Pure- Forensic/Addictions Practice

[SomeDoc]

All of the attendings I've come across who are fellowship trained in either, do a mix of general psyhiatry and the subspecialty they were trained in. I was told by one of my attendings that he has to balance both addiction psychiatry with outpatient general psychiatry, simply because pure addictions leaves him with not enough patients due to restrictions (I was surprised, as 90 sounded like a lot to me- am I missing something here?).

Is this pretty common? How feasible is it to do pure addiction psychiatry or forensics?

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[IAmAUser]

All of the attendings I've come across who are fellowship trained in either, do a mix of general psyhiatry and the subspecialty they were trained in. I was told by one of my attendings that he has to balance both addiction psychiatry with outpatient general psychiatry, simply because pure addictions leaves him with not enough patients due to restrictions (I was surprised, as 90 sounded like a lot to me- am I missing something here?).

Is this pretty common? How feasible is it to do pure addiction psychiatry or forensics?

can't speak to addiction, but I think that is possible. you are limited in the number of suboxone patients you can carry though (may be what your attending was referring to).

forensics I can tell you is not possible to do 100%. You need to continue treating clinical patients to have courtroom credibility as an actively practicing psychiatrist.

 

[whopper]

It is possible though extremely unlikely to do pure forensics, so yeah I'm technically disagreeing with you IAMUSER, though I also believe you are right. The devil is in the wording.

The general recommendation is for forensic psychiatrists to due some clinical psychiatry because if you don't use it, you lose it. Sitting in court all day, making evaluations on your colleagues who are practicing clinical psychiatry, for example in an involuntary commitment hearing, without doing the actual work yourself will put you in a disadvantage.

And sometimes the court will want very specific explanations on clinical things such as labs, descriptions of how certain disorders or diseases are affecting the person, and often-times they want more than just psychiatric explanations. E.g. I had to do a forced med hearing on someone refusing all her meds, she's psychotic and she has bad HTN. I had to explain that her not taking BP meds could cause significant harm and she doesn't understand this, explain the various degree of harm with HTN (e.g. mild HTN vs. hypertensive crisis), and that this was also a critical factor as to why she needed psychiatric meds.

 

[vistaril]

All of the attendings I've come across who are fellowship trained in either, do a mix of general psyhiatry and the subspecialty they were trained in. I was told by one of my attendings that he has to balance both addiction psychiatry with outpatient general psychiatry, simply because pure addictions leaves him with not enough patients due to restrictions (I was surprised, as 90 sounded like a lot to me- am I missing something here?).

Is this pretty common? How feasible is it to do pure addiction psychiatry or forensics?

when people say addiction, unless they are the medical director or staff psychiatrist at a place like Bradford, they are referring to suboxone pretty much. I mean there arent any other real "treatments" for addiction.....

and you can only have so many suboxone patients. Even if you cap out, thats only going to occupy a fraction of your time......most assessments/intakes are going to be done by the people who work as medical director types of rehabs....

of course capping your outpt suboxone pts does not require a fellowship in addiction. It doesnt even require being a psychiatrist if you didnt do an addiction fellowship. I know of several family medicine types without any formal addiction training(besides the suboxone online course) who are always right at capacity with their outpt suboxone......

i think these addiction fellowships(especially the ones that arent research track) are going to have a lot of trouble filling. My understanding is that a few have already moved to part time and extending the time length of training in an attempt to attract people.....for any non-child/non-forensics fellowship, the recent graduate needs to ask: what skills can this fellowship give me that I don't already have, can't acquire in my pgy4 year doing electives, etc.......if the applicant feels that the fellowship is just a way to hire a staff psychiatrist for 55k, of course that's not going to be very tempting.

as for being eligible to be "certified" in addiction or psychosomatic or whatever, for a lot of cases who cares? Heroin addicts arent going to pay you anymore just because you have a certificate framed in your office......

 

[notdeadyet]

when people say addiction, unless they are the medical director or staff psychiatrist at a place like Bradford, they are referring to suboxone pretty much. I mean there arent any other real "treatments" for addiction.....

