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Unread 10-02-2009, 09:09 AM   #1
NancyB
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Default DEA Letter Sparks Fears About Intimidation of Buprenorphine Docs

This is why there is still so much more to be done in educating people about addiction and medication-assisted treatment.

http://www.jointogether.org/news/fea...ars-about.html

DEA Letter Sparks Fears About Intimidation of Buprenorphine Docs
October 1, 2009

By Bob Curley

A recent letter from the Drug Enforcement Administration (DEA) to doctors certified to prescribe buprenorphine sparked concerns about intimidation and a perceived attempt to suppress the number of physicians prescribing the anti-opiate medication -- an impression that the Obama administration moved quickly to dispel.

The July 24 letter was addressed to individual healthcare providers who had received waivers from the Drug Addiction Treatment Act (DATA) in order to prescribe Subutex and Suboxone, both buprenorphine-based drugs that are used as an alternative to methadone maintenance.

DEA Miami Field Office diversion manager Barbara A. McGrath wrote that waiver recipients are "subject to inspection" by the DEA and that the agency was developing plans "to include inspections of DATA-waiver practitioners." About 18,000 physicians currently are authorized to prescribe buprenorphine.

"To accurately plan for and properly allocate resources effectively and efficiently, we are attempting to discern whether the DATA-waived portion of your medical practice will need to be inspected," according to McGrath, who advised recipients of the letter who don't want to prescribe the drug can exit the program by filling out an attached form. "Once DEA receives and processes your request, we can remove your name from the list of those medical practices scheduled for inspection," McGrath wrote.

The letter then goes on to require that physicians who want to continue prescribing or dispensing buprenorphine for treatment of opioid addiction complete a questionnaire and prepare for an inspection visit by having a variety of documents on hand, including DEA forms, their state license, treatment documentation, and their CSAT certification and waiver letter.

Objectively, the letter could be read as a simple administrative missive aimed at determining which doctors are subject to inspection under the DATA law. But given DEA's reputation among some doctors for choosing heavy-handed enforcement over patient needs -- along with a perceived hostility toward buprenorphine and other opiate-replacement therapies -- the letter resulted in an immediate outcry from recipients.

"Clearly these letters suggest to physicians that if they don't want a DEA inspection they can just opt out of prescribing Suboxone," said Richard Saitz, M.D., a board-certified addiction medicine specialist and professor at the Boston University School of Medicine, who received one of the DEA letters at his home address. Saitz said that the letters may have led some doctors to conclude that "it is the last straw and not worth it to them to put up with all of the challenges one needs to surmount to prescribe buprenorphine."

Charles O'Keeffe, a professor at Virginia Commonwealth University School of Medicine and an epidemiology and community health expert at the school's Institute for Drug and Alcohol Studies, noted that the majority of letter recipients were family practitioners and internal-medicine specialists who "went to the trouble to take the courses and get certified to prescribe" -- in other words, just the kind of providers that buprenorphine backers are hoping will embrace the drug as a way to treat addiction in office-based practices rather than clinical settings.

"Overall, the feeling was that it was inappropriate to single out these physicians," who may be especially vulnerable to feeling pressured by the DEA, said O'Keeffe.

Tom McLellan, deputy director of the Office of National Drug Control Policy (ONDCP), said the field's reaction was understandable, and that the Obama administration is working on a followup letter that will explicitly encourage physicians to become certified to prescribe buprenorphine.

"If you didn't know where the (DEA) letters came from it could be interpreted as a purely administrative document," said McLellan. "The problem is if you get a letter from the IRS or the DEA, it evokes strong emotional reactions."

McLellan told Join Together that acting DEA administrator Michelle Leonhardt "understood immediately" how the letter could have been misinterpreted. "She repeatedly assured me that neither she nor the DEA are against buprenorphine or are trying to discourage the use of buprenorphine," said McLellan. "They are merely trying to carry out their regulatory responsibilities."

"Let's cut DEA some slack on this," McLellan continued. "The field has to understand that this is not your father's ONDCP or DEA -- we're trying to work together to increase the appropriate availability of buprenorphine."
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Unread 10-02-2009, 01:34 PM   #2
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Incredible.

Nancy, IMO what is needed is a proactive and friendly regulative educational program, to not just regulate doctors on treatment protocol, but, to educate them, to support them, to build peer support patient networks and so on.

Why is it so damn hard for government agencies to be proactive?

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Unread 10-02-2009, 05:31 PM   #3
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Sheesh like we and our doctors don't have enough problems! Hope Obama does something in our favor
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Unread 10-02-2009, 05:31 PM   #4
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Here's the letter that went out from the DEA to certified physicians. Although the DEA can audit every certified physician, they are NOT required by law to visit everyone, like they have chosen to do. I wish the DEA spent their limited resources on fighting the drugs people actually die from. This will discourage doctors from treating the addicted people in their community. It's already the most regulated drug in office-based practice, why add this inconvenience?

Tim





7/24/2009


Dear Registrant:

On October 17, 2000, Congress passed the Drug Addiction Treatment Act (DATA) which permits qualified practitioners to administer or dispense (including prescribe) any Schedule III, IV, or V narcotic drug approved by the Food and Drug Administration specifically for use in maintenance or detoxification treatment to a narcotic dependent person. At this time, the only two drugs approved for such treatment are Subutex® and Suboxone®.

