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Unread 07-07-2011, 02:34 PM   #1
NancyB
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Default We need your help regarding the patient limit

Hi, I had written to Kathleen Sebelius, head of HHS, a couple of times regarding access to Suboxone treatment and finally received a response from Dr. Westley Clark, Director of CSAT (Center for Substance Abuse Treatment).

The head of HHS can, without an act of Congress, change the patient limit. I was requesting the limit be lifted, changed or allow PAs and APRNs the ability to become certified. I expressed concerns over lack of treatment availability, long waiting lists, doctors charging outrageous fees for treatment and people being forced to purchase Suboxone on the street - all consequences of imposing such a limit.

Dr. Clark's response - I've bolded a couple of points.

Thank you for taking the time to write to Secretary Sebelius regarding the availability of buprenorphine treatment. We at the Department of Health and Human Services (HHS) are concerned about the problems that you have identified in your letter – that patients are unable to receive treatment because certified physicians have met the 30 or 100 statutory patient ceiling, the general lack of certified Drug Addiction Treatment Act of 2000 (DATA 2000) waived physicians in some communities, and the costly pricing set by some physicians. You suggest that HHS exercise its authority to modify the physician patient limits under DATA 2000. Alternatively, you suggest that the prescribing authority be expanded to permit nurse practitioners and physician assistants to become certified buprenorphine addiction treatment prescribers.

The Substance Abuse and Mental Health Services Administration (SAMHSA) occasionally receives inquiries about the DATA 2000 patient limits, which as you note, was increased by legislation in 2005 to permit prescribing to a maximum of 100 patients. Your request is the first from a patient advocacy group.

In implementing DATA 2000, SAMHSA has certified over 22,000 physicians to prescribe buprenorphine products for addiction treatment, and more physicians are certified every day. Over 5,000 of these physicians have been authorized to prescribe for up to 100 patients. In 2010, almost 800,000 patients received prescriptions for buprenorphine for the treatment of opioid addiction. Although a recent June 27, 2011 article in Alcoholism & Drug Abuse Weekly refers to the Suboxone 100-patient limit as being a barrier in a community in Missouri, we are unaware of any systematically obtained data that would support changing the patient limits as you propose. If you are aware of a source for these data, please forward that information to the SAMHSA contact identified below. You have also proposed extending prescribing authority to nurse practitioners and physician assistants as a measure to increase treatment capacity. DATA 2000 currently limits eligibility to licensed physicians; however, there has been interest and activity within the U.S. Congress to review this restriction. Congress has to date not proposed legislation and HHS has not developed a position on this issue.

We understand the importance of having adequate access to safe and effective substance abuse treatment resources, including buprenorphine addiction treatment resources. If you would like to discuss this further, please contact (contact name, phone and email removed as I'm not sure if the person is publicly listed).

We appreciate your interest in this issue and your support for expanded substance abuse treatment opportunities.


Sincerely,



H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM
Director
Center for Substance Abuse Treatment


-------------------------------------

If you have had difficulties finding treatment, are or have been on a waiting list, were overcharged because of lack of treatment availability, please post your story in this thread. I'd like to gather as much information as possible and present it to CSAT to see if we can make any headway with the limit.

Thanks!

Nancy
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Unread 07-07-2011, 09:47 PM   #2
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I've had extreme difficulty in finding treatment. I was on the verge of over-dosing and needed help right away. I live in Abilene, Texas.

In a 300 mile radius search I found these results:
~4 drs that were certified in buphreophone treatment but were no longer in drug abuse and treatment practice.
~5 drs I called in a 300 mile radius were already at the cut off ceiling limit and only had waiting lists which I was put on. I am roughly number 50 or above in all 5 lists. which is a wait of around 2-2 1/2 years.
~1 dr I finally got ahold of within the 300 mile radius is already at his cut of ceiling limit and I am number 3 on his waiting list. He stated that wait could be up to a year.
The dr I currently go to is 3 hrs away and at or near the top of his ceiling limit too.

To try and get help It took me non-stop phone calls for 3 days and referrals to other drs to find treatment before I ended up over dosing or committing suicide because I needed help immediately and no one could help me.
If this 1 dr I found had not taken my insurance I would not of been able to afford treatment and most likely would be dead now.

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Unread 07-07-2011, 10:03 PM   #3
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Nancy,thank you so much for taking the time to do this.

