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Suboxone and Addiction

Discussion in 'Medical Students - MD' started by TommyDee, Jan 12, 2018.

  1. TommyDee

    TommyDee

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    Jan 12, 2018
    Throwaway for obvious reasons.

    25 y/o MS2. I’ve been prescribed suboxone for the last 8 years after struggling with pain and painkillers through my teens. Heavily addicted, but well-managed with suboxone. I’ve come off it twice but always went back on for fear of relapse. Never “actually” relapsed because of the safety net.

    Going into clinicals and residency, I’m extremely worried about how this will effect my career. Literally no one can give me a straight answer, even my psychiatrist who works with doctors.

    I know I’m going to need to take drug tests, and suboxone will come up. Will the school/hospital/attendings be notified, even if I have a prescription?

    Will I need to put it on residency applications? Will PDs be Informed?

    Will this affect malpractice insurance and liability? Will I be able to be employed?

    Will I need to register with a PHP even if I never truly “fail” a drug test (really bad - PHPs cost 30,000 a year!)

    The only information I can find is that about 2/3 of US States, including mine, permit physicians to practice while taking suboxone as part of a PHP. Ideally I would not be enrolled in a PHP.

    If you have any knowledge of this situation, please help.

    I know there’s gonna be a few people who will say “just get off suboxone!” I’ve done this a few times, and it simply is not an option for me.
     
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  3. BigRedBeta

    BigRedBeta Why am I in a handbasket? Physician 10+ Year Member

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    Wow, this is a new one.
    And yeah, I don't think anyone can give you a straight answer because it's all going to be highly dependent on where you end up, who works there, and what the policies and bylaws for the institution might be...which can and do change, often without much notification.

    1) despite your declaration that it's not an option for you, the simplest way forward in terms of your career is to get off the suboxone. I respect the fact that it makes the rest of your life more difficult. My question for you though is, do you really anticipate being on suboxone for the rest of your life?

    2) You have to be forthcoming with this information during the interviews and especially with PD's. Lies of omission, particularly of this nature, will get you into much hotter water than laying it out in the open. People want to be able to help you through what's already a difficult period. There will be programs that will reject you when they learn of your issues, and from their end, it's because it's simply more work to have you be around then someone else. But hiding this fact will make everything a lot harder when it comes out later. @aProgDirector can explain their thoughts for your situation, but ultimately openness and honesty will get you a lot further.

    3) Not all programs require drug tests, but many do. You'll need to disclose to your housestaff office and show your prescription. Your day to day attendings do not need to know

    4) Anesthesia is probably off limits for you. I doubt that's a surprise, but I don't think it would be a healthy choice for you in the first place and no program is going to want to take that risk.

    5) There are real chances that the suboxone will affect your ability to practice medicine at every stage of the game - state licensure is just one part, but you'll need to disclose this for hospital credentials, to employers, to malpractice insurance carriers, and when you apply for a DEA number or state level controlled substances registration (this is a big one). Any of those parts could spell trouble. And some of it you won't know until you've gone through the application process and everything is submitted and then you get rejected or given conditions on which you receive probationary approval. And getting recredentialed is the part where I worry something will sneak up on you, as medical staff bylaws get changed without a ton of notification, so what was fine 2 years ago, all of a sudden is a big deal when you go to renew.

    6) The current political and societal landscape regarding opioid addiction is also going to be challenging. People are much more aware of the issue than they were even 2 years ago and that may lead to a changing set of regulations for licensure, so again, you might be fine the first time through and have trouble two or three years later. And lots of government agencies are under pressure to disclose more information to the public, so who knows where your name might show up and what patients may find out about you. With yelp and all the other doctor rating sites out there, it's impossible to tell how that might affect your reputation.

    7) If they are interests to you, it's probably worth a hard look at fields like radiology and pathology where there's less patient interaction for a layer of plausible deniability in case there are any challenges with the stuff I mentioned in point #5. I'm not saying that you have to go to those fields by any stretch, just that if you're already interested in them, exploring them fully would be a good idea. On the surface, they appear less risky than fields like EM or critical care where opioids are stocked nearby and there might be greater liability to an institution.
     
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  4. TommyDee

    TommyDee

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    Jan 12, 2018
    What exactly do I need to disclose to PDs, hospital credentialling, DEA, and malpractice insurance carriers? What do they ask?

