Drug Court Organization Lobbied Against Suboxone

For years, people familiar with the benefits of buprenorphine have wondered– who is the idiot standing in the way of increasing access to this life-saving treatment?  One of the idiots was recently identified, when an open-records request by the Huffington Post uncovered a letter to HHS Secretary Sylvia Burwell from West Huddleston, then-CEO of the National Association of Drug Court Professionals.
In the letter, Huddleston wrote that allowing doctors to see more than the current limit allows ‘will result in the expanded use of buprenorphine in a manner that is less responsible and presents greater risk to the health and safety of the individuals and communities we both serve.’   The Huffington Post correctly points out that over 28,000 Americans died from opioid overdose in 2014, when the letter was written.
People familiar with buprenorphine know that the medication virtually eliminates the risk of death by overdose– even when taken incorrectly.  The anti-medication lobby, fueled by the large profits of revolving-door ‘abstinence-based’ treatments, has used fear of diversion of buprenorphine as a weapon against greater access to the medication.  But stories about diversion always fail to mention key facts about buprenorphine– for example that of the 30,000 US opioid overdose deaths last year, only about 40 had buprenorphine identified as one of the drugs in the bloodstream at the time of death.  And of those 30,000 deaths, none were CAUSED by buprenorphine.
There have been overdose deaths that were in-part due to buprenorphine or buprenorphine/naloxone medications (i.e. Suboxone, Bunavail, and Zubsolv).  But such deaths are rare.  In order for buprenorphine to contribute to overdose, the victim must 1. Have a low tolerance to opioids, and 2. Have a low tolerance to a second respiratory depressant, taken around the same time in sufficient amount.   In other words, someone physically dependent on opioids cannot overdose on buprenorphine.  In fact, buprenorphine products would precipitate severe withdrawal if taken by opioid addicts within a few hours of heroin, oxycodone, or other opioid use.
Drug courts in my area tend to avoid medication assisted treatments, with the exception of Vivitrol or IM Naltrexone.  There is no evidence that blocking opioid receptors for a year has any effect on death rates from opioids.  Studies have reported that patients who stay compliant with treatment, who return each month for another injection of naltrexone, don’t waste their money on agonists that would have no effect on them.  But what happens 6-12 months later, when probation ends and those patients are no-longer required to take naltrexone?
I wish I could tell you what happens– but I can’t, because nobody has done the studies to find out.  The cynic in me takes it further, wondering if anyone even cares what happens when people are temporarily maintained on naltrexone and then allowed to stop the medication?  I’ve asked physicians, prosecutors, and law enforcement the same question:  what happens to the person when the naltrexone is discontinued?  In response I usually hear ‘what do you mean?’  Or ‘how would I know, since I don’t see them anymore?’, or ‘I assume they do fine… don’t they?’
I don’t see much concern when I explain that people who stop naltrexone are in a state of ‘reverse tolerance’ making them more susceptible to death by overdose.   So I remind them of the large number of overdose deaths in people who were recently released from a controlled environment, such as residential treatment or incarceration, after tolerance dropped to normal levels.  Maybe I’ll point out the Australian studies that show a 12-fold higher death rate in addicts who were maintained on naltrexone.   But by that time I’ve lost the person’s attention– just as their attention leaves each addict when his/her probation expires.  ‘Not my problem anymore.’
Huddleston is no longer the CEO, but the NADCP continues to express a muddled message about buprenorphine medications.   If you have a minute, you might consider educating the NADCP staff about the value of buprenorphine treatment.
Meanwhile, HHS Secretary Burwell says changes to the cap are coming.  I received 12 calls last week from people looking for help.  I’ll keep telling them to try to be patient.

Bangor to Maine: Too Much Suboxone Treatment!

First Posted 11/26/2013
As I read about the moratorium on buprenorphine treatment programs in Bangor, Maine, I thought about the scene from the movie Titanic where the people who found safety in lifeboats struggled to keep those in the water from climbing aboard. The Bangor city council recently voted to impose a moratorium on expanding buprenorphine treatment programs for 180 days, at least in part because of concern that Bangor had become ‘port in the storm’ for heroin addicts with nowhere else to turn.