As you know I've had many problems. I don't guess that would include the situation with Ins. of which I'm still fighting the damn bull dogs. At this point I have to go back up there tomorrow b/c they still have not signed the PA. She had told me last time just find a way to pay for the increase. You know I won't do that..Not without a fight. If there were more Dr. that took Ins. I would be able to go to another Dr. and not deal with this kind of stress.

I so appreciate all the time and concern that you have for so many of us.
Marie
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Unread 07-08-2011, 01:04 AM   #4
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If a Dr had a NP on staff that could take the course and prescribe Sub on their own could that practice have 200 patients. Is the number of patients specific to a practice or to the number of providers within the same practice.

The second Sub Dr I went to I never saw. Their rule, I was told, was that I see the Dr every third or fourth visit. But, from the very get go and forever more, I was always seen by the NP.

If the Dr happened to be in the office during my appt time, the NP would print out the Sub script on the computer and take it to the Dr to sign. It was up to the NP how much Sub to give me.

If the Dr happened not to be in the office while I was there, then the NP would just phone in my script. Now tell me, what's the difference in bestowing upon the NP the ability to prescribe Sub directly without a co-signer from the MD.

wayne
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Unread 07-08-2011, 03:40 PM   #5
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Thanks SuzyQz, Marie and Wayne! I hope we get some more people to post their stories.

Wayne, the number of patients would be specific to the certified person only, so if the practice had 5 certified doctors/APRNs/PAs they could take 500 patients. That would take alot of the supply/demand factor right out of the picture. We've seen doctors in New York City - one of the most expensive cities in the country - charging $50 for a monthly visit. There are a lot more doctors there than patients, so they can't charge $2,500 like we've seen some doctors do.

Can't hurt to try, right?

Nancy
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Unread 07-09-2011, 08:23 AM   #6
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This is a good opportunity to share some of the real issues going on and maybe plant a seed which will grow. I hope a lot of folks take advantage of it.
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Unread 07-09-2011, 12:18 PM   #7
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I read a comment by a physician that stated that the vast majority of his patients have been on subs for a long time...so he is just seeing them once every few months for refills. I guess this makes it tough for new patients as their only opportunity comes if and when someone drops from the role. I you don't live in a large metro area, this really contributes to lack of access.
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Unread 07-09-2011, 03:57 PM   #8
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Default Lack of Treatment available, costs, Suboxone popularity

Even though I live, and lived at the time of starting treatment, in a state where there's a lot of drug addiction, it was hard to find a doctor who prescribed Suboxone. It was hard to find a doctor who even knew what Suboxone is. Even now, when I called Emergency Rooms in my area, (as directed by Here to Help Program), to find an ER Doctor who was Certified, out of 4 hospitals in my area, not one of the Doctors or Nurses at any of these ER's knew what Suboxone was ---and they didn't bother to ask me why or research further.

I found my doctor through the NAABT matching system. I was so glad to find him, even though his office only accepted one type of insurance, which was not mine. I was so happy to find a doctor, that it did not bother me to pay $120.00 a month to see him, plus pay over $600.00 a month out of pocket for the Suboxone. We went through everything we had in the bank, sold everything we could live without, even a car, clothes, furniture to pay my bills. After four years, I still pay the $120.00 a month, but luckily got help with the medicine. But I paid for medicine out of pocket for 3 1/2 years. Because of lack of doctors prescribing, my husband and I still felt like we were glad to pay that amount of money to save my life. I had been physically dependent on pain killers after a neck surgery. Oh, and the worker's compensation would not pay for the Suboxone treatment, because, according to them, it did not have anything to do with my neck surgery. This shows how more physicians and others being able to prescribe would help. And also, it would help buprenorphine treatment become more popular, more people would be more educated about it.

As far as allowing PA's and Nurse Practitioners to prescribe, I believe that is a good idea for many reasons. A lot of PA's and NP's have worked previously as RN's or LPN's, and probably are more experienced with medications than even physicians are. I believe that they are just as qualified to prescribe, as long as they are educated properly on buprenorphine treatment.

