Expanding suboxone prescriptive privileges to PA's and NP's

[RURALMED]

Hi all, 

 

I read a fascinating article regarding patient access to suboxone (buprenorphine and naloxone) treatment in rural towns. They found that only  3.0% of primary care physicians obtained waivers to prescribe suboxone in rural towns across the country.¹ This means that  >30 million people live in counties without access to buprenorphine treatment.¹

 

As many of you know, suboxone is one of the few drugs that PA's and NP's cannot prescribe even in states that allow these providers to prescribe schedule II-V drugs. My research is going to focus on expanding suboxone treatment in rural towns by allowing primary care PA's/NP's to prescribe it after appropriate CME training. 

 

If you were a primary care PA in a rural town, would you sign up for the 8 hour class, obtain the DEA waiver, and prescribe suboxone to your patients with opioid addiction ? 

 

 

1. Rosenblatt RA, Andrilla CH, Catlin M, Larson EH. Geographic and specialty distribution of US physicians trained to treat opioid use disorder. Ann Fam Med. 2015;13(1):23-6.

[cordelia*8]

I shadowed with a PA in Oregon who was prescribing and administering suboxone.

[Gordon, PA-C]

I'm not primary care, but there's no way in hell I'd sign up for that.

 

Who wants to be the provider of choice for all the druggees and addicts from a 5 county radius?  Good luck dealing with pain med seekers all day long.  If you have any decent folks coming to your clinic, they will be driven away by the riff raff.

[primadonna22274]

Amen to that, Gordon. I hate drug addicts and have zero interest in treating more of them.

 

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[andersenpa]

What is the evidence for the efficacy of suboxone programs?

Do they reduce addiction and negative drug related outcomes?

Do they reduce health care cost burden?

 

If they are beneficial why would we not support them?

[EMEDPA]

What is the evidence for the efficacy of suboxone programs?

Do they reduce addiction and negative drug related outcomes?

Do they reduce health care cost burden?

 

If they are beneficial why would we not support them?

you could ask those same questions of methadone programs....I think in a perfect world we should taper folks off opiates, not replace an "illegal" one with a "legal" one. on my trauma service rotation this is exactly what they did. anyone on the service for a few weeks on methadone maint. was tapered off during their stay and a note sent to their local methadone clinic saying they no longer required those services signed by the chief of surgery.

[db_pavnp]

a note sent to their local methadone clinic saying they no longer required those services signed by the chief of surgery.

 

This strikes me as pretty funny.  But this was decades ago, right?

[hrubenstein]

I believe suboxone does have its therapeutic uses(in a taper program) but its largely just another cash mine for big pharma. Replacement therapy for opiate addicted patients cannot be solved with a magic drug that a provider can prescribe with a cme course. Many people are on suboxone for years now while still abusing drugs like benzodiazepines and marijuana on the side, much like the liquid handcuff effect of methadone. Where's the quality of life here? none. Just my two cents.

[Convertable]

Really disheartened by the responses here.  Drug addiction is a medical issue, and while you  may not be "called" to help with the problem, refusing access to suboxone literally kills people.  Study after study after study has shown that a therapeutic approach, like that employed in parts of Europe, has much better outcomes both in terms of saving lives from OD's and in actually rehabilitating drug-dependent patients.  

 

Keep in mind that many people who are opioid dependent were given their first dose from a healthcare provider that they trusted, only to be thrown to the wolves of withdrawal (or worse) by those who would classify them as a drug-seeker.   

 

Suboxone saves lives.  That is the heart of it.  I hope that the next generation of PA's has more compassion than the opinions of those in this thread.

[hrubenstein]

Fat people and drug addicts are the few groups that are still socially acceptable to look down upon.

[EMEDPA]

This strikes me as pretty funny.  But this was decades ago, right?

20 yrs ago next month.