The are many kinds of addiction that psychiatrists treat. Suboxone is only one modality for treating one type of addiction. In fact, there are psychiatrists who work in addiction for which suboxone is a small or negligible part of their practice.

No interest in debate, I'm just posting this for premeds or med students so that they aren't mislead. Do a basic search on addiction psychiatry and you'll see what it entails. I'm not sure what vistaril's experience is, but his appears to go counter to the field of addiction psychiatry.

Not picking on you, Vistaril, but jeeze, man, how could you get to we you are and only need addiction folks who did primarily suboxone?

 

[F0nzie]

I know some docs in pp will only do Suboxone detox tapers and will not provide any maintenance therapy. Not sure why exactly? Practice philosophy? Way around the cap?

As far as 100% addictions, the only settings I am aware of of are academics, methadone clinics, community detox centers, and some of the resort style substance abuse treatment programs.

 

[nitemagi]

Suboxone, methadone, vivitrol, just a couple of meds for addictions. But not the only. Plus the mgmt of comorbid d/o's.

 

[digitlnoize]

I'm not sure what vistaril's experience is, but his appears to go counter to the field of addiction psychiatry.

Not picking on you, Vistaril, but jeeze, man, how could you get to we you are and only need addiction folks who did primarily suboxone?

It's funny, as soon as I saw the thread title, I knew what vistaril's post was going to be before I even opened the thread and read the first post. Namely, and I'm paraphrasing here: "No you can't do addiction psychiatry. That might make money, which is something psychiatrists aren't allowed to do because everything we do is inferior to "medical" doctors." Sigh. Sorry.

OP: I know a number of people who do addictions only and forensics only. I would say that it's more common to do forensics as a side job, but everyone I know who does addictions is quite busy doing just that alone. Whopper can speak more to the forensics stuff, but I think, in general, it's difficult to get enough forensic cases to make a full time job unless you're some kind of superstar-giant in the field. However, there is other work for forensics too, including forensic units at state hospitals, jail work, etc, and most the people I know who do forensics full time tend to do either a blend of these, or work in academics and run fellowships while doing cases on the side...

 

[notdeadyet]

Suboxone, methadone, vivitrol, just a couple of meds for addictions. But not the only. Plus the mgmt of comorbid d/o's.

Disulfiram, naltrexone, etc.

 

[vistaril]

Suboxone, methadone, vivitrol, just a couple of meds for addictions. But not the only. Plus the mgmt of comorbid d/o's.

I should have written suboxone/methadone instead of just suboxone...but the point was clear- you're doing opiate substitution for opiate addicts. Same principle...one bullet.

Naltrexone, camphor, antabuse.....those aren't used much because they aren't very effective. (actually some would say not effective at all) And most of the antabuse isn't even used by addiction people but rather old school primary care types.

Addiction(outside of being a director of a rehab and doing assessments) = suboxone.

 

[vistaril]

OP: I know a number of people who do addictions only and forensics only...

you can't do addiction full time unless you work for a Bradford-type place or have a state funded position as like a health substance monitoring officer.

Suboxone patients are capped. Pure and simple.

Oh right...but there is camphor and antabuse. Good luck filling up your office spots with people you are maintaining on antabuse.

 

[vistaril]

I know some docs in pp will only do Suboxone detox tapers and will not provide any maintenance therapy. Not sure why exactly? Practice philosophy? Way around the cap?

As far as 100% addictions, the only settings I am aware of of are academics, methadone clinics, community detox centers, and some of the resort style substance abuse treatment programs.

on the last point you are correct.

On your first point, part of it may relate to the cap. I also know some addiction people who will not do *forever* maintenance therapy. They will do tapers over an extended period of time. It is *not* clear at all that opiate addicts should be maintained forever on some big dose of suboxone......there is a lot of disagreement on this.

We need to remember that when we maintain a patient on suboxone, that does have stigma and will cause them functional limitations in a lot of areas. Is being maintained on suboxone forever better than shooting heroin? Of course. Is being maintained on suboxone ideal? Of course not.

 

[vistaril]

I should have written suboxone/methadone instead of just suboxone...but the point was clear- you're doing opiate substitution for opiate addicts. Same principle...one bullet.