The more medical professionals that are allowed to prescribe Suboxone would also make Suboxone more popular, and the more people who are educated about it, the better treatment will be.
Thank You Nancy, I hope this helps a bit.
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Unread 07-11-2011, 09:00 PM   #9
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I paid out-of-pocket for my son's Suboxone treatment to the tune of over $6,000. This was after searching daily for a physician who would treat him. Yes, there were doctors near our home certified in this type of treatment, but most either decided to forego "those" patients or had already reached their limit. My son's first doctor is serving time in prison for an attempted murder (murder for hire) 3 years ago and is still listed on SAMHSA's list of providers. How many other physicians within the 22,000 quoted are no longer practicing medicine or never did treat with Suboxone after being certified? At the present time, within our 250,000 population area, there is one lone ranger with a full house who does not accept new patients. Clearly, the data that SAMHSA is providing is outdated, inaccurate, and nonreflective of the reality that faces those seeking timely treatment with Suboxone.
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Unread 07-12-2011, 04:10 AM   #10
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I think there is often confusion over the term "certified". Any licensed physician can write scripts for controlled meds, but a special DEA number is required to prescribe buprenorphine for opiate addiction. To get this number, the doc has to complete a brief course, along with complying with a few other requirements.

This stuff amounts to jumping through bureaucratic hoops...which isn't the same as being experienced in using the drug to treat those in or seeking recovery!
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Unread 07-13-2011, 10:01 AM   #11
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Quote:
Originally Posted by mom View Post
I paid out-of-pocket for my son's Suboxone treatment to the tune of over $6,000. This was after searching daily for a physician who would treat him. Yes, there were doctors near our home certified in this type of treatment, but most either decided to forego "those" patients or had already reached their limit. My son's first doctor is serving time in prison for an attempted murder (murder for hire) 3 years ago and is still listed on SAMHSA's list of providers. How many other physicians within the 22,000 quoted are no longer practicing medicine or never did treat with Suboxone after being certified? At the present time, within our 250,000 population area, there is one lone ranger with a full house who does not accept new patients. Clearly, the data that SAMHSA is providing is outdated, inaccurate, and nonreflective of the reality that faces those seeking timely treatment with Suboxone.
Absolutely. As of July 1st there are 19,743 doctor who currently hold a DATA-2000 waiver (certified to prescribe buprenorphine for addiction). But only 12,763 appear on the SAMHSA locator (65%). We did an informal audit and found only about 1/2 of those are accepting new patients. (32% of total waived) That's less than 1 in 100 of the doctors who prescribe the drugs people become addicted to also prescribe the safer treatment medication should one of their patients become addicted.

To make it worse, the pace of addiction is more than the pace of new doctors becoming certified (net of dropout/newly certified). In the summer of 2009 the DEA announce a new plan (not required by law) to audit every DATA-2000 waived physician, unannounced. This added burden was the last straw for many doctors who already feel reimbursement rates are too low and patient limits prevent making adding needed staff cost effective. As a result the dropout rate for physicians went from an average of 18/month to 66/month since the announcement. In May-June for example 111 doctors were certified but 54 surrendered their waiver. It's also worth noting that many of the dropouts were eligible for 100 patients while all of the new docs are limited to 30 patients for the first year. We've got to end this!
Tim
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Unread 07-13-2011, 09:22 PM   #12
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Competition in Central Ohio for prescribing doctors is good, meaning that fairly reasonable treatment cost can be found, with just a little effort. The problem is, as it has been for 5 years now is the patient limit. I have been blessed over this time to be able to interact with a large number of local people who are using Suboxone Therapy and each time we go to help someone new, it is patient limits which is the hindering factor. Yes, a fair amount of time cost also can be hindering, but, nearly always that can be worked out, once the support system is setup. The patient limit though cannot be worked out. The more vocal we are, the more letters and emails we send & the more doors we knock on, the better. It can be really heartbreaking to see a person trying to do the next right thing, only to be knocked down, time and time again, by the system ,,,,,,, an old out of date system which is almost setup to see the person fail. The system actually lends it's self to failure, not just with Suboxone, but, recovery in general.
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Unread 07-14-2011, 12:10 PM   #13
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I just received the June-July new doctor/dropout numbers
According to the DEA (comparing June's wavered doctor list with July's)

Gain= 108 new doctors
Lost= 82 doctors
Net= 26 new doctors


Tim
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Unread 07-14-2011, 02:07 PM   #14
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Default my friend can't get help

My best friend is also addicted to opiates. She has no problem getting them but every problem getting off of them.
I started Suboxone 3 weeks ago and I'm doing great. Her intentions were to start the following Monday. She found outage was pregnant on Saturday and the dr refuses to see or treat her.

