urge to use opioids. After identification of triggers-use CBT to tackle those.

Question for you Sazi, since I have not gotten my suboxone training yet (will in a few months). Would you consider the patient have an "emergency" reserve of suboxone (just a few pills) even after the patient has successfully detoxed & is no longer in need of the medication? I figure given the high rates of relapse for any substance, it'd be a possible strategy for them to have an emergency supply should something go wrong. I figure better to take a suboxone & call the doctor than a relapse where the pt takes in some heroine.

 

[OldPsychDoc]

I don't know if you interpreted my statement right.

There's the saying that is true-"it has to get worse before it gets better" for most to want to stop their substance abuse.

Yes there are people who want to sincerely get off of a substance, and that's actually something I look forward to seeing-that's why I gave the congratulations. Its a nice thing to have. This is something I've seen almost everyone in the field mention..

Well, to my reading it really came across as though you were saying that it's exceedingly rare to find a user who wants to quit. I just wanted to reinforce that most patients KNOW they have a problem and DO want to quit--they just have to get past piles of past experience and societal attitudes telling them they can't, or that they won't "until they hit bottom". There's always a lower bottom. If we take an attitude that they have a treatable illness and that we'll be there to help, they can start quitting now--before they have to drift still lower.

In regards to the antidepressant use-I have read some literature that backs it up as a theory-but its sparse--very sparse. I don't see too much research in this area. The greenbook's booklet on treatment of substance doesn't mention antidepressants as a treatment (as far as I know-read it last about a year ago)...

Just to clarify, you won't find antidepressants in the literature as an "evidence based treatment" for a substance use disorder, because they aren't a treatment for the disorder. They are an adjunctive treatment for the co-morbid mood and anxiety symptoms associated with the substance use disorder. This is where our practice has to diverge from protocol-driven flow charts and become based on clinical judgment in an individual patient-physician relationship.

Substance dependence is a long road with several triggers. CBT is a good tool to fight that. It could be that the patient is still experiencing triggers to use opioids, and maybe using the suboxone to fight off those triggers that could be inducing episodes of craving.

I wouldn't push too hard for an "intolerable" dose reduction. Pushing someone too hard, too fast could cause them to fall off that difficult mountain climb they spent months to get where they are at. If the patient is pushing to get off the suboxone more quickly than you think is safe-this shows strong motivation on her part which is a good sign, but let the patient know the pitfalls and that in this area there usually aren't any quick solutions.

I think what I'd do is still give her the suboxone but try to have her space it out as much as she can--telling her if she has to, its still there for emergency use. Have her document how often she is taking it and trying to work with her on gradually decreasing it on her own whlie identifying any triggers that could be causing an urge to use opioids. After identification of triggers-use CBT to tackle those.

Very reasonable points, all.

 

[whopper]

No problem OPD. I can see where you got the interpretation. My fault. Sometimes writing on a board vs talking in person can come across differently.

 

[Anasazi23]

Question for you Sazi, since I have not gotten my suboxone training yet (will in a few months). Would you consider the patient have an "emergency" reserve of suboxone (just a few pills) even after the patient has successfully detoxed & is no longer in need of the medication? I figure given the high rates of relapse for any substance, it'd be a possible strategy for them to have an emergency supply should something go wrong. I figure better to take a suboxone & call the doctor than a relapse where the pt takes in some heroine.

I probaby wasn't that clear in my initial description. I've treated quite a few patients with suboxone at this point, and have weaned quite a few off without too much difficulty. We've all heard outrageous stories of people unable to come off an SSRI or SNRI, requiring crushed tablet powder in water to eliminate what appear to be exquisite withdrawal side effects in stopping an antidepressant.

This situation is like that, but more difficult in a way. The t 1/2 of suboxone is around 37 hours. But this doesn't mean, as we know, that there will be no withdrawal effects until after the elimination period. I see this patient in the context of a high-end addiction center (food, drugs, alcohol, sex, even cluttering and collecting). The patients tend to be of a "higher" caliber, and many don't want insurance companies or their jobs finding out about their medication regimens. She's been off all exogenous opiates for close to two months, and will soon be leaving the program. There will likely not be someone available to her to continue prescribing the Suboxone. Even in NYC, it's harder than you'd think. She doesn't want to go through her insurance, and most "high end" docs take only cash which she can't quite afford.

The smallest pill form comes in 2/0.5mg. She's stating that taking any less than this dose at all results in intolerable cramping, nausea, headache, etc., resulting in her being unable to attend work. This includes shaving off sections of the tablet in an attempt to lower the dose.

