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

[EMEDPA]

do a little research on Naltrexone. great drug for use in some folks with addiction issues.

https://en.wikipedia.org/wiki/Naltrexone

[ksmith10]

Haven't read any of the responses on this topic yet and I'm sure that others have already done a much better job than I could do anyway of explaining the reasons why no sane PA is interested in taking up the torch for this cause, of all God-forsaken things. Suboxone is nothing more than the pain management "specialty" 's newest/newer cash cow, now that methadone is no longer lucrative as it's fairly easy for folks on longterm opioid maintenance "therapy" to obtain rxs in the name of chronic pain, which even Medicaid will pay for, and so people are no longer relegated to the daily cash clinics. Suboxone, however, has remained extremely expensive and uncovered by most (maybe all?) private insurers, and these physicians continue to make money hand-over-fist by convincing patients and their families that this is the answer to their problems when, in fact, it's simply another substance to add to the list of ones they were already hooked on and abusing.

[ohiovolffemtp]

I do EM in an older city pop ~60K that has a huge heroin problem.  I also work part-time in a primary care practice that does a lot of Vivitrol (injectable naltrexone - 1 month duration).  Here's my perspective:

• Nearly all of the heroin users started with heroin or other street drugs.  Prescription opiates were NOT the gateway drugs.
• Suboxone, methadone, or other daily use drugs don't work well for treating addiction - a chance to slip up exists every day.
• Long duration meds, e.g. Vivitrol, seem to work well for motivated persons, especially when the patient is in NA or other treatent.

So, I'd do Vivitrol, but not suboxone.

[ventana]

I do EM in an older city pop ~60K that has a huge heroin problem.  I also work part-time in a primary care practice that does a lot of Vivitrol (injectable naltrexone - 1 month duration).  Here's my perspective:

• Nearly all of the heroin users started with heroin or other street drugs.  Prescription opiates were NOT the gateway drugs.
• Suboxone, methadone, or other daily use drugs don't work well for treating addiction - a chance to slip up exists every day.
• Long duration meds, e.g. Vivitrol, seem to work well for motivated persons, especially when the patient is in NA or other treatent.

So, I'd do Vivitrol, but not suboxone.

 

 

 

 

My experience differs

 

prob 50% of heroin users started on pills, another huge # started with pills and still are doing pills,

fairly rare to get the isolated heroin user

 

Methadone and heroin is simply handed out like tottsie pops by the local clinics, they don't do squat to drug test or hold accountable for staying clean, therefore many many "clinic patients" are dirty urines......  illogical

 

 

Just starting with a vivitrol program.... will see

 

 

 

In my area the providers "fanned the flames" "poured gas on an already buring fire" with our past prescribing habits.....

slowly getting better

[ksmith10]

[*]Nearly all of the heroin users started with heroin or other street drugs. Prescription opiates were NOT the gateway drugs.

Wholeheartedly disagree. Perhaps it could be different in your particular patient population, but this is very VERY unrepresentative of the general population. Almost nobody decides one day to acquire syringes and inject something into their veins, or has the network of people around them to obtain black tar for smoking if they were opiate-naive or non- drug users in general. This is very much a progressive thing, and people rarely started down the road with the idea in mind that using heroin was something they wanted to do.

[SocialMedicine]

addiction is a medical problem ... and its treatment includes a large umbrella.  I agree with that statement. 

 

I agree that it is much more than a medication to treat. The approach MUST be multi specialty and multi discipline.  This is why I expressed some concern at just any primary care provider humping into this. You need a system in place to help these people ... therapists/psychiatry who take insurance or medicaid ... nurses who are familiar with these types of office visits ..... method to screen for drug abuse and opioid use in office  among other issues.    

 

However its possible to arrange this with a bit of work in most any setting. The clinician also should have some experience ... or access to mentorship in working with this patient population and health problem 

[greenmood]

I would, with caution. 

 

My Family Medicine rotation in school introduced me to this drug and the patient population it attracts. I would say about 20% of the patients at that clinic were there specifically for suboxone treatment. This was a private, single-physician practice, and my preceptor ran a pretty tight ship. Everyone was drug tested regularly, and she had a zero tolerance policy for unexpected results. I witnessed a few conversations she had with patients who had failed the drug test or showed up angry when she wouldn't refill their script without a visit and it taught me a lot about managing "high stress" patients.

 

That said, I really wouldn't want my practice to be 20% addicts, so I would proceed with caution.