    As far as I know (which isn’t much), these guys ask for any history of substance abuse, which id have to cop to anyway.

    Do you know if te suboxone itself poses problems, or is it my PMHx? It seems to me I’d have the same problems if, say, I was on long-term naltrexone (which trips drug tests all the time).

    Obviously anesthesia is out. I’ve known that for a while.My major interests are (big surprise) psych/FM with a focus on addiction in communities.
     
    Last edited: Jan 12, 2018
  5. CherryRedDracul

    CherryRedDracul Resident Sh!tposter Physician 5+ Year Member

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  6. JP2740

    JP2740 7+ Year Member

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    It was my understanding if you take a controlled substance that is prescribed and it shows up on a drug test no one finds out about it, not even the program.
     
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  7. TommyDee

    TommyDee

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    Jan 12, 2018
    If only if only. Though I don’t understand why suboxone would be an exception.

    There are some (a minority) of states that forbid doctors from practicing on suboxone... but fully allow them to practice on narcotic painkillers, so I’m looking for info that it seems like no one knows.
     
  8. Karmapaymentplan

    Karmapaymentplan

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    It might be good to look at residency programs that have positive views on treatment and harm reduction. If they have a positive, more liberal light on addiction and treatment, they may have more lax policies or will be more willing to make exceptions.

    With regards to medical licensing boards, it's best to work through a lawyer skilled in the intricacies of the state you want to practice in. I recently read an article on medscape about a physician who is having trouble getting his license because of a past medical history of depression 17 years ago, so roadblocks may be severe.

    Nonetheless, congratulations on being clean for 8 years! It is not an easy feat.
     
  9. aProgDirector

    aProgDirector Pastafarians Unite! Moderator SDN Advisor 10+ Year Member

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    You've asked some good questions. As has already been mentioned, the specific answers may depend upon the state, institution, program, and field you're considering. But I will try to address your questions in general.

    In a perfect world, no. The way this should be handled is this: You match into a program. On their intake form, they ask if you're on medication. You disclose that you're on suboxone which is confirmed by your provider. They perform your drug test, which confirms suboxone. This is reviewed by Occupational Medicine, who clears you since you're only on a legal and prescribed medication. Only Occ Med knows about this, and it should be kept private from your program.

    But, it's likely that your PD will need to know about this. We'll get into the application and licensing issues below. How much of the residency program staff will know about this is unclear, hopefully kept to a minimum.

    Smaller programs might not have separate Occ Med departments. Still, it's your private health info and should be kept private. Theoretically.

    Depends, because I think it could be argued either way. The relevant question on the ERAS app is this: Is there anything in your past history that would limit your ability to be licensed or would limit your ability to receive hospital privileges? I think you'll need to disclose your past history of heroin abuse. There's also questions about misdemeanors and felonies, so if you had any legal issues those will need to be disclosed also. The question is, do you need to disclose your current use of suboxone?

    "Yes" is the safe answer. One could argue that it might limit, or slow, your ability to get a license. And certainly, no one can complain later if you disclose. You might worry that programs will decline to interview you knowing about this, but will know that anyone that does interview you is willing to deal with it.

    "No" is not an unreasonable answer also. One could argue that this is your private medical history and does not need to be disclosed. You're stable for a long period of time. And that legal suboxone use should not impair you, nor affect your licensing.

    Personally, I think the best thing to do is disclose. Any program that doesn't interview you because of it, will likely freak out if they find out, and keeping it a 100% secret is going to be impossible. I'd want to be somewhere that they would support me.

    I don't think this will affect medmal at all, and I think that you'll get employed. Don't forget that you can always open a private practice, so you don't need anyone to employ you.

    I think it is 100% certain that any BoM is going to require you to do something, whether that's register with a PHP or undergo regular testing. But many PHP's are free. All you'll really need is some sort of ongoing testing. You might have to pay for the testing, or it might be covered by your medical insurance. Or Occ Med might do it.

    You're going to be enrolled in some sort of ongoing monitoring. Fight that, and your license won't be granted. This is non-negotiable.

    Summary:
    Because of the opioid crisis, heroin abuse is becoming "mainstreamed" by health systems. There is a paradigm shift that drug abuse is a medical problem, and not a moral failing. This will help you, as many training programs are "ahead of the curve", treating these patients, and more understanding.