[primadonna22274]

Believe me, I recognize that we practitioners largely CREATED this problem that is rampant opiate addiction because 15 years ago we were told it was criminal to undertreat PAIN. Problem is it's escalated so much and so fast. I worked very hard and went into huge debt to do what I do. I love my work but I choose to focus my attention on the elderly with multisystem disease. This is where my talent lies. I am thankful to those of you who can deal with addictions because that is NOT my talent. In fact, it's one of the major reasons I did not go into psychiatry, even though I am very drawn to mental illness and the interplay of biopsychosocial in medicine...but I just cannot understand addiction and it's not my cup of tea.

We are all different special snowflakes. I freely admit this is MY hot button issue and one I cannot shake after 15 years in the biz. What's yours?

 

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[gbrothers98]

I checked possibly.

 

Here is the rub with suboxone.

Participants know they can take suboxone and sell it to obtain other drugs.

Supposed to drug test patients but unfortunately not all insurances including Medicaid will pay for those.

The patients won't pay in most cases. So monitoring fails.

Suboxone and methadone patients usually dont fall into the payer mix most clinics desire. They may also make other patients, the clinic staff and the nonsuboxone providers uncomfortable.

 

I have been interacting with addicted patients from training till now. My attitudes have changed over time but I understand the lack of desire to care for this patient population.

Can be very manipulative and disruptive. Can have associated mental illness that makes management difficult.

Plenty of suboxone patients whom may never get off suboxone. They essentially have one of 2 choices, suboxone or street opiates. They just cannot stop, ever, no matter what.

 

But really this is no different than the tobacco and alcohol users that get readily treated without a blink of an eye. Or the elderly with multiple comorbidities that don't comply with treatment due to their moderate dementia that keeps them from participating fully in care but does not become severe enough to fully intercede for their own welfare. Or the long time hypertensive whom eschewed the cheap ACEI for 2 decades and now has kidney failure and is a candidate for dialysis.

 

Just have to modulate the approach to this type of patient just like you do for the other patients in one's career that are difficult. Also doesnt mean have to see all these patients. No reason to fill the panel up with suboxone patients. This can be a much more selective process that fits the needs of the practice and the comfort level of the provider.

 

As for PAs and NPs becoming suboxone providers, this is a no brainer. I know the majority of the suboxone providers in my local area. I am not going to do a comparison but I am well acquainted with their capabilities. So designating physicians as the only providers whom can prescribe suboxone is an arbitrary designation that has no basis in fact or science. 

 

G Brothers PA-C

[RURALMED]

I checked possibly.

 

Here is the rub with suboxone.

Participants know they can take suboxone and sell it to obtain other drugs.

Supposed to drug test patients but unfortunately not all insurances including Medicaid will pay for those.

The patients won't pay in most cases. So monitoring fails.

Suboxone and methadone patients usually dont fall into the payer mix most clinics desire. They may also make other patients, the clinic staff and the nonsuboxone providers uncomfortable.

 

I have been interacting with addicted patients from training till now. My attitudes have changed over time but I understand the lack of desire to care for this patient population.

Can be very manipulative and disruptive. Can have associated mental illness that makes management difficult.

Plenty of suboxone patients whom may never get off suboxone. They essentially have one of 2 choices, suboxone or street opiates. They just cannot stop, ever, no matter what.

 

But really this is no different than the tobacco and alcohol users that get readily treated without a blink of an eye. Or the elderly with multiple comorbidities that don't comply with treatment due to their moderate dementia that keeps them from participating fully in care but does not become severe enough to fully intercede for their own welfare. Or the long time hypertensive whom eschewed the cheap ACEI for 2 decades and now has kidney failure and is a candidate for dialysis.

 

Just have to modulate the approach to this type of patient just like you do for the other patients in one's career that are difficult. Also doesnt mean have to see all these patients. No reason to fill the panel up with suboxone patients. This can be a much more selective process that fits the needs of the practice and the comfort level of the provider.

 

As for PAs and NPs becoming suboxone providers, this is a no brainer. I know the majority of the suboxone providers in my local area. I am not going to do a comparison but I am well acquainted with their capabilities. So designating physicians as the only providers whom can prescribe suboxone is an arbitrary designation that has no basis in fact or science. 

