Please read: Dr. Jana Burson and the Prescribing practices of other providers

Good afternoon everyone!
From time to time I share a post from a blog that I read on a regular basis. The blog of Dr. Jana Burson.
As well as writing an excellent blog Dr. Burson is the physician in a mmt facility Located in North Carolina. The clinic she works in treats with both Methadone and Suboxone.
I admire her fairness and ability to understand and really care about her patients. Many times I have wished there were more providers like her.
So on to this weeks blog post. As usual comments welcome

Dr Burson writes:

I have a dilemma. A handful of physicians and physician extenders in my area appear to be skirting the regulations around prescribing buprenorphine (Suboxone, Subutex). They are helping opioid addicts, but not in a manner I consider to be completely appropriate.
Each Suboxone prescriber can have up to one hundred patients on the medication at any one time, as decreed by law. This regulation was put into effect because some lawmakers were haunted by the specter of Suboxone mills, run with the same lack of professional responsibility that we see in pill mills.
Only physicians can prescribe buprenorphine (Suboxone) to treat addiction. Nurse practitioners and physicians’ assistants, frequently termed physician extenders, can’t get the DEA “X” number that allows them to prescribe buprenorphine (Suboxone) for addiction. Many physician extenders say this isn’t fair, because they prescribe all manner of other opioids. Despite their objections, the law is what it is, and they can’t prescribe Suboxone to treat addiction.
And yet, it appears that some extenders are doing just that. In my area, two physician’s assistants, in separate practices, prescribe Suboxone to patients with addiction. These patients’ charts (I’ve requested records when patients transferred to me) show the provider knows the patients have addiction, but in each case the Suboxone is said to be prescribed for the treatment of “chronic pain.” I don’t doubt these patients have pain, since at least 30% of people with opioid addiction also have chronic pain. So technically, since they say they’re treating pain, they aren’t doing anything that’s prohibited…though the FDA would consider it to be off-label prescribing.
A few doctors who don’t have an “X” number have been doing the same thing – they treat patients with known addiction with Suboxone, but they say they use it for chronic pain. I’ve heard rumors that even doctors with an “X” number treat patients with pain with Suboxone, and don’t count these patients as part of their one hundred allowable patients. This allows them to prescribe Suboxone for more patients, and get around the one hundred patient limit.
I’m conflicted when I see these practices. One the one hand, I’m glad more patients are getting treatment, and this is much better than addicts buying Suboxone off the street. It’s the safest opioid, and in some patients it does treat pain. If it works for the patient, why should I care if some doctors and physician extenders are skirting the regulations, and why should I care if they are getting it for pain or addiction?
Because they appear to prove the lawmakers’ fears are legitimate. If we have providers who can’t or won’t follow the present regulations, how can we expect the government to lift the one hundred patient limit? Government officials and lawmakers start to wonder if medical professionals can be trusted to prescribe buprenorphine safely and appropriately if the one hundred patient limit is raised or lifted, if they see providers outwitting present regulations so that they can treat more patients.
In the interest of full disclosure, I have two patients I treat for pain with Suboxone. I didn’t start either patient, but inherited them from another doctor. In each case, I agree that they don’t have evidence of addiction, but Suboxone has been treating their pain very well. Since it’s working, I’m not going to demand they change medication, but I also count them as part of my one hundred patients, to be on the safe side. I do NOT want to get on the wrong side of the DEA.
In the past, I’ve called a few doctors who were prescribing buprenorphine without an “X” number. Both of them were shocked to discover the special regulations around this medication, so in some cases maybe it’s just lack of knowledge about regulations around treating addiction.
Two other colleagues and I did report a doctor to the medical board who prescribed a month’s worth of methadone for opioid addicts, but that’s different, given the dangers of methadone compared to buprenorphine.
I don’t want to report these doctors and extenders to regulatory bodies, because in the grand scheme of things, they are helping the patient, and technically they are following regulations, I think. Plus, I don’t want to have anyone report me to the medical board in retaliation. No one’s charts are perfect, and even though I feel I’m doing a good job treating patients, many decisions in Addiction Medicine are judgment calls. Good doctors can disagree on many of the issues.
For example, I have a few die-hard pot smokers among my one hundred patients. I see them a little more frequently than patients who don’t smoke, and I make the marijuana use an issue in counseling. I don’t (usually) kick them out of treatment for marijuana use. The data show that if you keep these patients in treatment, there’s a better chance they will, at some point, stop using. But I know many diligent physicians who would dismiss such a patient from treatment, because these doctors feel if they can only have one hundred patients, why not use those precious spots for patients willing to enter into full recovery, forsaking all illicit drugs.
Are they wrong? Am I wrong? No, because as I’ve said before, one person’s harm reduction is another person’s enabling. But if the person reviewing my charts for the medical board thinks I’m enabling, it could spell disaster for me. I don’t want to make that kind of trouble for another provider, or myself.
Also I worry if I confront these buprenorphine prescribers, they’d point out the very real financial incentive I have for wanting them to stop prescribing. If the patient is coming to them, they aren’t coming to the clinic where I work, and this reduces my clinic’s profitability. I’m employed as an independent contractor, so it wouldn’t benefit me directly, but the financial health of the clinic I work for would, indirectly, benefit me.
And yes, I’m petty enough to be miffed that I’m following the rules, and other doctors aren’t, yet they reap the same benefits. I’ve decided it’s human to be miffed about such things, but not healthy to get stuck in “miffness” and thus I’m writing this blog in an effort to release my feelings.
For now, I’ve decided I don’t have to do a thing. I’ll discuss the issue to the North Carolina chapter of the American Society of Addiction Medicine, and let those smart people decide the best course of action, if any.
To read Dr. Burson's Blog please visit:
Jana Burson

I personally feel that this Dr. is completely justified in her concern regarding other providers skirting the issue. What I have to wonder is that if a physician is willing to skirt the rules on prescribing Suboxone, what else are they willing to do? We all know that addicts are very good manipulators and liars, at least I was. If someone comes in and says I hurt and Suboxone helps, how do they determine if it is legitimate pain, or simply someone whose doc is sub and they have heard from someone else this is a way to get it without having to be labeled an addict. Or worse, what if it's someone who is neither an addict or actually in pain, and is simply there to receive the medication to divert it for financial gain? I truly worry that if the rules are not followed, then Suboxone treatment will suffer for those who are benefitting from it like me. Call me selfish, but I don't want to have to be in a situation where I have to go to a clinic to dose with my Suboxone everday and I fear that if something doesn't change and abuse of Suboxone keeps rising that's exactly where I will end up. I already go through enough crap because of people who divert and abuse Suboxone and I don't want a daily trip to a clinic, along with the extra cost that would bring to become part of what I have to do to continue my recovery. I do think she is right in discussing the issue with the local chapter of the American Society of Addiction Medicine, but unfortunately if these dr.s aren't treating addiction legitimately and are skirting the laws they problem aren't worried about medical societies either. I mean if the DEA doesn't scare them what is a medical society going to do. I am pleased to see a physician who cares about legitimizing Suboxone treatment and not doing any more harm as it seems to be rare, but in my opinion, those who are skirting the laws are not doing anyone any favors, and most likely are only in in for financial gain. I think they should be reported for doing so regardless of what consequences there may be.

» Great Read: My Favorite Patients are Addicts, by Jana Burson
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