The legislation waives the requirement for a qualified practitioner to obtain a separate DEA registration as a Narcotic Treatment Program (NTP). Although a DATA-Waived practitioner is waived from the requirement, he or she is subject to inspection by the Drug Enforcement Administration. Under the authority of the Controlled Substances Act (CSA) (21 U.S.C. 822(f)), DEA is authorized to conduct periodic inspections of registrants to ensure compliance with the CSA and its implementing regulations.

The Drug Enforcement Administration’s is in the process of preparing its Fiscal Year 2010 Regulatory Work Plan (which begins October 1, 2009) to include inspections of DATA-Waived practitioners. To accurately plan for and properly allocate resources effectively and efficiently, we are attempting to discern whether the DATA-Waived portion of your medical practice will need to be inspected.

Our records indicate that your DEA registration currently includes a unique identifier which designates you as a DATA-Waived practitioner (also referred to as an “X number”). DEA believes that in some cases practitioners were simply seeking continuing education credits, and were not aware that the training would result in the issuance of a modified DEA Registration. In many instances these practitioners are not operating as a DATA-Waived practitioner and simply do not need a modified registration for their practice.

If you do not now or in the future plan to treat opioid dependant patients, you are not required to maintain a modified registration. Should you choose to, you may request removal of the unique identifier by simply filling out the attached form and returning it to the DEA. Once DEA receives and processes your request, we can remove your name from the list of those medical practices scheduled for inspection.

Please be assured that this will not affect your ability to legitimately prescribe or dispense controlled substances (other than Subutex® and Suboxone®) under your DEA registration number. If, at a later date, you elect to treat opioid dependant patients, the unique identifier (“X number”) can be reinstated upon your written request.

If you are prescribing and/or dispensing buprenorphine for the treatment of opioid addiction, please complete the attached questionnaire and return it to the DEA by facsimile at* (954) 306-5352 or by mail no later than September 15, 2009:


The DEA appreciates your effort to remain in compliance with the CSA. You can obtain an Informational Document entitled, DEA Requirements for DATA-Waived Physicians Who Treat Narcotic Addiction Using Buprenorphine at www.DEAdiversion.usdoj.gov to assist in your preparation for a DEA inspection.

Sincerely,
Diversion Program Manager
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Unread 10-02-2009, 05:39 PM   #5
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The DEA just couldn't stand being a part of this could they? So now they want to flex their muscles! They make me sick...
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Unread 10-02-2009, 09:58 PM   #6
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What, specifically, are they "inspecting" and looking for? This makes me angry.
I just don't understand why there is so much controversy with this medication when it is so helpful and doesn't hurt anyone. It saves people, and lowers the crime rate and helps stop the spread of disease.
What do all the opponents have against people being well and feeling well?
I just don't get it. Really.
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Unread 10-02-2009, 09:59 PM   #7
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This may be a ploy(threat) on the part of the DEA to try and get Drs to surrender their "x" number and to discourage new Drs from obtaining one.

Assuming this is not a ploy and they are serious about this nonsense, there is still so much left undone by the DEA, in the area of illegal drug enforcement, that ANY monies they allocate/divert to step up invading Sub Dr's offices will be a gross misallocation of resources.

IMO, this whole notion has less to do with scrutinizing Sub Drs and more to do with targeting and stigmatizing Sub patients.

I cannot believe THIS congress, who is resposnsible for DEA oversight, will stand still and allow this to happen. But anything is possible.

In terms of a renegade government agency being created, not withstanding the CIA, none compares with the DEA.

If the pharmaceutical industry did not possess such political clout, no telling how drugs would be classified. Don't be surprised if the DEA starts a campaign to equate Buprenorphine with Methadone. And pushes for it to become a Class II narcotic.

Wayne
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Unread 10-02-2009, 10:03 PM   #8
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What if that were to happen? If it was classified as a class 2 narcotic? Would that mean that it would no longer be available at a doctor's office? Is that something that is likely to happen?
Again, I just don't get it!!
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Unread 10-03-2009, 08:58 AM   #9
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It's hard enough to find qualified, educated physicians who understand the induction process and what it takes for an overall treatment plan to become successful in medication-assisted therapy. This, IMO just tells the good doctors - the ones with established practices that add real value to the treatment (like psychiatrists and pain doctors) - to stay away. Medicine is a business, and the DEA/Obama, etc, need to promote the idea that more help is needed; that more physicians need to take this on not just for their patients sake, but because it will be good business for them. Somehow this has to be made easier for the doctors, not harder and still have some kind of standards - a tough match, but doable in a motivated society.

Patient outcry alone will not do it. I begged my psychiatrist to get his waiver - it was just a few hours out of his life - but he already has a successful practice and doesn't need the headaches of yet more scrutiny of his practice.

Making Sub a C2 would be a death knoll for effective treatment. The whole idea is for patients to be treated like normal patients with a treatable condition.

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Unread 10-03-2009, 09:16 AM   #10
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Well said packrat, your dead right.