Naltrexone, camphor, QUOTE]

meant campral of course...but honestly efficacy is about the same

 

[digitlnoize]

you can't do addiction full time unless you work for a Bradford-type place or have a state funded position as like a health substance monitoring officer.

Suboxone patients are capped. Pure and simple.

Oh right...but there is camphor and antabuse. Good luck filling up your office spots with people you are maintaining on antabuse.

I will make sure to tell my friends and colleagues with addiction only practices that they have to close because you said they couldn't do it. I guess my University will also have to shut down our addictions clinic and fire all the full time faculty who work there. I'll also make sure to call my new C-L attending a liar the next time he tells me of his last job, doing additions only for > 5 years. Because you are right. It's totally impossible.

It's a good thing people achieve the impossible every day.

 

[nitemagi]

you can't do addiction full time unless you work for a Bradford-type place or have a state funded position as like a health substance monitoring officer.

Suboxone patients are capped. Pure and simple.

Oh right...but there is camphor and antabuse. Good luck filling up your office spots with people you are maintaining on antabuse.

Again, generalizing, oversimplifying, giving misinformation, black and white thinking, and dismissiveness without substance or sources to the generalizations.

Suboxone alone is capped at 100 patients (even if you're seeing those patients for $100 each once a month, do the math).

Best thing to do with Vistaril IMO is just to throw out his/her posts. It takes a lot more effort to constantly correct them with the experience of everyone else here (noticed how in almost every case no one agrees with him/her).

 

[digitlnoize]

Again, generalizing, oversimplifying, giving misinformation, black and white thinking, and dismissiveness without substance or sources to the generalizations.

Suboxone alone is capped at 100 patients (even if you're seeing those patients for $100 each once a month, do the math).

Best thing to do with Vistaril IMO is just to throw out his/her posts. It takes a lot more effort to constantly correct them with the experience of everyone else here (noticed how in almost every case no one agrees with him/her).

I keep trying to ignore them and failing. I'm worried some innocent pre-med lurker is going to read one and fall for it!

 

[whopper]

I've had a few patients on Gabapentin to reduce relapse in alcohol abuse and dependence, Antabuse, and Naltrexone and they all worked very well. There are evidenced based studies showing Gabapentin has benefits with alcohol abuse.

The above patients were in private practice. Those patients are usually different than the ones you'll see in the hospital. Private practice patients, as a whole, want treatment, usually have a better GAF and insight vs. people in the hospital are often times there because someone made them go there.

Campral, now there's one where I never really saw much of a benefit. At least with Gabapentin, my alcohol abusers told me they actually noticed a positive difference and they felt a significant decrease in their desire to drink. None of the people I ever put on Campral told me they ever felt a difference---ever.

 

[vistaril]

Again, generalizing, oversimplifying, giving misinformation, black and white thinking, and dismissiveness without substance or sources to the generalizations.

Suboxone alone is capped at 100 patients (even if you're seeing those patients for $100 each once a month, do the math).

Best thing to do with Vistaril IMO is just to throw out his/her posts. It takes a lot more effort to constantly correct them with the experience of everyone else here (noticed how in almost every case no one agrees with him/her).

If you have anything to add....like some *good* evidence based literature that suggests there are effective non-suboxone/methadone medications out there for addiction, I'd be interested in hearing about them.....some cites to the primary literature would be nice as well.

 

[whopper]

Do you just mean opioid dependence?

For alcohol, here's one of the studies for Gabapentin with alcohol use.

 

[surftheiop]

Couple years ago I was working on a chart review project for an academic outpatient substance abuse treatment program, it had 2 full time addiction psychiatrists, plus a couple fellows and then rotating residents and they all stayed plenty busy. I think opiates were only about 30% of the visits there.

 

[nitemagi]

If you have anything to add....like some *good* evidence based literature that suggests there are effective non-suboxone/methadone medications out there for addiction, I'd be interested in hearing about them.....some cites to the primary literature would be nice as well.

As opposed to your incredibly evidence based claims which every other clinician here refutes? Addiction to what? What qualifies as "good" to you?