Anyway, the point of my rambling was just to see if people had experienced this and had any insight in how to get her "under" the hump.

 

[strangeglove]

I'm wondering if you could take advantage of the placebo effect in this situation. I can't help but think that the patient is very attentive to the dosages she's being given and quite involved in rituals such as shaving and splitting tablets, etc. She also seems very anxious about the fact that she's on suboxone, which is evidenced by the fact that she's seems so invested in getting off of it. This could explain why even miniscule reductions in dose (i.e. reductions that may not really be making a difference pharmacodynamically) are precipitating withdrawal; even though the actual reduction in dosage is very small, she perceives this reduction as quite large (I'm guessing that previous dosage reductions haven't met with similar withdrawal, even though amount of the reductions have probably been quite large). Opioids are also notorious for being very susceptible to placebo effects (there's quite an interesting neuroscience literature about this, in fact). I know it's probably ethically problematic, but perhaps you could tell her that you're giving her the same dose while actually giving her smaller and smaller doses, until they become basically homeopathic doses. If this works, the question then becomes what do you do with the withdrawal you precipitate by merely telling her she's no longer getting any suboxone.

 

[OldPsychDoc]

I'm wondering if you could take advantage of the placebo effect in this situation. I can't help but think that the patient is very attentive to the dosages she's being given and quite involved in rituals such as shaving and splitting tablets, etc. She also seems very anxious about the fact that she's on suboxone, which is evidenced by the fact that she's seems so invested in getting off of it. This could explain why even miniscule reductions in dose (i.e. reductions that may not really be making a difference pharmacodynamically) are precipitating withdrawal; even though the actual reduction in dosage is very small, she perceives this reduction as quite large (I'm guessing that previous dosage reductions haven't met with similar withdrawal, even though amount of the reductions have probably been quite large). Opioids are also notorious for being very susceptible to placebo effects (there's quite an interesting neuroscience literature about this, in fact). I know it's probably ethically problematic, but perhaps you could tell her that you're giving her the same dose while actually giving her smaller and smaller doses, until they become basically homeopathic doses. If this works, the question then becomes what do you do with the withdrawal you precipitate by merely telling her she's no longer getting any suboxone.

Theoretically an interesting idea (often done with methadone which can be diluted as a liquid)--however, the practicalities of Suboxone, which is a sublingual tablet, would make this fairly near impossible to pull off.

 

[whopper]

This situation is like that, but more difficult in a way.

I get it now. Difficult situation indeed for the patient. Don't know how hard it is to find one in NYC but I've heard stories.

Only thing I can suggest that comes to mind is to find such a doc and to outreach to other nearby areas if she cannot find one. Difficult.

 

[OldPsychDoc]

...The patients tend to be of a "higher" caliber, and many don't want insurance companies or their jobs finding out about their medication regimens. She's been off all exogenous opiates for close to two months, and will soon be leaving the program. There will likely not be someone available to her to continue prescribing the Suboxone. Even in NYC, it's harder than you'd think. She doesn't want to go through her insurance, and most "high end" docs take only cash which she can't quite afford.
...

This is the kind of patient I'd keep on as an outpt, provide some ongoing Motivational Interviewing type therapy. Why don't you offer to "keep" her? See her monthly at a pre-arranged rate. Start your own cash-pay practice...

 

[Chrismander]

This is the kind of patient I'd keep on as an outpt, provide some ongoing Motivational Interviewing type therapy. Why don't you offer to "keep" her? See her monthly at a pre-arranged rate. Start your own cash-pay practice...

Funny that you bring this up, I was going to start another thread cause I had a question about this rolling around in my head. Thanks OPD! Feel free to move into another thread if this is too off topic.

1) When can you get buprenorphine certified?
2) Is there any benefit to being buprenorphine certified while a resident?
3) Specifically, could a resident (like Sazi here) "moonlight" by offering low-cost addiction psychiatry services outside of his residency program? Or is this a huge no-no?

I imagine that starting what would essentially be a part-time cash-only private practice could be much more perilous (medically/legally) than a standard moonlighting job... issues of followup, availability, etc would be big, plus whether you'd have the infrastructure to support a responsible addiction office (frequent urine testing, and whatever non-psychiatric services they'd need to get, like social workers, etc).

is this even feasible, or just a pipe dream? If feasible, is it ethical? No one seems to question the "ethicalness"** of pulling an extra shift at another hospital across town to get some extra cash (provided you're not going over 80 hours or interfering with your educational training), but is seeing a patient as an outpatient when you're still in training somehow different? Practically speaking, is it harder to get malpractice coverage for this as opposed to "standard moonlighting"?

Thanks guys & gals!