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Unread 10-03-2009, 10:52 AM   #11
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Quote:
Originally Posted by MicheleJ View Post
What if that were to happen? If it was classified as a class 2 narcotic? Would that mean that it would no longer be available at a doctor's office? Is that something that is likely to happen?
Again, I just don't get it!!
If sub were rescheduled to a schedule II doctors would not be able to prescribe it for addiction. It would only be available from methadone clinics. But to show how screwed up the laws are any doctor can prescribe it for pain and still would be able to even if it were a schedule II.
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Unread 10-03-2009, 01:27 PM   #12
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Some of you may know that I'm actively seeking a new Sub doctor. I've made many, many phone calls to different doctors offices that were given to me by 'Here To Help". Sadly, alot of the offices I've called told me that they either are no longer "Suboxone providers", or that they will SOON stop being a Sub provider. Being a Sub patient myself, and knowing the beneficial effects that this medication and its prescribing physicians have on an addicted individual, I became curious. I asked these office managers or nurses that I spoke with..."Why??" Their answers all sounded the same..."It's too much of a hassle. The government seems to come down on us MORE because we're trying to help people w/ Sub than it does when we prescribe Oxycontin or other narcotics." As a matter of fact, my fiance (who is also a Sub patient) recently had an appt w/ his doctor. I had asked my fiance to find out if his Doc had any openings for Sub treatment that I may be able to get into. His doctor told him that he's seriously considering not treating w/ Sub any longer. He, too, said it's too much of a hassle. And, that although he truly loves helping the addicted individuals who come to him for help, "Big Brother" is making it harder to do. I personally hope something changes here. We NEED these doctors, and MORE of them. But they're only being scared away....
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Unread 10-03-2009, 02:21 PM   #13
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I had no idea how widespread this problem is, Janie. Not to be an alarmist, but Under a scenario where sub DRS became scarce all the work I put into improving my quality of life during recovery would be lost and i'd be right back where I started - at the mercy of "big brother" in liquid handcuffs. Ok I realize this is probably not the most likely scenario, but I would really be in a bind right now if I were unable tocontinue treatment with the level of freedom I have now.
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Unread 10-03-2009, 03:20 PM   #14
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Packrat, You and me both!! I was a user for 6 or 7 years. I tried MANY times to get well, and failed each time.....UNTIL, I began Sub treatment. It was and is a godsend to me. If not for it and the success I've had while taking it, I know I'd still be using and most likely in jail...as that's where I was going if I didn't seek treatment (according to the DA). The longest I was ever "clean" before Sub? Approx. 4 months. Right now I'm 7 months completely and totally "clean" thanks to Sub and my Sub doctor. I KNOW for a fact that I'd most likely be dead right now if not for Sub...I was a reckless and careless user...there are days that I have no recollection of. Sub gave me my quality of life BACK...and I don't want to lose it again because of our government playing "god" with our health and our lives.
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Unread 10-03-2009, 05:15 PM   #15
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This really makes me angry.
I too called around a few weeks ago. Not because I need a new Sub. doctor (yet) but just to see who was out there and how easy it would be to find a doctor who prescribes in my city, and who has openings. I found too that a lot of the docotrs listed as Sub. treatment doctors no longer prescribe Sub. I didn't ask why. But, I heard a few "Oh, he doesn't do that anymore", as if I should know better than to even ask such an outrageous thing!!
I would be screwed too if this happens. I was in PAWS all of the time when I was not taking Vicodin. That is how I would have to live without Sub. And to think that there are people out there who want me (and everyone, of course) to live a life of suffering. Again, (for the third time now), I just don't get it!!!

I asked before, but does anyone know what the DEA will be looking for when they go and see the doctors?
This will be another reason doctors will use to justify charging such outrageous rates to Sub. patients, they will say that it's for the the nusiance of having the DEA bothering them.

And, Tim and Nancy, in your opinions, how likely is it really that this will happen, that Sub will be a class 2 narcotic?
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Unread 10-03-2009, 07:06 PM   #16
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If Sub were a Class II drug......what would, possibly, happen? If, at the same time, Sub was considered equal to Methadone(which by far would be the worst case scenerio), chances are we would be required to get our Sub at a Methadone clinic, or Sub clinics would spring up.

It would be a nightmare, for sure, and would go against the whole purpose of using Sub to treat opiate addiction, in the first place.

I think the US gov and all private health agencies recognize that prescription addiction, in this country, with opiates such as hydros leading the way, is at epidemic proportions. it makes no sense, whatsoever, for the feds to take measures that would restrict or reduce a person's access to a proven form of treatment.

IMO

wayne

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Unread 10-03-2009, 08:05 PM   #17
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"If the pharmaceutical industry did not possess such political clout, no telling how drugs would be classified. Don't be surprised if the DEA starts a campaign to equate Buprenorphine with Methadone. And pushes for it to become a Class II narcotic."
Wayne
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"I think the US gov and all private health agencies recognize that prescription addiction, in this country, with opiates such as hydros leading the way, is at epidemic proportions. it makes no sense, whatsoever, for the feds to take measures that would restrict or reduce a person's access to a proven form of treatment".
IMO
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Hi Wayne,
I am not trying to be difficult, but the way I am reading this is that you are contradicting yourself.
I am just wondering if this is a real and true possibility, that this could happen. I know I am doing exactly what I know I should not be doing, which is worrying about things that I have no control over.
However, this is no small thing. This is my life, so I can not help but to be extremely concerned about this. I don't want to go without Sub, and I also don't want to go to a clinic every day to "dose". I planned on staying on Sub indefinately. Yes, I also know that everyone else feels the same way and do not want to go without Sub or go to a clinic either.
I guess I am afraid that one day we will get up and all of the sudden there will be no more Sub. I feel that the quality of my life would be horrible without it.
Actually, I don't know what I'm saying!!
I guess what I am hoping is that everyone will say, "Don't worry MicheleJ, that will never happen, or the liklihood of that happening is remote".
But, I also want to hear the truth.
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Unread 10-03-2009, 09:58 PM   #18
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Michele
Sorry. Didn't mean to come across as sounding contradictory. My words and thoughts sometimes do not intersect.