 

[billypilgrim37]

I don't quite understand the emphasis on the few tools we have to directly help addictions with pharmacotherapy, though I think some of them are very helpful. I've had patients who have been on antabuse and thought it was a lifesaver. Not common, but it happens. The clinical trials network is doing a lot of work on vivitrol and I think we're going to see more insurance companies covering it due to its relative effectiveness and cost savings.

MOTIVATIONAL INTERVIEWING is the effective, evidence-based intervention of addiction psychiatry. And it is very much the psychiatrist's role to participate in the process during their brief interactions, even if the interactions inevitably have to focus on medication. Opioid substitution is effective and important, but the addiction psychiatrist is going to be seeing crack addicts, cannabis addicts, meth addicts, alcoholics, benzo-addicts, etc, and treating them regardless of whether there is a specific pharmacologic agent to target the drug of choice.

I have been wrestling about whether to do an addiction fellowship after child training, and the more I realize the opportunity cost of a 6th year of training compared to getting a job, the more I'm leaning against it, but addiction psychiatry is a robust field and subspecialty worthy of a whole year of extra training. It's a lot more than just a single tool. If it wasn't going to cost me 100k in salary, I'd be really excited to do it.

 

[nitemagi]

I don't quite understand the emphasis on the few tools we have to directly help addictions with pharmacotherapy, though I think some of them are very helpful. I've had patients who have been on antabuse and thought it was a lifesaver. Not common, but it happens. The clinical trials network is doing a lot of work on vivitrol and I think we're going to see more insurance companies covering it due to its relative effectiveness and cost savings.

MOTIVATIONAL INTERVIEWING is the effective, evidence-based intervention of addiction psychiatry. And it is very much the psychiatrist's role to participate in the process during their brief interactions, even if the interactions inevitably have to focus on medication. Opioid substitution is effective and important, but the addiction psychiatrist is going to be seeing crack addicts, cannabis addicts, meth addicts, alcoholics, benzo-addicts, etc, and treating them regardless of whether there is a specific pharmacologic agent to target the drug of choice.

I have been wrestling about whether to do an addiction fellowship after child training, and the more I realize the opportunity cost of a 6th year of training compared to getting a job, the more I'm leaning against it, but addiction psychiatry is a robust field and subspecialty worthy of a whole year of extra training. It's a lot more than just a single tool. If it wasn't going to cost me 100k in salary, I'd be really excited to do it.

 

[vistaril]

As opposed to your incredibly evidence based claims which every other clinician here refutes? Addiction to what? What qualifies as "good" to you?

ummm....I'm not the one claiming something. If you say something works, then you should be able to show me the evidence that it does.

 

[vistaril]

Do you just mean opioid dependence?

For alcohol, here's one of the studies for Gabapentin with alcohol use.

well I don't see it attached(so I can't comment on this one in particular you are thinking of), but mostly gabapentin is used in acute and mostly sub-acute settings to prevent very early relapse....again in more of a subactute PAWS sort of setting.

When used in this setting, which is how we use it, I'd classify it more as an acute drug which *may* decrease cravings and relapse for pts in an intensive outpt type setting.

Not terribly applicable to tools a non-inpt addictionologist would use on an outpt basis.

The data I've seen on the non-suboxone/methadone stuff......antabuse, campral, naltrexone, IM naltrexone, ibogaine in other countries, etc.....they don't meet any reasonable standard for what is considered good efficacy.

 

[vistaril]

MOTIVATIONAL INTERVIEWING is the effective, evidence-based intervention of addiction psychiatry. QUOTE]

it's also something that one certainly doesn't need an addiction fellowship to get good at.

 

[whopper]

Oops--yep forgot to cut and paste.

http://www.ncbi.nlm.nih.gov/pubmed/18052562

There's others showing gabapentin works for alcohol. The comments you made about gabapentin, Vistaril, are IMHO quite astute. Yes, data did come out showing it may only be of benefit temporarily.

 

[michaelrack]

Suboxone alone is capped at 100 patients (even if you're seeing those patients for $100 each once a month, do the math).