Here she is, pregnant and addicted. Also she gets Medicaid now, there is still nobody within a 300 mile radius that will treat her. They either don't accept Medicaid, are cash only, won't accept pregnant patients or are a 4 hour drive which she can't make.

All the drs on the matching system are NOT in practice at all anymore. And apparently haven't been for a long time. There is a waiting list for a dr about an hour away but was told she could get seen in about 1-1 1/2 years!!! She needs help now, the baby will be born by then. She's severely upset and the drs told her to absolutely NOT detox because she could miscarry yet noone is willing to help. It's been a phone list of calls, lists, protocols, waiting and waiting and still NOTHING! It's been a non stop daily search for 3 weeks now!
Just one story out of many on how difficult help is but yet how easy addiction is.
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Unread 07-14-2011, 02:26 PM   #15
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Hi SuzyQ,
Thanks for posting I’m sorry your friend is having trouble finding help. I want clear up one thing you said, “All the drs on the matching system are NOT in practice at all anymore.” I think you mean the government controlled locator. The matching system asks doctors to respond by email and only those who currently have openings participate. Matching system doctors are required to renew their participation in the program every 6 months, thus maintaining a current list and eliminating the shortfalls of the government’s list.(which still includes some doctors who have died or are in prison) If she hasn’t tried the matching system yet here is the link www.TreatmentMatch.org

Hopefully she will find someone, but her chances are greatly reduced being pregnant and with Medicaid as the method of payment as very few doctors accept Medicaid for the treatment of opioid addiction. Your post is another great example of why we need to end the current and unnecessary rationing of lifesaving care.


Tim
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Unread 07-19-2011, 12:02 AM   #16
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Wayne,
You are a big advocate of more training for physician’s, and unless I misinterpreted your post it seems you feel it would be in everyone’s best interest to allow PAs and NPs to start treating? That would be a horrendous way to fix this broken system.
Wayne and Tim,
More mandatory training of physicians is needed, proper reimbursement by insurance companies is necessary, allowing non psychiatric physicians to be on mental health panels, removal of the 100 patient limit for ABAM certified physicians, and policing of insincere DATA2000 physicians is perhaps a much better way of addressing the problem. Allowing more medical personal the ability to prescribe this medicine is a shotgun approach that never works in medicine. If every physician had the right to treat opiate dependence with bup, suboxone, meth or any chemical, I sincerely doubt the addiction population would be better off, in fact IMO it would multiply their current problems multifold.
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Unread 07-19-2011, 07:17 AM   #17
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Hi jdjk, but wouldn't it stand to reason that if PAs and APRNs can prescribe full agonists, then why, with the same training that is required of MDs, would that be a 'horrendous way to fix the system'? Especially in rural areas where there is a lack of MDs to begin with. Those PAs and APRNs could also be required to take the additional training that you spoke of right along with MDs. Through the years here we've seen quite a few patients who have met the doctor one time and then the nurse or PA in the office handles the appointments from thereon out.

We have also had quite a few emails from PAs and APRNs who specialize in addiction, are certified addiction counselors, and work along with physicians specializing in addiction questioning why they are allowed to prescribe full agonists but cannot prescribe the medication to help people who become addicted to those full agonists.

If patients had more of a choice when looking for a Suboxone prescriber, again it stands to reason that prices would go down (the simple economics of supply and demand - we see that in areas where there are a great number of doctors, NYC for example, where office visits are commonly under $100), and insincere prescribers wouldn't find it as appealing to prescribe. Also word-of-mouth would be harmful to their practices because patients would be able to more easily find a competent provider instead of being stuck with a doctor they don't like because s/he's the only one available.

In any event, something has to be done. Especially with the continuing dropout of certified physicians because of the unnecessary imposition of the DEA. From Tim's earlier post:

Quote:
Originally Posted by TIM View Post
I just received the June-July new doctor/dropout numbers
According to the DEA (comparing June's wavered doctor list with July's)

Gain= 108 new doctors
Lost= 82 doctors
Net= 26 new doctors


Tim
My opinion.

Nancy
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Unread 07-19-2011, 02:52 PM   #18
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I got to see one of my favorite people today, my doctor. IMO, she is a excellent general practitioner & a excellent addition doctor. She gets it. She understands this disease and equally important, she understands Suboxones place in the overall process. She listens, really listens and she is very comfortable to chat with and to share with. I can always count on honest, caring and no BS responses and advice from her. Further, she is interested in the patients overall recovery program, even more so than she is in prescribing them Suboxone.