What I was trying to say is, if not for the clout drug companies have on the Hill in Washington, rx drugs may be classed differently, or outlawed all together. If the DEA had its way, I'd say Oxycontin would be outlawed. Hydrocodone would be a Class II.

I was using hydrocodone as an example of one of the many rx drugs that are abused in this country. At one point, I know the state of Tn wanted it changed from a Class III drug to a Class III drug. That would mean no more refills could be marked on the script, no more calling in of hydro scripts and the paperwork the pharmacies would have to keep would be a lot more extensive. I think the drug makers have enough clout to stop such a thing from happening. And I am glad they do. Drugs used for legitimate pain should not be harder to get because someone like me became addicted to it.

I am dead set against Sub being a Class II drug. I doubt it will be, but you never know. According to Tim, Bupe(injectible) was a Class IV drug. It was when Bupe was formulated into the pill form of Subutex/Suboxone that it became a more controlled substance. I believe Tim said the science/data did not support such a change. But I guess the DEA got its way. That is the kind of stuff that concerns me.

Had I never gotten addicted to rx drugs, I may be wearing a balck suit with a mask and busting down the doors of old ladies. But I did become addicted and my thinking has since evolved. I try to keep an open mind and see both sides, but some of the stuff our gov. has and is engaged in, while fighting this, so called, War on Drugs, defies common sense. IMO, of course.

Bupe is a Class III drug but, IMO, should not be. Hydrocodone is a Class III drug, as well. The way the DEA classifies drug, the lower the number, the higher the potential for addiction/habituation. IMO, there is no way Sub is in the same league as hydrocodone in terms of someone becoming addicted. My concern has more to do with the DEA getting its way when they do not have the science or stats to back their stance up. The seem to shoot from the hip. I am glad drug companies have the political capital to see they are kept in their place.

As far as this notion concerning the DEA putting pressure on Sub Drs, IMO, if it happens, it will have less to do with the DEA having a bias against the Sub providers, and more to do with the DEA's prejudice towards us Sub takers.

Anything I write, should be taken with a grain of salt. I am just expressing one person's point of view.

wayne
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Unread 10-04-2009, 12:12 AM   #19
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How much has all the negative publicity about sub (such as the Baltimore Sun article) and all the complaints about sub doctors posted on various forums contributed to the current decision by the DEA to visit sub doctors? Probably little but then again….

I might be in the minority but I don’t view the DEA visitations (uh oh, that sounds almost religious) as negative. Just as nature provides a strong wind to weed out dead branches from a tree, this action might in the end benefit addiction med because those physicians that really find a calling in treating addiction will weather this storm. Hopefully one of the best things that can come about from this, is, removal of the 100 patient limit.

Wayne, I am a little confused. Perhaps I misread but please explain why making sub a schedule II drug (which I have not heard or read anything about) would change the current situation.

IMO the biggest threat to the current program is the possible changes to the health care being proposed on capital hill. IMO sadly, very sadly, treatment and care of substance dependant patients will be at the bottom of lawmaker’s priorities.
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Unread 10-04-2009, 12:31 AM   #20
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Quote:
IMO the biggest threat to the current program is the possible changes to the health care being proposed on capital hill. IMO sadly, very sadly, treatment and care of substance dependant patients will be at the bottom of lawmaker’s priorities.
Amen, I couldn't agree more!
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Unread 10-04-2009, 12:35 AM   #21
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jdjk .............. where have you been? I'm glad you chimed in here.

I have a question, do you feel that a more rounded and aggressive mentoring program for prescribing doctors would be helpful in standardizing induction protocol?

Mike
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Unread 10-04-2009, 07:59 AM   #22
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or would it deter doctors with established practices from getting involved in the first place?
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Unread 10-04-2009, 09:39 AM   #23
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Well Packrat, I think those already practicing would need to be grand fathered and hopefully they would be responsible enough to participate on their own.

The time involved to follow a good protocol for induction is deceiving, as the total time may be longer than what many doctors dedicate to the patient now, the actual time involved by the doctor him or herself really isn't all that much more and support staff can cover most of it, in a matter of minutes.

IMO doctors who do not do it are simply lazy, over charging for services rendered and irresponsible in their obligations to their patient.

By starting new doctors off with a more "required" standardized protocol and mentoring program, in time that would force the less "patient obligated" doctors to either get on board to suffer loss of business to quality competition. Yes, I know that would be long down the road.

Is it really worth continuing to sacrifice quality for numbers? Maybe that is a good question as well. To me it isn't.. Or maybe this opens the door for a new kind of support service, which I have given serious thought to. However, just adds cost for the patient and would walk on the outer fringes of the law. Though myself and my lawyer believe it can be made legal.

Mike
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Unread 10-04-2009, 09:42 AM   #24
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To add to my last comments. The reason I harp on induction protocol so much and good basic understanding being provided to the patient is because I am convinced that the better start one gets in their recovery, the better the entire process is. Frankly the doctors hold the key to this.

Mike
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Unread 10-04-2009, 11:09 AM   #25
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....Wayne, I am a little confused. Perhaps I misread but please explain why making sub a schedule II drug (which I have not heard or read anything about) would change the current situation. ....
Hi Jdjk,
DATA-2000 only allows for the office based treatment of opioid addiction with specially FDA approved opioid medications of schedule III,IV and V. If Suboxone was moved to a schedule II doctors would no longer be able to prescribe it, at least not for opioid addiction.