.

don't forget the urine drug screens (approx $300 each)

 

[vistaril]

Oops--yep forgot to cut and paste.

http://www.ncbi.nlm.nih.gov/pubmed/18052562

There's others showing gabapentin works for alcohol. The comments you made about gabapentin, Vistaril, are IMHO quite astute. Yes, data did come out showing it may only be of benefit temporarily.

yeah I agree that's when I would use it, and I have used it that way before(ie writing a guy a 2 week script after I DC him after being detoxed and he isn't going to a treatment center).....but as I said my concern as an outpt addictionologist would be what I can offer my patients in my clinic. And more specifically(going back to the original point) what would I learn in an addiction fellowship that would help me be a better clinician in that capacity?

I feel more than qualified to treat opiate addicts now in an outpt setting. I feel more than qualified now to work in a detox setting if I chose that.

As for alcohol...what they really need is to be detoxed, to enter a treatment program and/or get involved in AA and community support programs. Obviously as a physician/psychiatrist I can detox them, but then what is my role after that? To tell them to get a sponsor and go to meetings? To educate them on what addiction is and the health consequences? Again, I just don't see how an addiction fellowship is required or even beneficial in that capacity.....

 

[vistaril]

don't forget the urine drug screens (approx $300 each)

what programs there are charging 300 bucks a pop for urine drug screens? A UDS that separates out different opiates and tests individually for the presence of the non-detectable ones on standard panel and confirms presence of bup does not cost 300 dollars....

Not sure what specific uds a lot of the fam med/IM guys with suboxone pts typically get, but the pts sure as heck arent paying anywhere near that sort of money to be seen.

 

[notdeadyet]

ummm....I'm not the one claiming something. If you say something works, then you should be able to show me the evidence that it does.

Vistaril- when you claim that the medications or modalities that are commonly used to treat a patient do not work, you are claiming something. I know you tend towards dismissive, but dismissing something is a claim.

Saying that suboxone and methadone are the only "real" treatments used in the entire field of addictions, not only are you making a claim, you're making a sweeping claim. Those disagreeing with you aren't making claims, they're just denying yours. Which incidentally was made with zero evidence and flies in the face of best practices and common sense.

 

[F0nzie]

I don't quite understand the emphasis on the few tools we have to directly help addictions with pharmacotherapy, though I think some of them are very helpful. I've had patients who have been on antabuse and thought it was a lifesaver. Not common, but it happens. The clinical trials network is doing a lot of work on vivitrol and I think we're going to see more insurance companies covering it due to its relative effectiveness and cost savings.

MOTIVATIONAL INTERVIEWING is the effective, evidence-based intervention of addiction psychiatry. And it is very much the psychiatrist's role to participate in the process during their brief interactions, even if the interactions inevitably have to focus on medication. Opioid substitution is effective and important, but the addiction psychiatrist is going to be seeing crack addicts, cannabis addicts, meth addicts, alcoholics, benzo-addicts, etc, and treating them regardless of whether there is a specific pharmacologic agent to target the drug of choice.

I have been wrestling about whether to do an addiction fellowship after child training, and the more I realize the opportunity cost of a 6th year of training compared to getting a job, the more I'm leaning against it, but addiction psychiatry is a robust field and subspecialty worthy of a whole year of extra training. It's a lot more than just a single tool. If it wasn't going to cost me 100k in salary, I'd be really excited to do it.

Agree with motivational interviewing (MI) as an evidence based approach. I would also add the importance of psychotherapy/CBT once the patient is engaged in combination with pharmacotherapies.


Past Year Perceived Need for and Effort Made to Receive Specialty Treatment among Persons Aged 12 or Older Needing But Not Receiving Treatment for Illicit Drug or Alcohol Use: 2010

Source: 2010 National Survey on Drug Use and Health (NSDUH).


Reasons for Not Receiving Substance Use Treatment among Persons Aged 12 or Older Who Needed and Made an Effort to Get Treatment But Did Not Receive Treatment and Felt They Needed Treatment: 2007-2010 Combined

Source: 2010 National Survey on Drug Use and Health (NSDUH).