I haven’t been to Bangor, but I live in Bangor-like conditions. Bangor clinics treat more than the city’s share of people addicted to opioids. The city has three methadone clinics, treating a total of 1500 people, many of whom travel from outside the city for treatment. Numbers on buprenorphine treatment were not provided in the articles I’ve read, and so I don’t know if buprenorphine/Suboxone prescribers in Bangor carry the same heavy load.

Some editorials about the Bangor situation have suggested that buprenorphine treatment is unfairly targeted because of the large number of methadone patients. The two types of treatment are often confused, especially since methadone clinics now dispense buprenorphine to some patients and methadone to others. But buprenorphine-based products differ from methadone in that they can be prescribed for addiction treatment, whereas methadone can only be dispensed—initially on a daily basis. The medications are similar in that both are the most reliable methods to cut the number of overdose deaths from pain pills or heroin.

By ‘Bangor-like’, I’m referring to the lack of buprenorphine-certified physicians in northeast Wisconsin and the Michigan Upper Peninsula, and the need for residents of those regions to travel in my direction to see a buprenorphine-certified provider. There are also regions of the Upper Peninsula where pharmacies have stopped providing Suboxone. The exit of one pharmacy created greater pressure on remaining pharmacies, creating a death spiral that ended with no pharmacies dispensing Suboxone across a wide region.

To people without addictions, I suspect that large numbers of opioid addicts lining up for care look like the people who tried to climb into the Titanic lifeboats. People who have lost everything to addiction can seem a bit desperate with their dated clothes and late-model cars. Newcomers to treatment look rough after weeks of lousy sleep and the lack of toiletries that go with living in a car. A group of patients outside a methadone clinic are less picturesque than a Starbucks shop.

But there is nothing pretty about blocking treatment facilities that could save lives, out of concern that the good city of Bangor is doing too much good for the surrounding area. It is always revealing to apply attitudes toward addiction to other diseases. If Bangor was a Mecca for cancer treatment, with several hospitals to attract patients from miles around, would the city council be concerned? Success rates with buprenorphine rival cancer treatment success rates; is it more important, or more rewarding, to save the life of one patient over another?

I am frustrated that the regulations for treating opioid dependence keep more doctors from helping carry the load. I’m frustrated that the ‘systems’ that have taken over much of the healthcare landscape discourage buprenorphine-certification of their employed physicians. I find it ironic that almost all hospitals requires ACLS certification for their staff physicians, but none require buprenorphine certification—even though most doctors will rarely if ever have to run a ‘code’, while patients seeking help for addiction are plentiful—and ignored.

But a surplus of doctors willing to navigate the maze of regulations to offer methadone treatment or willing to sign on to random DEA inspections to prescribe buprenorphine medications is a good thing. An even better thing would be for a city council to take pride in not turning away people struggling with an epidemic that has become the number one killer of young adults in much of the country. We all agree that opioid dependence is a disease. Let’s hope that in 180 days, Bangor will decide to treat it like one. The solution, in 1912, wasn’t to have even FEWER lifeboats.