A couple years ago the world health organization (WHO) debated rescheduling buprenorphine because of the abuse overseas of the mono-product. They concluded that the rescheduling would limit access and have an overall detrimental effect, not just on addiction but HIV, HEP-C, overdose deaths, and drug related crime. Had they reschedule it to II, that doesn't mean the FDA would have to followed but they usually do keep in sync with the WHO. We must make sure that it is never rescheduled. (here's the WHO determination document, page 5) also, check out our April 2006 newsletter that announced the decision and included some interesting background.

Fortunately, after the Baltimore Sun attack articles, it prompted the Baltimore grand jury to convene and study the accusations, they found claims of danger and misuse to be greatly exaggerated and found buprenorphine to be safe and effective. Here is the actual report if anyone ever needs to cite it: http://www.baltimorehealth.org/info/...anuary2008.pdf

I hope you're right and the 100 patient ration is rescinded. With 700,000 doctors able to prescribe the dangerous drugs people get addicted to and overdose from,and only 18,000 currently certified buprenorphine physicians (of which only about 7,000 are actually prescribing) the 100 patient limit is an unnecessary denial of access that's costing lives.

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Unread 10-04-2009, 02:04 PM   #26
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Originally Posted by OhioMike View Post
Well Packrat, I think those already practicing would need to be grand fathered and hopefully they would be responsible enough to participate on their own.
Mike,

Yes, no question about grand-fathering those already practicing.

I do agree with you, I just don't see established physicians with medical disciplines that could really help, such as psychiatrists, pain specialists, and addiction specialists jumping at getting into this line of business on their own. This is one area where real progress in recovery could be realized - through the synergies of multiple disciplines. What I see most of (at least on the East coast) is general practitioners taking advantage of the free-market to structure their addiction-specific practices any way they want and jumping at maximizing their cash influx. I can't tell you how many doctors I went through who had structured their Sub practices around high cost medical treatment - exclusive of the meds themselves - knowing that patients are at the end of their rope and have nowhere else to go. I spent more time than I should have had to in order to find a doctor who actually understood the induction process. Had there been a pamphlet issued by SAMHSA describing the approved induction processes as a requirement for medication-assisted treatment and each doctor recommends one of the accepted standardized inductions during the initial interview process it would a) reduce malpractice risk b) insure the physician actually understands the process c) give the patient some measure of confidence that this nightmarish "induction" process they have "heard" so much about is something that will actually work. Think about it - how many people post in the Welcome Room with titles like, "Induction tomorrow - terrified?"

Anyway, I definitely agree that focus on standardizing the induction process to mitigate risk of PW and stabilization issues is fundamental to a successful recovery process.

Regards,

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Unread 10-04-2009, 04:25 PM   #27
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Hello,

Wayne, yes, I know your opinion is just that, your opinion. It did, however, get me thinking about this and concerned.
I am hoping that something good will come out of these inspections. One thing I would like to see would be doctors not being allowed to price gauge patients and getting away with it because like Packrat said, they are "at the end of their rope" and are willing to pay. But, a lot of doctors are only in it for the money, and if they are limited to what they are allowed to charge, maybe that will discourage them from prescribing Sub. too. So, that could also end up being a downside.
And, yes, of course, the 100 patient limit needs to be eliminated also. That would benefit so many people.
I asked before a few times above, what is the DEA on the lookout for, and, is it likely that Sub. will become a Schedule 2 narcotic? I know Tim said we must not let that happen, but, is it likely?
I know Tim and Nancy deal with "fact based" information, and there are no "fact based" answers to my questions.
Just wondering, do Tim and Nancy ever speak of their opinions at all?
Or, are they stupid questions that I asked?
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Unread 10-04-2009, 07:27 PM   #28
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I am not, at all, against inspections. They are needed to weed out the wackos.

What I am against is Drs who prescribe Sub becoming a DEA 'special project'. Internal Medicine Drs or Family Practicioners, who prescribe Sub, should not have the Feds up their butt, more so than other Drs in their field, simply because they chose to treat addicts.

The way I reads this is they would concentrate, heavily, on the charts of us Sub users. That would be fine with me. I welcome their scrutiny. But the DEA, while reviewing my chart, should also review the charts of patients being prescribed Demerol or Morphine(for example).

It does not take a brain surgeon to recognize this notion(which may or may not come to pass) for what it is. I do not, for a second, believe this has anything to do with the Drs, per se.

jdjk
There is no movement to make Sub a Class II. I was just saying don't be too surprised if that were to happen. Personally, I do not believe Sub will ever be a Class II but that does not mean the DEA would not try to put that square peg into the round hole.

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Unread 10-04-2009, 10:34 PM   #29
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Michele
Unless I am the one who's asking there are no stupid questions.

I did not mean to worry you in taking about Sub going to a Class II drug. Personally, I do not think it will ever happen. I was just saying I would not be surprised if the DEA tried to have it reclassified.

You and I are in TOTAL agreement, on the price gouging. Unfortunately, increased inspections by the DEA will not address that issue. It may work the other way. If Drs feel they are going to have to deal with, even, more red tape and intrusions by the DEA, they may use those factors in justifying raising the cost of Sub treatment.

With all this talk about healthcare reform_which most people agree we need but can't seem to agree on the remedy_don't be surprised if all patients(not just Sub), start paying more out of pocket for healthcare. This may happen as a result of fear on the part of the healthcare provider, in their anticipation that some sweeping change in legislation will take place, which will adversely effect their bottom line.