Drug Alcohol Depend. 2010 Mar 1;107(2-3):221-9. Epub 2009 Dec 6.
Naltrexone and combined behavioral intervention effects on trajectories of drinking in the COMBINE study.
Gueorguieva R, Wu R, Donovan D, Rounsaville BJ, Couper D, Krystal JH, O'Malley SS.
Source
Yale University School of Public Health and School of Medicine, New Haven, CT 06520, USA. [email protected]
Abstract
OBJECTIVE:
COMBINE is the largest study of pharmacotherapy for alcoholism in the United States to date, designed to answer questions about the benefits of combining behavioral and pharmacological interventions. Trajectory-based analyses of daily drinking data allowed identification of distinct drinking trajectories in smaller studies and demonstrated significant naltrexone effects even when primary analyses on summary drinking measures were unsuccessful. The objective of this study was to replicate and refine trajectory estimation and to assess effects of naltrexone, acamprosate and therapy on the probabilities of following particular trajectories in COMBINE. It was hypothesized that different treatments may affect different trajectories of drinking.
METHODS:
We conducted exploratory analyses of daily indicators of any drinking and heavy drinking using a trajectory-based approach and assessed trajectory membership probabilities and odds ratios for treatment effects.
RESULTS:
We replicated the trajectories ("abstainer", "sporadic drinker", "consistent drinker") established previously in smaller studies. However, greater numbers of trajectories better described the heterogeneity of drinking over time. Naltrexone reduced the chance to follow a "nearly daily" trajectory and Combined Behavioral Intervention (CBI) reduced the chance to be in an "increasing to nearly daily" trajectory of any drinking. The combination of naltrexone and CBI increased the probability of membership in a trajectory in which the frequency of any drinking declined over time. Trajectory membership was associated with different patterns of treatment compliance.
CONCLUSION:
The trajectory-analyses identified specific patterns of drinking that were differentially influenced by each treatment and provided support for hypotheses about the mechanisms by which these treatments work.

 

[michaelrack]

what programs there are charging 300 bucks a pop for urine drug screens? A UDS that separates out different opiates and tests individually for the presence of the non-detectable ones on standard panel and confirms presence of bup does not cost 300 dollars....

Not sure what specific uds a lot of the fam med/IM guys with suboxone pts typically get, but the pts sure as heck arent paying anywhere near that sort of money to be seen.

that is what private insurance was reimbursing several yrs ago for a dipstick UDS. Not sure what reimbursement is now.

Patients are willing to pay quite a lot out of pocket to get suboxone- $200+ a month (for office visit/uds).

It's been several yrs since I did suboxone; I ordered a lot of UDS's because it was required by some insurance companies(to cover the suboxone) and was the standard of care then.

 

[vistaril]

Vistaril- when you claim that the medications or modalities that are commonly used to treat a patient do not work, you are claiming something. I know you tend towards dismissive, but dismissing something is a claim.

Saying that suboxone and methadone are the only "real" treatments used in the entire field of addictions, not only are you making a claim, you're making a sweeping claim. Those disagreeing with you aren't making claims, they're just denying yours. Which incidentally was made with zero evidence and flies in the face of best practices and common sense.

when one claims something works, the burden of proof is on them to prove it. Certainly the burden isn't on me to prove a negative......

and by "treatments", I obviously meant pharmacotherapy in an outpt setting. And no, that doesn't "fly in the face" of best practice and common sense. There is not good ebm out there that suggests that naltrexone or antabuse is effective at substantially improving long term outcomes for example.....if there was, I would be using those things.

 

[vistaril]

that is what private insurance was reimbursing several yrs ago for a dipstick UDS. Not sure what reimbursement is now.

Patients are willing to pay quite a lot out of pocket to get suboxone- $200+ a month (for office visit/uds).

It's been several yrs since I did suboxone; I ordered a lot of UDS's because it was required by some insurance companies(to cover the suboxone) and was the standard of care then.

here suboxone visits are mostly self pay, and there is a *lot* of competition to get pts. Tons of pcps are doing in addition to psychs. Addicts shop around, and because of the large supply there is a lot of downward pressure on self pay office visit total charges....after the intakes and initial visits, many pcps are doing it for like 65 dollars a repeat visit

 

[michaelrack]

here suboxone visits are mostly self pay, and there is a *lot* of competition to get pts. Tons of pcps are doing in addition to psychs. Addicts shop around, and because of the large supply there is a lot of downward pressure on self pay office visit total charges....after the intakes and initial visits, many pcps are doing it for like 65 dollars a repeat visit

I was one of the early prescribers of suboxone. I guess that the $ in suboxone tx is not as much as it used to be.