    You will need to disclose your past drug problems, and any legal problems you may have had. You might be able to legally avoid disclosing your suboxone use, but that's probably a mistake. Putting it out there for programs to see might decrease your number of interviews, but those are programs that may fire you if they find out and that's a much worse fate. Best to be at a program that's willing to work with you. Plus, once it's out there, you don't need to worry about it leaking out.

    You will be put into a monitoring program. It might be run by the PHP. It might be run by your institution. It might be run by the BoM. Details will depend upon where you match. Whether you will be asked to pay for the costs of monitoring, or not, will completely depend upon the circumstances. This is another reason to consider being open about this.

    If you're going to talk about it in your application, you might want to write your PS about it. I expect it would be a very unique and powerful story.
     
  10. TommyDee

    TommyDee

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    Jan 12, 2018
    Thanks APD. Can always count on you.

    Some questions that I’d love if you could answer:

    1) Does this (effectively) rule out competitive specialties for me, should I change my mind about fields? (Aside from anesthesia).

    2) How would my predicament change if I came off suboxone? Given my Hx of substance abuse, it *seems* to me as though actually being off suboxone come match won’t help me all that much.
     
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  11. aProgDirector

    aProgDirector Pastafarians Unite! Moderator SDN Advisor 10+ Year Member

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    1. Competitive fields are, by definition, competitive. How often will your history / use of suboxone be seen as a strength? Rarely, if ever. (Perhaps if you're interested in getting into that work, but then that's not competitive). So the real question is whether it will be seen as a negative. My guess is yes -- given an equivalent candidate without these issues, they will likely pick the other person to avoid the whole issue. That said, because opioid abuse is so common, it's possible that someone in residency leadership will have been affected by it -- probably not themselves, but a family member, or a friend. And then it's possible that they may see past this. So, I don't really know. I expect it will make getting a competitive spot more difficult, but perhaps not impossible. But making ortho or NS "more difficult" basically makes them impossible.

    2. Coming off Suboxone doesn't fix the problem. But it does make getting licensed more straightforward. But, coming off Suboxone and then relapsing torches your career in a very bad way.
     
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  12. mehc012

    mehc012 Big Damn Hero 5+ Year Member

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    Does it affect anything that, at least from how OP's first post read to me, it was a) painkillers instead of heroin b) seems to have been precipitated by actual pain management and c) was as a teenager, meaning any infractions, if they occurred, would have been as a minor (and also I feel like people judge bad teenage decisions differently than poor adult decision making) ?
     
  13. Peach Newport

    Peach Newport board certified in jewish dermatology 2+ Year Member

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    My guess is no.

    In my experience, People who hate addicts don’t give one purloined f**k why you’re an addict. If you say it’s because of insanely irresponsible prescribing practices (which statistically nowadays is probably mostly true), They assume you’re lying about it anyway. Good people don’t become psychologically dependent on opioids, after all. Lots of really good and comprehensive research by Purdue pharma in the 90s strongly supports the hypothesis that addictive drugs only act on the limbic systems of filthy degenerates anyway.
     
    Last edited: Jan 14, 2018
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  14. michaelrack

    michaelrack All In at the wrong time Physician SDN Advisor 10+ Year Member

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    since subutex (buprenorphine) is a synthetic opiate, it doesn't show up on standard drug tests- it has to be specifically tested for
     
  15. TommyDee

    TommyDee

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    Jan 12, 2018
    Thank you for everyone responding to this thread. You guys have been really helpful and surprisingly supportive.

    A close friend of mine who is familiar with my situation has suggested that I do an AMA, for anyone who wants to know what addiction and withdrawal is like from the perspective of someone with medical training, what it’s like to be a med student in recovery, etc.

    I do not feel *entirely* comfortable making a new thread for an AMA, UNLESS Many of people are truly interested, and you guys think it will do some real good.

    I’m happy to answer any questions you may have in this thread, or a private message. It’s obviously a pretty important subject to me, and if my input can in some way lead to more understanding of what addiction is like, then I can at least feel good about what I’m doing.

    Thanks again. And if anyone has more information, it’s very appreciated.
     
    UnassumingToad likes this.

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