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Unread 10-05-2009, 08:02 AM   #30
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Thanks Wayne.
Yeah, I thought that too, that having to deal with the Feds would cause them to raise the cost of the Sub. treatment. And, if they can't do that, then they just won't prescribe Sub and then there would be a shortage of doctors.
It wouldn't surprise me if we all start paying more for all healthcare. I agree that something needs to be done with this healtcare situation, but I have no clue as to what.
I think I read that the Obama Administration is in favor of Sub. treatment, but, it is just at the bottom of their list of concerns.
Well, all I can say is I hope we are all okay.
Thanks again Wayne for getting back to me.
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Unread 10-05-2009, 01:15 PM   #31
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I know the legislation that allowed Sub to be prescribed the way it is now had bi-partison support.

The good(and bad) thing about any legislation already on the books is that it takes an act of congress to overturn it. And congress has a hard enough time dealing with what is in front of them, much less looking back and revisiting old legislation.


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Unread 10-05-2009, 08:44 PM   #32
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Wayne,
I didn’t know that it would take an act of congress to overturn whether or not Sub would be allowed to be prescribed. Interesting. I learned something new here.
Well, they do have so much in front of them to worry about, so hopefully they won’t have time to focus on taking it away from us and ruing so many lives. I feel better now knowing this information in regard to keeping it legal for doctors to prescribe Sub. instead of having to "dose" at clinics.
Thanks.
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Unread 10-05-2009, 10:36 PM   #33
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Michele
I am not a history nor political science major but, as I have gotten older, I have become less interested in ESPN and more interested in the way the gov functions..... or not.

In terms of Bupe being prescribed out of Dr's offices, congress set the rules, including such things as patient limits. I assume they were the ones who required Drs to take the course, and obtain the special number needed to prescribe Sub.

The "x" number Drs must have to wrote for Suboxone is in addition to their existing DEA number. Without their DEA number, the "x" number would be useless( I presume). It is that DEA number that allows the DEA to monitor Drs as closely or as loosely as they wish. Same with pharmacies. They too have DEA numbers.

Where is the DEA and who is minding the database, when regular M.D.s start ordering drugs, normally used in hospital settings, for high profile celebs.

Wayne
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Unread 10-06-2009, 05:45 AM   #34
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Hi, this link has a ton of information, including the language of DATA 2000 (Drug Addiction Treatment Act of 2000) - under which Suboxone treatment falls.

http://www.naabt.org/30_patient_limit.cfm

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Unread 10-06-2009, 08:46 AM   #35
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thankyou nancy,
i hope you are having a wonderful day and a great week.
take some time for yourself
hugs,
denise
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Unread 10-06-2009, 10:05 AM   #36
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Mike,

Sorry it took so long to get back to you on your question. The difficulty in implementing standardize induction protocol is in the enforcement. How could you insure that a physician is following the standardize protocol. And this assumes that every patient responds nearly the same. What about the exceptions. Further I can make a strong case that the suggested protocol of office induction with low dose in the first 24 hrs is faulty.
But again even if a perfect protocol was found how do you enforce it?
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Unread 10-06-2009, 10:34 AM   #37
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jdjk,

Thanks for the response. I may not have explained myself the best. I agree with you and I understand that no dose protocol can be standardized due to each persons individual issues. So I completely agree there and understand. I also understand the problems of regulating exactly what takes place in each office setting to office setting and I agree, that would be very tough.

However, what I would like to see changed is the most common problem we see here and which I see take place here locally. That is the lack of induction monitoring, instruction and education towards the patient.

jdjk, we have chatted enough that you know I am not only pro Suboxone, but, pro physician. IMO the patient / doctor relationship is vital to ones success.

But, time and time again one of the first problems people encounter is being sent home to do a self induction with next to no information, understanding or monitoring. This frustrates me to no end. Heck, many of the people cannot even get their doctor on the phone if they are having problems in the middle of the induction process.

So yes, I feel that the process should be monitored for a period of time and begun in the office setting and the patient provided proper educational material to reading during this time, so when they go home, they will know what to expect and how to respond to it.

Let me use one of my former doctors as an example.

He would bring the patient into the office in the morning. They evaluate the patient to make sure they were in WD enough for induction, then they would begin the process with either 2mg or 4mg tablets. (these dose amounts are used just as an example) He would administer and monitor until the patient was out of WD and Cravings. The patient would then be sent home with medication. They would return the next afternoon for evaluation and to set the daily starting dose. The patient in everything went well would only be out of work on the first day, as the follow up appointment would be made after work the next day, if possible.

Further, the doctor had someone available via the phone at any hour for the patient to phone, if they experienced problems.

While in the office setting on the first day, as nurse did most of the work with the patient, the doctor was able to tend to all other patients without interrupting his/her normal day.

So I would like to see a proactive, friendly, motivating mentoring program to instill this type of care into prescribing doctors.

I hope that explains my concern a little better.

Mike
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Unread 10-06-2009, 11:07 AM   #38
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Mike,

I completely agree with you. The physician must be in contact with the patient throughout the induction process. This is extremely important. If one looks back on my posts over the last couple of years, one of the most important questions to ask a physician is - how do I contact you after hours (this applies not only to the induction but during the entire treatment process) It is a big red flag if it appears that there will be difficulty in contacting the physician after hours. Optimally it should be 24/7. When I tell my colleagues this some roll their eyes. But believe it or not, excluding those calls generated during the induction process, my calls are at a minimum.
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Unread 10-06-2009, 11:29 AM   #39
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jdjk,

Yes, I remember those posts and they were excellent advice and I share that advice often. Again, it means the patient also taking responsibility.