I asked her what she thought of raising the patient limit for Suboxone prescribers. I will try to share her response as accurately as she shared it with me.

She said it is needed and yes, that it would help. However, she doesn't feel that every doctor is deserving of it and maybe frankly that too many doctors are not deserving of it.

Her concern, her complaint, or maybe better put, the gripe which burns her backside as it does mine, are the doctors who are standing in their parking lot waving their script pads in the air to only write Sub scripts and make all the money they can, doing basically nothing else to help the patient. Yes, I know by name a good example of such a person.

Or the doctor who charges 300.00 just to get on his/her waiting list.

In other words, she knows and feels that the patient limit needs to be increased, but, she feels and I agree, that only the doctors who are really fully treating the disease and the patient should be permitted to accept more than 100 patients.

Because the others only serve to add to the horror stories we read about here nearly daily!

Her finale comment to me was ,,,,,,,, "I want to send my children to college too, but, not at the expense of my patients health and not at the expense of me not being able to sleep at night!

Mike
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Unread 07-20-2011, 08:33 AM   #19
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Hey Nancy,

Thank you for taking the time to do this. I think it is very important that people have access to treatment. I do not think giving carte blanche access to all doctors to prescribe it is wise, but I do believe that doctors who are properly educated should be allowed to see more patients.

My experience:
I was in Florida when I first started Suboxone treatment. Since Florida is Grand Central for pills in America, it was relatively easy and inexpensive to start treatment.

Then I moved to South Carolina. I moved to Charleston, which is not some small, one doctor town. However, I could only find half a dozen doctors who were even listed as prescribing Suboxone. I had a hard time getting them to call me back, one of them told me they were not taking new patients, and another one wanted $1000 for "induction" even though I had already been stable on Suboxone for four months. One of the offices I actually got on the phone referred me to a treatment center, and that is where I ended up going.

It wasn't easy finding a doctor in South Carolina and I was almost resigned to driving ten hours round trip to Florida once a month to continue my treatment.

Thanks and best of luck with this!
Bruce
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Unread 07-20-2011, 08:35 AM   #20
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Hi Nancy,
Your post generates the following questions – Are PAs/NPs adequately trained to MEDICALLY treat addiction. How can the underserved be adequately treated?
I am double boarded in a medicine specialty and in addiction medicine. As medical director for 2 outpatient community substance abuse clinics staffed by social workers and psychologists who employ various forms of therapy such as cognitive behavioral therapy, motivational therapy etc I am intimately aware of non chemical ways of treating addiction. I am not setting the stage to polish my apple but to explain that with all this training and experience I still, many times, feel challenged to the limit of my abilities. A big reason for this is that most patients I encounter are very complicated. The large majority did not become addicted and do not relapse because they are seeking euphoria or lack will power. Rather they are attempting to address disease processes such as PTSD, bipolar, severe anxiety or unrelenting depression as well as Axis II disorders. So although there are probably a very few PAs/NPs who have managed to obtain sufficient training and experience necessary to adequately treat substance abusing patients, I suspect that many who claim so are exaggerating their credentials and abilities. Concerning their claim that they should be allowed to prescribe bup because they have the ability to prescribe opiates is as illogical as the arsonist who claims he should be allowed to become a fireman because he knows how to set fires. Incidentally, there are only 2 ways to certify in addiction medicine - by fulfilling extensive ASAM/ ABAM requirements or by completing an addiction subspecialty via a psychiatry fellowship (neither of which to my knowledge are open to PAs/NPs.) (See note below on PA/NP training.) Just as PAs/NPs are not adequately trained so goes the 8 hr course physicians. At one time, I was one of those 8 hr physicians but I quickly understood it was imperative that I obtain considerably more training if I wanted to provide the best care to my patients. And, the physicians in it mainly for the money are not only inadequately trained but dangerous because of their motive. So, IMO the way to address this problem is not to throw more undertrained professionals or paraprofessionals at the problem but to get rid of the 100 pt limit. Allow addiction certified physicians to treat as many as they feel they can properly handle. Mandate that insurance companies allow addiction certified physicians to bill for their time and adequately reimburse them for their effort. For underserved areas it may be possible to allow telecommunication medicine. This is an area that needs to be explored in more detail and holds promise until such time that there are adequately trained physicians available to see those underserved patients in person. Concerning the physician dropout rate, I love what I do, I love my patients and if I was independently wealthy I would treat for free because substance abuse patients are much more appreciative than most general medical patients. I question the dedication of those physicians that buckle under mild pressure. Perhaps it is better that they are not treating patients.