 

G Brothers PA-C

Thank you G.B. I have a hard time understanding the stigma when WE  created this mess. I arranged a voluntary 2 week rotation at a suboxone clinic with a PA and 95% of the patients would not fit the mental picture that most people paint of these patients. We cared for professionals that became addicted to narcotic pain medication after surgeries, procedures, and long-term use for non-cancer pain. They also used it for chronic, non-cancer pain in patients with neurodegenerative disorders. As a rural PA, I hope to be able to use suboxone as another tool to care for my patients and prevent the disproportionate numbers of overdose deaths in rural towns.  I know it's a complex issue and I may be too naive to see the wider spectrum at this point in my training. 

[Guest Paula]

Fat people and drug addicts are the few groups that are still socially acceptable to look down upon.

 

European white males?

[ventana]

I shadowed with a PA in Oregon who was prescribing and administering suboxone.

 

That PA was not prescribing suboxone

 

only doc's with DEA X can - federal issue

 

have seen some strange arrangements where the PA does all the work and somehow the doc writes.....

 

 

 

I "write" it at one job, but it is actually under the Doc.

[SocialMedicine]

i agree with you convertable. drug addicts are the most stigmatized people in our society. a decent amount of them are not bad people just dealing with something they cannot control.

 

And im not sure clinicians are as much to blame as the entiore society. Remember it was pharmaceutical companies, investors, politicians, researchers, and our culture that fed this epidemic. Read some of the early research on opioid safety .... it looked safe and sensical to the non researcher. Additionally the powerful euphoria of opioids was a problem long before MD and PA were around.

 

I think suboxone offers something for some patients. It should be more accessible. I think it is a good idea for primary care to play more of a role in this. HOWEVER, patients with opioid dependence, addiction, abuse etc can be difficult to manage. You need to be experienced or have experienced back up. Additionally you need an entire office set up to manage this .. from refill policies to urine tox screenings etc.

[SocialMedicine]

I wonder if suboxone lowers over dose deaths ?

I know for a fact narcan in the community does ... Not just first responders but family members of people who inject drugs (PWID) and PWID themselves.

[rev ronin]

Supposed to drug test patients but unfortunately not all insurances including Medicaid will pay for those.

The patients won't pay in most cases. So monitoring fails.

Um, no monitoring, no new rx, period.  So, it really doesn't matter who pays or not, if you're being consistent in expecting drug monitoring, they either do it or go elsewhere.  Some labs will write off the ridiculous balances after a few "good faith" attempts to balance bill for the testing.

[Convertable]

I have worked with drug-dependent patients  and am very good friends with an addiction psychiatrist who is conducting research on some cutting edge therapies for narcotic dependency.  Really exciting stuff.   For now, methadone and Suboxone are far from ideal, sure, but they are better than death, which is the likely result if patients are not transitioned to them.  For reasons still unknown, some patients are able to kick the habit while others are not.  Socio-psychological factors are often at play.  We have a lot to learn, and I hope the future holds better treatments for these patients.  In the time being, harm reduction is important.  These patients can be difficult, to say the least, and I applaud anyone who devotes his or her time to helping this population.  

[hrubenstein]

Maybe the right setting for addicts is not a medical setting. Hmmm just a thought.

[andersenpa]

you could ask those same questions of methadone programs....I think in a perfect world we should taper folks off opiates, not replace an "illegal" one with a "legal" one. on my trauma service rotation this is exactly what they did. anyone on the service for a few weeks on methadone maint. was tapered off during their stay and a note sent to their local methadone clinic saying they no longer required those services signed by the chief of surgery.

Ha we detox people off tobacco as well after CABG

Same principle, different drug

[andersenpa]

Fat people and drug addicts are the few groups that are still socially acceptable to look down upon.

And PAs

[andersenpa]

Maybe the right setting for addicts is not a medical setting. Hmmm just a thought.

Unless you consider mental health part of medicine

[hrubenstein]

Unless you consider mental health part of medicine

I do consider mental health part of medicine but addiction is a very specific disease under that large umbrella. I don't think addiction can be treated with a pill, there's just so much more to it. Getting clean takes guts. A solid look at who you are as a person as well as a fundamental change in your belief system, not something suboxone or methadone on its own could ever accomplish.