I'm not surprised that your calls are at a minimum after the induction process and honestly, that is a tribute to how you care for, instruct and educate your patients. My doctors would share that reality with you.

Let's face it, taking Sub it's self and dealing with side effects only created by Sub is not rocket science for the patient. Some good basic guidelines and honestly it is a very easy program to follow.

Anyway, that is what frustrates me between the doctor / patient relationship and I really do feel it happens more than it should and honestly it is very easy to fix. I guess that adds to my frustration, the fact that it is one of the easy things to avoid.

So I would like to see a proactive mentoring or even information sharing program to make doctors aware of some of the things which are learned in forums like this, so they can help ease these problems, since it really is a easy fix, most of the time.

My personal experience and my experience with others has convinced me that if a person gets off to a good start and not just with taking the medication, but, understanding it, then their positive experience really enhanced. And as you have just given witness to, it makes the doctors job that much easier down the road with the patient.

Mike
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Unread 11-10-2009, 12:01 PM   #40
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dea is a joke! why dont u do your job dea an get the damn drugs off the street! but oh no u got to attack people that are trying to get better! losers!!
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Unread 11-22-2009, 01:22 PM   #41
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Here's a letter I sent to the DEA, asking for them to refer patients to the matching system if abandoned by their doctor or if their doctor was forced to reduce their patient roster...so far no response.


Drug Enforcement Administration
Office of Diversion Control
Attn: Joseph T. Rannazzisi
8701 Morrissette Drive
Springfield, VA 22152
(202) 307-7165

October 14, 2009

Dear Mr. Rannazzisi,

A number of buprenorphine prescribing physicians have abruptly stopped treating patients citing either a pending DEA visit or the visit itself, according to dropped patients that are also members of our website. This results in more patients out of treatment and possibly seeking diverted buprenorphine in an attempt to self medicate, opposite of the DEA’s intent. I’m not faulting the DEA for doing its job, only bringing this to your attention and offering a solution.

Our 501(c)3 non-profit organization has a free online matching system that helps connect patients with certified buprenorphine providers. I recently sent referral cards to DEA field offices (sample enclosed) in case they were aware of a situation where patients were abandoned by their physician and needed another provider. Unfortunately, I received a call from one agent who explained they were unable to inform physicians of this lifesaving service.

If the DEA’s intent is to limit diversion, then it is also in their best interest to prevent dropped patients from remaining untreated and entering the diverted medication market. Therefore, I’m asking that you find some way to allow DEA field agents to communicate to physicians, who have the need to place patients with other physicians, that a service exists to do this, thus preventing dropped patients from seeking diverted medication. This would also be useful to physicians who have exceeded their patient cap and need to reduce their patient roster.

We have 2,650 participating physicians, and currently an 85% connection rate. Patients can register at www.TreatmentMatch.org I invite the DEA to work with the recovery community in a cooperative fashion and capitalize on the synergistic potential.

Thank you for your time,



Timothy P. Lepak
President, NAABT,Inc.
www.naabt.org
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Unread 11-22-2009, 03:38 PM   #42
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A person's or an agency's silence can speak volumes.

Unfortunately, Tim, this is not the way the this country's so called War on Drugs is being waged, especially by enforcement agencies. The DEA is not interested in, nor do they care about helping place folks in treatment. Their goal is to place as many people as possible, in jail.

wayne
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Unread 11-22-2009, 11:28 PM   #43
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Tim,

Do you know what the penalty will be for a doctor who has exceeded the number of Sub. patients that he/she is allowed to treat at one time? (Either the 30 or the 100) (Whether presently or in the past).

I ask this because even though I have an excellent doctor, he wants to help everyone he can. I know for certain that he has had more than 100 Sub. patients at once. He told me so.

See, one day, I believe it was my second visit or so, I overheard the office woman while she was on the telephone (I don't know her title, the one who makes and verifies appointments, answers the phone, calls in prescriptions, etc........)

She was on the phone with a pharmacy phoning in a prescription for Sub. and the person on the phone obviously asked her a question about it. I heard her telling the person on the phone that Suboxone was the doctor's "main specialty now".

So, since there was no one else in the waiting room at the time, I went up and made conversation with her with the main goal of finding out how many Sub. patients the doctor treats. I literally just asked her how many patients the doctor treats with Suboxone. She told me about at least 150 "right now", or something like that. (I don’t know what she was thinking to have actually told me that!!!)

When I went in to see the doctor then, I told him what she said, and I said to him flat out that I thought that there was a limit to the number of Sub. patients that he is permitted to treat at one time. My doctor told me that yes there is a limit, and that yes, he did currently treat more than the 100 people. He said he wants to "help as many people as possible", and told me that he "doesn't like to turn anyone away who needs help".

I asked him what would happen to his patients if he got caught. He told me that "no one ever checks on that". And, that if they did, and if he got caught, that they would have to take him to court first, and that they wouldn't just shut him down. He said he would have to fight it first.

Although it was inappropriate for this conversation to even have taken place, I appreciated his honesty. I have the kindest and most caring Sub. doctor.

And, our conversation took place in June of this year, before the DEA Audit was announced. Since I learned of the DEA Audit, I have thought about just asking him about it, but, I don’t want to make him upset with me.

What are your thoughts as to what is going to happen to him when he is investigated by the DEA? Or, do you happen to know what actually will happen to him when he is caught? Are you aware of any doctors who did this and got caught during the DEA audit?