 

[BobA]

here suboxone visits are mostly self pay, and there is a *lot* of competition to get pts. Tons of pcps are doing in addition to psychs. Addicts shop around, and because of the large supply there is a lot of downward pressure on self pay office visit total charges....after the intakes and initial visits, many pcps are doing it for like 65 dollars a repeat visit

Couldn't be more different around here - massive shortage of suboxone MDs in this neck of the woods.

 

[vistaril]

Couldn't be more different around here - massive shortage of suboxone MDs in this neck of the woods.

why? is there a population of pts that cant actually pay for it there?

If so, simple supply/demand would dictate that more prescribers should jump on board....

the work required to get a suboxone license is fairly minimal.

 

[nitemagi]

why? is there a population of pts that cant actually pay for it there?

If so, simple supply/demand would dictate that more prescribers should jump on board....

the work required to get a suboxone license is fairly minimal.

Oh young one. Pure supply/demand economics doesn't work in healthcare. Too many other factors get in the way.

 

[vistaril]

Oh young one. Pure supply/demand economics doesn't work in healthcare. Too many other factors get in the way.

but the 'other factors' here actually make supply/demand more likely to happen naturally.

The supply angle is relatively unrestricted since the barrier for entry is low(any licensed physician is eligible to get a suboxone number)

The demand angle is also relatively unrestricted as it is mostly self pay so "true" demand can be attained....

There are few cleaner examples in medicine where supply/demand curves would exist.

 

[digitlnoize]

but the 'other factors' here actually make supply/demand more likely to happen naturally.

The supply angle is relatively unrestricted since the barrier for entry is low(any licensed physician is eligible to get a suboxone number)

The demand angle is also relatively unrestricted as it is mostly self pay so "true" demand can be attained....

There are few cleaner examples in medicine where supply/demand curves would exist.

Most docs I know don't want to deal with the headaches of being a suboxone prescriber. It's a tough patient population to deal with, plus there's the meticulous record keeping and the Feds breathing down your neck all the time.

Heck, I'm going into psych, and I don't even want to go anywhere near the stuff.

I do agree with you though, that if normal supply and demand were going to occur in medicine, it would likely be here. Psych in general, in fact, is better than most of medicine in that regard. Not perfect, but better.

I guess supply of providers for this is a regional phenomenon. There's only a couple people within a 3-4 hour drive who deal in this stuff around here.

 

[billypilgrim37]

I do agree with you though, that if normal supply and demand were going to occur in medicine, it would likely be here.

Except that the disease process in question limits the ability of the consumer to pay, compromising the demand. That's a pretty significant market distortion.

 

[michaelrack]

Except that the disease process in question limits the ability of the consumer to pay, compromising the demand. That's a pretty significant market distortion.

Many addicts-not all- get the $ to pay for suboxone the same way they get the $ to pay for illicit drugs (prostitution, etc)

 

[michaelrack]

Most docs I know don't want to deal with the headaches of being a suboxone prescriber. It's a tough patient population to deal with, plus there's the meticulous record keeping and the Feds breathing down your neck all the time.

Heck, I'm going into psych, and I don't even want to go anywhere near the stuff.

I do agree with you though, that if normal supply and demand were going to occur in medicine, it would likely be here. Psych in general, in fact, is better than most of medicine in that regard. Not perfect, but better.

I guess supply of providers for this is a regional phenomenon. There's only a couple people within a 3-4 hour drive who deal in this stuff around here.

I think supply and demand do operate with suboxone therapy. Factors decreasing supply include state/fed oversight (the risk that government may take away licenses/shut down the doc is a cost that is factored into the supply curve). Factors decreasing demand include the availabilty of substitute products (illegal drugs). Cheap/easy availability of illicit drugs (substitute goods) would lower the demand for suboxone. Other factors affecting supply include other sources of income for docs- in my case the availability of $ from practicing sleep medicine influenced the decision to leave suboxone behind.