**P.S. what's the word for "ethicalness"? my brain isn't working, and i don't feel like looking it up. Damn fourth year senioritis!

 

[josehernandez94]

**P.S. what's the word for "ethicalness"? my brain isn't working, and i don't feel like looking it up. Damn fourth year senioritis!

ethicality i believe.

your questions are interesting. i'm curious to hear the responses (though my bet is that your hunch is right--probably not kosher).

 

[Anasazi23]

1) When can you get buprenorphine certified?

I believe that you can receive the waiver certificate prior to being licensed, but the licensure applies to your DEA, which will then start with an "X" instead of it's normal first letter. After getting licensed, and then you get your DEA, you can apply for the waiver, and you'll be certified.
http://buprenorphine.samhsa.gov/waiver_qualifications.html

2) Is there any benefit to being buprenorphine certified while a resident?

I got certified as a resident. It looked good on fellowship apps and I'm able to prescribe Suboxone as part of my moonlighting...in this case, at an addiction clinic.

3) Specifically, could a resident (like Sazi here) "moonlight" by offering low-cost addiction psychiatry services outside of his residency program? Or is this a huge no-no?

This usually isn't allowed by the residency program. In most cases, if moonlighting is allowed at all, then moonlighting gigs need to be approved by the psychiatry department program director. "Mini private practice" is almost universally not allowed. I'm sure that there are some places that might allow this, though I haven't personally heard of any.

I imagine that starting what would essentially be a part-time cash-only private practice could be much more perilous (medically/legally) than a standard moonlighting job... issues of followup, availability, etc would be big, plus whether you'd have the infrastructure to support a responsible addiction office (frequent urine testing, and whatever non-psychiatric services they'd need to get, like social workers, etc).

Well, it's feasible, and really can be not such a huge deal, but the issue boils down to malpractice insurance. You will need to be accountable for the patients, provide coverage for when you're gone, etc. As you mention, if you're going to claim to do a mini-addiction tx center, you'll need some more resources, such as urine testing, if you so choose to do this.

is this even feasible, or just a pipe dream? If feasible, is it ethical? No one seems to question the "ethicalness"** of pulling an extra shift at another hospital across town to get some extra cash (provided you're not going over 80 hours or interfering with your educational training), but is seeing a patient as an outpatient when you're still in training somehow different? Practically speaking, is it harder to get malpractice coverage for this as opposed to "standard moonlighting"?

Thanks guys & gals!

**P.S. what's the word for "ethicalness"? my brain isn't working, and i don't feel like looking it up. Damn fourth year senioritis!

Ethics to me goes as far as someone else's mores and values. They're not mine. They're theirs. This doesn't make me popular with pontificating and controlling academics, but that's fine with me too. Be concerned more with what's legal and what you're able to do for the patient competently and in your own sense, ethically...keeping in mind that if you're caught by your residency, you're out.

 

[OldPsychDoc]

Funny that you bring this up, I was going to start another thread cause I had a question about this rolling around in my head. Thanks OPD! Feel free to move into another thread if this is too off topic.

1) When can you get buprenorphine certified?
2) Is there any benefit to being buprenorphine certified while a resident?
3) Specifically, could a resident (like Sazi here) "moonlight" by offering low-cost addiction psychiatry services outside of his residency program? Or is this a huge no-no?

What Sazi said....but also, the training will be cheaper (even free sometimes) if you're a resident.

Also, let me put a plug in just for getting as many docs as possible (psych and otherwise) trained in on this med. IMHO, the barriers to using this stuff are artificial and needlessly bureaucratic--especially when you compare it to the ease of prescribing benzos and opiates! As a result there's some kind of "mystique" around it--docs don't want to get the training because "it must be a hassle to use", patients can't find docs to prescribe it, nurses don't know how to administer it, pharmacies don't stock it...etc. So get out there, get certified, prescribe it where appropriate, see how patients respond to it...it's pretty cool.

 

[whopper]

the barriers to using this stuff are artificial and needlessly bureaucratic--especially when you compare it to the ease of prescribing benzos and opiates!

the legal limit as to how much can be prescribed was recently increased from what I understand.

Had an attending who told me that due to the demand of this med, the day he ends someone on it, he'd get someone else on it because it is that effective & in demand.

However he had a problem. Some patients of his unexpectedly relapsed & begged him to restart them on this medication and he couldn't due to the legal limit. He said one of his patients that he could not restart ended up overdosing a few days later.

This same attending mentioned he was convinced that this death could've been prevented had he given him the medication and that if he had a similar situation in the future he would seriously consider breaking that law if it meant saving someone's life.