When are the investigations taking place? Have they all occurred already? Have some occurred?

Will they close my doctor down when they discover the number of patients he was treating? What will happen to us, his patients? Will they allow him treat us, his Sub. patients, until we are able to find new doctors? Or at least write us an additional prescription with refills until we are able to locate new doctors?

Even if he refers us to another doctor, the other doctor probably has patients of his/her own, and, will not be able to also take on all of my doctor’s Sub. patients besides.

I have signed up for the doctor matching system from time to time. This just to see who is out there. I had responses twice, and now, I have been registered for about almost two months, and have not had a response from a Sub. doctor. Nothing. Granted, I am not “actively” really seeking a new Sub. doctor. But, do you think that maybe I should be?

This is my main concern about being on Sub., always needing to make sure I have someone to prescribe it to me.

Oh, and additionally, I called my own doctor's office once since I learned of the audit pretending to be someone else, just to see if he was still taking new Sub. patients, and I was told that he is not.

Then I asked if there was anyone that I could be referred to. The lady kept asking me questions, and then, eventually my doctor got on the phone and asked me some questions and eventually told me that he would see me!!!! He just felt bad I think. I just pretended to be disconnected then, of course.

I originally found my doctor via the doctor locator on this website. At least I know he is not responding to anymore of those.

Also, I am certain my doctor also still sees his non-Sub patients as well. What would happen to them?
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Unread 11-23-2009, 06:38 AM   #44
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Hi Michele, one case that I know of - a doctor had well over 300 patients - he was told to get his number down to 100. He gave patients refills and so that they could find another doctor. As for the matching system, do you keep renewing your application? Because it will lapse if you don't renew it.

Thought I'd give a quick answer to a couple of things you mentioned.

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Unread 11-23-2009, 08:39 AM   #45
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Thats a really interesting situation Michele and I really think it's sad that this limit is even in effect. Back in the day when depression was the "new" thing I can't imagine those patients going through what us Sub patients have to face... People who were depressed or had any kind of mental problem were looked at as "crazy" and they were scrutinized sometimes locked up in a padded room, thought of as an embarrasment and often treated as one by doctors and as far as insurance, well, you could just forget about them covering ANYTHING for you if you suffered with this because it wasn't acknowledged. Addiction and choosing to treat it medically is looked at much the same way right now but all we can do is hope and be proactive in our treatment and advocate Medical Assisted Treatment. Just look how long it took for that whole Mental health issue to change and become accepted AND paid for by insurance AND to be viewed as an actual illness or disease of the brain. Hell now every other commercial is about a new treatment for depression. I can only hope that I live to see the day when Sub treatment finally is recognized as a real medical treatment for a VERY REAL brain disease and for more insurances to cover the treatments and medications and as Ohio Mike and many others have stated that there NEEDS to be certain rules and regulations in favor of the patients and their treatment (ie: smooth induction and better matnience) and better relationships between the patient and the doctor. I kind of feel as tho we are the gueanie pigs for this treatment and we are somewhat paving the way for others to come just as those did before us.
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Unread 11-23-2009, 09:18 AM   #46
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nancy,
i have a question for you.
what do you mean by renewing micheles application?
i found my suboxone dr through the matching system also.
i am in a program where it's a whole process until they feel you have gotten enough from the meetings,groups and education there and then all a person needs to do is come back once a month to see the dr for their refills.
the dr i see practices out of two separate offices and i have no clue how many patients he has,but i know there is a waiting list as of now.
thankyou,
denise
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Unread 11-23-2009, 10:00 AM   #47
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Hi Denise, with the matching system if you haven't found a doctor, you have the option to click a button that keeps you on the list to see if there are others out there.

If that expires, then simply register again.

https://www.naabt.org/patient_doctor/patient_login.cfm

Nancy
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Unread 11-23-2009, 11:15 AM   #48
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MicheleJ,
I don't know what would happen if the DEA required your doctor to decrease his patient load. Maybe it would go to court and put a spotlight on this unnecessary rationing of safe and effective addiction treatment. Some physicians have told me they feel it is in violation of their oath to turn people away because of an arbitrary restriction on helping people. They plan to fight it, if confronted. Restricting how many people can get addiction treatment while not restricting how many people can receive addicting medications is counter-intuitive, senseless, and cruel. Maybe the DEA audit will bring attention to this ridiculous "protection" from lifesaving treatment.
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Unread 11-23-2009, 12:13 PM   #49
Jamesisdone
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Tim,
This has to be probably one of, if not, the best things that I have read on this site. It really makes alot of sense and I really hope that a lot of the doctors feel this way!
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Unread 11-23-2009, 01:16 PM   #50
gotoffmdone
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I hope ENOUGH Drs do standup and fight, and that they have the backing of the AMA. When it is all said and done the government will have its way. Fighting an agency such as the DEA will yield no results favorable to patients or treating Dr, IMO.

Congress is where things will have to get done. They will be the ones to relieve the restrictions placed on Drs. And things move at a Snail's pace when it comes to revisiting and revising laws on the books.

I do not think a Dr has to be treating a patient to feel as though they may be in violation of their oath. "First do no harm" can mean having to say no to someone in need of the kind of treatment they offer. Drs willing to help people should not be kept from doing so by any branch or level of government. Our government does not stick their nose this far up the butts of other private sector businesses. If they did, the banking industry would not have gotten so far out of control.

wayne
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