Buprenorphine Regulations and Unintended Consequences

First Posted 8/28/2013
I realize that I am halfway through a post called ‘Suboxone Abuse Part I’.  This is poor form, but I am now going to get halfway through a second topic before finishing the first one.  Sorry.
I recently came across a problem relating to the new healthcare law.  I was thinking about writing ‘How the Affordable Care Act Is Killing a Few People’, but I figured that such an inflammatory title would chase away about half of my readership.   So I used the title I liked second-best.
I’ll first write about a couple background issues that are obvious to those of us who work in healthcare but less obvious to others.  These things are important to know, in order to understand the second post.  I won’t try to take one political stand or another, so hopefully the people who reflexively support or bash either side will take a chill pill, tune into the issue, and allow my perspective to filter into their knowledge base.
When I was in med school, I bought a brand new Hyundai for $3900. The car was a ‘loss leader’.  Businesses owners use loss leaders to increase buzz about the business or to get people through the door, hoping to make up the loss by selling more profitable merchandise.
You may have noticed the disappearance of private doctor practices over the past 20 years.  There are many reasons for the loss of private practices, but from the perspective of an owner of such a practice, a primary reason is because individual doctor visits, especially for primary care, have become loss leaders for healthcare systems.  Patients attached to systems through loss leaders– primary care physicians– become sources of profit when they are admitted, have MRI’s or surgeries, or see specialists.
Look at the cost for different types of ‘health care.’  Your insurer pays less than $200 for a doctor to sit with you, 1:1, for 15-30 minutes.  That same amount of time in an MRI costs your insurance ten times more, and an hour in the operating room costs $5,000-$20,000.
Health systems negotiate with insurers with an eye on the big picture.  An orthopedic injury—say a torn ACL—brings an ER visit, X-rays, MRI, surgery, and physical therapy, with revenues well over $20,000. A patient with heart disease brings in $50,000 or more for EKGs, stress tests, cardiac ultrasound, angiogram, angioplasty, and bypass surgery.  Cancer care can top $100,000 when surgeries, radiation therapy, and chemotherapy are included. Even a relatively common injury—lumbar disc herniation– requires MRI, PT, a variety of injections, and laminectomy or spinal fusion, with revenues up to and over $100,000.
While individual doctor visits are more common than heart surgery, the MRI suites and catheterization centers are the profit generators for health systems and the hot topics of insurance negotiations.  To the big systems, whether the family practice doc is reimbursed $120 vs. $160 per visit is a minor consideration—just as we are more careful buying a home than a soda.  But solo-practice docs must carefully consider the payments for office visits, since they are the ONLY revenue.   Independent docs are offered the discounted reimbursements that insurers pay the big healthcare systems, but unlike the systems, small practices have no high-revenue services to subsidize lower-revenue patient visits.  With no high-revenue services to subsidize lower-revenue patient visits, independent physicians must be very careful in providing discounts to be part of insurance panels.  Some types of payments—the $30 for a 20-30 minute office visit paid by Medicaid—won’t keep the lights on after malpractice, office staff, rent, and utilities are paid.
It is hard to run a business selling only loss leaders.  That’s why the Hyundai dealer tried so hard to get me to test drive other cars. It wasn’t until I threatened to make a fuss about ‘bait and switch advertising’ that I was allowed to buy the $3900 car pictured in the newspaper ad.  There was no profit in that sale, but the dealer knew that most people would turn away from the unwashed beater and consider other cars on the lot (he didn’t take into account how broke med students are!).  Without bigger sales, the business can’t survive.
The second issue I need to cover is the shortage of doctors who prescribe buprenorphine, and the reason that buprenorphine prescribers are more likely to be independent or small-practice physicians.
To prescribe buprenorphine, doctors must take a short course and fill out some paperwork—not a big deal.  A bigger deal is that buprenorphine-certified doctors must allow random inspections by the DEA without cause.  Doctors who work for health systems get a paycheck each week, often regardless of the number of patient visits.  For an employed doctor, does it make sense to take an extra course, file extra paperwork, and agree to random inspections, in order to see more people but for the same pay?
Patients in need of buprenorphine treatment have usually lost a great deal due to their addictions, and are not great ‘sources of revenue.’  I suspect that my own enjoyment treating addiction comes in part from my personal experiences ‘in the field’.    Beyond that type of interest, young doctors do not leave residency eager to take on patients who have been dishonest with other doctors, who early in treatment appear a bit ‘rougher’ than their other patients, and who have no disposable income!
The two issues must be understood and combined, in order to understanding the second half of the story (that I will get to eventually…).   In review, the first point is that individual medical practices are disappearing because of a flawed business model.  Fees charged for individual appointments are far lower than revenues from tests, procedures, and surgeries.  Large systems can subsidize doctor visits with revenue from MRIs and surgery centers.  Doctor visits are ‘loss leaders’ for more profitable services.  One cannot make a ‘business’ from loss leaders, without the second half of the equation.
And second, doctors who prescribe buprenorphine are more likely to be independent practitioners with their own businesses.  Another way to say it is that doctors who are employees of health care systems are less likely to obtain certification to prescribe buprenorphine.  The extra patients that comes with buprenorphine certification cause more paperwork and more regulation, without an increase in pay.  Beyond personal motivations, doctors have no incentive to treat addiction; in fact there are significant disincentives to becoming buprenorphine-certified.
Put the two together, and you have more and more communities where several large systems compete for patients, and nobody prescribes buprenorphine except for the one or two independent practices that haven’t closed yet.