This occurred before the legal increase, so I don't know if that increase gave him a comfort zone that could prevent this occurrence from happening again.

 

[Chrismander]

I believe that you can receive the waiver certificate prior to being licensed, but the licensure applies to your DEA, which will then start with an "X" instead of it's normal first letter. After getting licensed, and then you get your DEA, you can apply for the waiver, and you'll be certified.
http://buprenorphine.samhsa.gov/waiver_qualifications.html

I got certified as a resident. It looked good on fellowship apps and I'm able to prescribe Suboxone as part of my moonlighting...in this case, at an addiction clinic.

Thanks sazi. very helpful. Point of clarification--what's the difference between getting licensed and getting a DEA number? I thought once you had your license and could write scrips, you automatically could write narcs too?

This usually isn't allowed by the residency program. In most cases, if moonlighting is allowed at all, then moonlighting gigs need to be approved by the psychiatry department program director. "Mini private practice" is almost universally not allowed. I'm sure that there are some places that might allow this, though I haven't personally heard of any.

Well, it's feasible, and really can be not such a huge deal, but the issue boils down to malpractice insurance. You will need to be accountable for the patients, provide coverage for when you're gone, etc. As you mention, if you're going to claim to do a mini-addiction tx center, you'll need some more resources, such as urine testing, if you so choose to do this.

As far as moonlighting goes, all I ever hear about are inpatient gigs, or psych ER stuff. You're saying is that "mini private practice" is out, but what about working in someone else's private practice? You say you moonlight in an addiction clinic--what's that like? Are you basically doing "mini-private practice" under someone else's roof with their infrastructure, or is really just a per diem thing? I ask cause if the job involves suboxone, you can't do much else on account of the 30 or 100 patient limit, right? I mean, if he's already maxed, bringing you in per diem with no long-term committment doesn't do anything for him--if you write for another 30 patients, and then vanish, he (and those 30 new patients) are screwed, until he can find another moonlighter.

 

[Anasazi23]

Thanks sazi. very helpful. Point of clarification--what's the difference between getting licensed and getting a DEA number? I thought once you had your license and could write scrips, you automatically could write narcs too?

Licensing and DEA are two different animals. Licensing comes after Step III. Once you recieve your passing grade, you apply to the medical board of whatever state in which you want to practice. Unfortunately, it's not universal, which I think is *****ic. This usually involves providing proof of everywhere you've done schooling, transcripts, all medical licensing exam results, etc. Many folks do fsmb.org. It's a centralized application service that in theory helps streamline the process.

The DEA (Drug enforcement administration) number is a separate process in which you register with the DEA as a prescriber. Your number is unique to you, and technically, is attached to the practice or institution in which you practice, though many docs never change their DEAs when they move jobs or even states. You can't get a DEA without a license, but you can get a license without having a DEA, and prescribe under the auspices of a hospital DEA. This is the common scenario in residency programs, for example.

As far as moonlighting goes, all I ever hear about are inpatient gigs, or psych ER stuff. You're saying is that "mini private practice" is out, but what about working in someone else's private practice? You say you moonlight in an addiction clinic--what's that like? Are you basically doing "mini-private practice" under someone else's roof with their infrastructure, or is really just a per diem thing? I ask cause if the job involves suboxone, you can't do much else on account of the 30 or 100 patient limit, right? I mean, if he's already maxed, bringing you in per diem with no long-term committment doesn't do anything for him--if you write for another 30 patients, and then vanish, he (and those 30 new patients) are screwed, until he can find another moonlighter.

Working in someone else's private practice is normally a very gray and shady area in terms of moonlighting. I would venture to say that few, if any, residency programs would allow this, if they knew about it. I couldn't tell you a great reason why, but I do know that almost all moonlighting gigs are inpatient floors, hospital general calls in psychiatry, ERs, specialty clinics and jails/prisons.

In my particular scenario, I'm basically operating as a psychiatrist provided as a part of comprehensive treatment team for the addiction center. They have social workers doing most/all of the grunt work, such as case management, insurance stuff, group therapy, individual therapy, psychosocial evals, reports, disability claims, etc. I have to review some of it as a medically-licensed person, but I also am paid as a contractor. So, I bill for my time.

In terms of the suboxone, I can say that there is dropout and turnover. So, I never seem to be in too much danger of going over my limit. Quite the opposite actually. If I did just up and leave, there would be a big problem for them in terms of providing suboxone for all those patients, since they technically belong to the center, and are not mine, per se. In fact, part of any contractual agreement as a contractor-physician is that you cannot self-refer from that source, nor can you siphon patients to your own practice without prior consent or reason.