SIDE NOTE – PAs are trained on the physician model whereas NPs are trained on the nursing model consequently IMO, PA training is far superior to that of a NP. Yet PA training doesn’t approach in depth or breath the training a physician is required to undergo. In my area there are many NPs who complete a BSN (college degree) take 30 credits ONLINE complete 850 hrs in a clinic setting and are now given the right to “practice” medicine under minimal supervision. Medicine has become so complex it is nearly impossible to keep up yet the standards for licensing “practitioners “continues to decline.
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Unread 07-20-2011, 09:07 AM   #21
NancyB
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Quote:
Originally Posted by jdjk View Post
For underserved areas it may be possible to allow telecommunication medicine. This is an area that needs to be explored in more detail and holds promise until such time that there are adequately trained physicians available to see those underserved patients in person.
Hi jdjk, I appreciate your dedication to your patients and to addiction treatment. Although, I do not agree with your broadbrush dismissal of NPs and APRNs to become certified.

As regarding telemedicine, we have one person here who is doing that very type of treatment right now, and she's quite happy with it. So that does hold a lot of promise for people such as her in a remote part of the country.

On the locator: http://www.treatmentmatch.org/local/
Telemedicine providers are listed separately when they are available in that state. For example, if you put in a NYC zip code, such as 10001, you can see how they are indicated.

So I think we can agree to disagree on some points.

Nancy
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Unread 07-22-2011, 07:25 AM   #22
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Hi, still looking for people's experiences.

Thanks!

Nancy
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Unread 07-26-2011, 09:59 PM   #23
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Hi,

When I was looking for a suboxone doctor, finding one proved almost impossible. I went to the SAMHSA website for help with locating a certified provider. I called absolutely everyone on the list withing a 50 mile radius. And absolutely every one was either at their patient limit, in one case the nurse was unbelievable rude and unhelpful and was willing to put me on a three week waiting list if i put down $400 as a holding fee (non refundable) and followed that up with another $450 for the office visit (cash only). I also had a couple clinics tell me that I was misinformed and that there was no doctor who prescribed suboxone at those locations. Eventually as a last resort I just google searched for a doctor. This is how I found mine. He is a doctor in internal medicine and wasn't listed, but luckily he had room and got me in THAT DAY and I have had just a wonderful experience having him as my doctor. The prices have been expensive still, but MUCH much more reasonable than any of the other clinics I checked with.
Gen
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Unread 08-17-2011, 01:11 PM   #24
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bump
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Unread 08-18-2011, 12:38 AM   #25
gotoffmdone
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jdjk
Your post generates the following questions – Are PAs/NPs adequately trained to MEDICALLY treat addiction. How can the underserved be adequately treated?

Excellent question and just by asking the question you appear to be providing the answer.

Do you think a person with an MD at the end of their name is trained to treat addiction, a specialty unto its own, by taking one inadequate course via CD. This is not about who went through medical school and who did not. I went to a pain clinic for years to get my Methadone and Fentanyl and liquid oxycodone. Not one time did I come face to face with an MD that worked there. I saw the NP the entire time.

This entire post seemed to me to be about more access to treatment. Not about the increase in quality or consistency of treatment. I take that to mean more people being able to take the course, get their X number, then being able to pass out scripts for Bupe.

Absolutely the training needs to be more adequate. It needs to be longer and much more in depth. There is no reason PAs and NP cannot sit through those classes and soak up whats being taught. Actually they may come unarmed with their medical school and resident bias towards addicts and the disease of addiction.

I have never set foot in a class in some medical school but I really believe I could induct and treat people using Sub if I was given the chance. I would not hesitate to do so. Since the Drs I have come into contact with do not seem interested in learning anything beyond their certification course on their own, when I had a desire to learn more about the treatment I was getting, I had to do the research myself.

Give me a while coat, a pen, a pad and immunity from proscution and I could do the exact same thing as other Sub providers are doing and I doubt anyone would notice the difference. Except I may have a little more empathy.

wayne
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