 

[diagonal]

but the 'other factors' here actually make supply/demand more likely to happen naturally.

The supply angle is relatively unrestricted since the barrier for entry is low(any licensed physician is eligible to get a suboxone number)

The demand angle is also relatively unrestricted as it is mostly self pay so "true" demand can be attained....

There are few cleaner examples in medicine where supply/demand curves would exist.

Out of curiosity, and who can blame me for asking the question given your tone on this forum, but do you think you're genuinely helping your patients at all with psychiatry? Or are you doing it simply because you find the material easy to intellectually consume, it provides a nice lifestyle, and medicine in general sucks?

I'm not judging either way, because I understand both motives. I'm just interested in your perspective.

 

[billypilgrim37]

Many addicts-not all- get the $ to pay for suboxone the same way they get the $ to pay for illicit drugs (prostitution, etc)

Seems like a bad deal for them. I would think that illicit drugs would be much cheaper than suboxone (and why get clean if getting clean means you're still stealing and turning tricks?). I certainly believe you though.

 

[TexasPhysician]

Factors decreasing supply include state/fed oversight (the risk that government may take away licenses/shut down the doc is a cost that is factored into the supply.

How much increased risk is there with Suboxone? I don't see how you could get into more trouble with this than say Ambien. What am I missing?

 

[digitlnoize]

Except that the disease process in question limits the ability of the consumer to pay, compromising the demand. That's a pretty significant market distortion.

I totally get that. I spent almost 10 years working at a music store. Try selling expensive gear to the one segment of the population that, by definition, has no money.

I think supply and demand do operate with suboxone therapy. Factors decreasing supply include state/fed oversight (the risk that government may take away licenses/shut down the doc is a cost that is factored into the supply curve). Factors decreasing demand include the availabilty of substitute products (illegal drugs). Cheap/easy availability of illicit drugs (substitute goods) would lower the demand for suboxone. Other factors affecting supply include other sources of income for docs- in my case the availability of $ from practicing sleep medicine influenced the decision to leave suboxone behind.

All true. All of this (on both ends of supply and demand) are mitigated by the severe shortage of providers and shortage of demand though. So, we wind up wih decreased demand, but greatly decreased supply, which typically (depending on where you live) works out in favor of the suboxone provider.

At least, I haven't heard of many people not being able to fill up to their quotas very quickly. Which leads me to believe that in most places, there is more demand than supply.

I still don't want the headaches though. Not my cup of tea.

 

[F0nzie]

here suboxone visits are mostly self pay, and there is a *lot* of competition to get pts. Tons of pcps are doing in addition to psychs. Addicts shop around, and because of the large supply there is a lot of downward pressure on self pay office visit total charges....after the intakes and initial visits, many pcps are doing it for like 65 dollars a repeat visit

I do not understand how Suboxone visits in your area are mostly self-pay. Regardless of where you are in the country, most PCPs will accept a wide variety of insurances. Providers cannot simply cherry-pick Suboxone patients and demand cash as it would violate their insurance contracts. An exception to this is if the patient is on an insurance plan that is not offered by the practice or if the patient does not have insurance. These exceptions, however, do not mean the practice is self-pay. It just means the the patient is paying out-of-pocket because of lack of insurance. The alternative scenario I can think of is your area has mostly niche Psych/addiction cash practices that are self-pay because they operate on an out-of-network basis. Either way, your claim does not appear to be representative of the rest of the United States. If you believe it is, I would like to hear of any evidence you have supporting the claim.

 

[billypilgrim37]

I totally get that. I spent almost 10 years working at a music store. Try selling expensive gear to the one segment of the population that, by definition, has no money.

Right, and then you realize the only buyers are folks who went to medical school and gave up their dreams of being rock stars! Full circle

And I think this contributes somewhat to the banjo and mandolin market being so different from the guitar market (most of your buyers are middle-aged guys with reasonable jobs, not heroin addicts deciding between a paul reed smith and a dime bag). Though I'm guessing I've used a lot more banjo and mandolin than you have, seeing as my redneck past is still nipping at my heels. You seem more of a carpetbagger than a scalawag.