Each physician who prescribes buprenorphine for opioid dependence can treat only 30 patients at a time during the first year as a certified prescriber. After a year, physicians can apply to have the limit increased to 100 patients. I have been at the 100-patient limit for some time, in part because of the shortage of providers willing to undergo training and go through the paperwork to get certified. 
At the same time, there are no limits at all on the number of patients who can be treated by doctors with high-potency opioids, and no limits or regulations on the types of conditions that can be treated using narcotics. It is no surprise that I receive several calls per day from people who ask for help, who I am forced to turn away.
The 100-patient cap, combined with the shortage of doctors, results in one of the few areas of true health care rationing, and it is only appropriate that the rationing hit drug addicts– those viewed as society’s least deserving. I realize that some people see ‘inability to pay’ as a form of rationing, and I understand the point. But inability to pay has at least a theoretical solution—if not an actual solution if enough hoops are jumped through. For opioid dependence, the patient cap is an absolute restriction, with no grievance or appeal process for those left out.
I feel for the patients who call asking for help, and for the parents who sometimes call in place of the child-addict. If I am the first person called, the callers are surprised and angry at being turned away. Here they finally got up the nerve to ask for help, and the person on the end of the line won’t DO anything?! More often, though, my name was found halfway down a long list of telephone numbers from poorly-updated web directories of Suboxone doctors, and disappointment can be heard in the voice of the caller before the entire question is asked: are YOU accepting any new people?
The good part of the cap, I suppose, is that it reduces the opportunity for unscrupulous practices to become ‘Suboxone mills’, turning out addict after addict with easy prescriptions but without adequate education, follow-up, and counseling. I buy into this argument, but at the same time, I wonder why the concern over unscrupulous practices focuses so intensely over those who treat addiction? Should there not be equal concern over the number of patients that a neurosurgeon can care for?
Now that we have urgent care centers in supermarkets, is there no limit to the capacity for the doctor in the meat department to provide adequate care and follow-up for the patients who stop by? Or is it OK if a general practice doctor decides to schedule 20 patients per hour, so that each patient receives a bare minimum of focused care with no time for preventative medicine?
But we think differently about THOSE doctors—those who work in the clean world of treating asthma and ulcers and hemorrhoids—than we do about the docs who work with drug addicts. With the former, there is an assumption that the doctors are good people who will know their own limits and do the right thing—even as any trip to the doctor points out the folly of that assumption. And the latter group of doctors—those who stoop to treating addiction—are assumed to be incapable of determining, by themselves, the appropriate number of patients who can be safely seen in their practices. The expectation of bad practice comes from negative attitudes toward those with addictions, with doctors guilty by association. In short, the medical specialty of addiction treatment suffers the same negative stigma as do the addicts themselves.
Given these attitudes, I do not expect the shortage of buprenorphine prescribers to end anytime soon.
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3 Comments
JohnB007 · July 17, 2011 at 9:32 pm
No wonder there is a Big Pharma conspiracy re; every damn thing to do with treatment of, well, every damn thing. I can see the need for the initial cap, but after that, it seems odd, and at conflict with other regulations, as Subdoc points out. Is there a cap for pt numbers if methadone is used? Pardon my ignorance, “I aint from round these here parts”. I’m seeing my Suboxone Dr in a fortnight to discuss my desire to end my need for Sub. I can handle the chronic pain now (I think), so have to get my head around going lower than 7mg / day. Tried before, very slow taper, and it didn’t work. Could not handle the depression and pain. I’ll go over the forum (again) for those who have succeeded. Anyone reading this who has tried and succeeded (or not for that matter) I pray leave a submission on that part. As Subdoc says, not enough doctors to help, those who do are capped at some level, and this site has helped more than the authorities seem to deem fit. Sub Drs here have to go through training as well – it is well paid, and the cap is one based on clinical time available, as most are GP’s (Primary Physicians – whatever the USA equivalance is) or in some other area as well. Despite the extra income it generates, there are bugger all Sub Drs here as well.
fhahaicehawk · July 19, 2011 at 9:55 pm
I am a VERY FORTUNATE patient of Dr. Junig and Suboxone has saved my life from spiraling out of control. From a knee surgery in 2003 to September 2009 I was on painkillers. My orthopedic surgeon prescribed 4 to 6 750 mg Vicodins a day for the first 3 months and I and I mean “I” stretched it out to 6 years!
I fell in love with Vicodin… it made me feel like I was 27 again even though I am i my early fifties. I was NEVER an abuser of drugs and I fell into a trap I NEVER saw coming. I took 2 750 mgs in the morning with my coffee and egg McMuffin and I felt GREAT! It did not matter if I was hung over from drinking or if I felt a little ill upon waking up… I KNEW that I was only 2 pills away from feeling super!!!
My life took a dramatic turn in 2009. I am a professional salesman and the father of 5 great children. My wife has been absolutely supportive in my quest to overcome my addiction. In September of 2009, Doctors began cutting me off and I would get EXTREMELY ILL. I began faking known injuries from playing sports all of my life at Urgent Care Centers just to obtain 30 pills that would only last me 4 days. I even began buying Vicodin from family and friends who were all too willing to make $6 to $10 a pill.
I told my wife that my back was killing me and that was why I had to take painkillers… the truth was I was ADDICTED! I went to my primary doctor and broke down in his office and told him I did Not want to die… I was already consuming over 8 pills a day and that was just to feel NORMAL! I no longer felt great or high from the drug… I was a prisoner in my own body! Dr. K sent me to a known Suboxe Doctor across town.
Upon arriving at the Local Subox Doctor, they told me to take a seat in the lobby… I suffered for another hour and 10 minutes before they put me into a room. About 20 minutes after that the Doctor came in and gave me the 50 questions required prior to breaking a 8mg Suboxone pill in half and told me to put under my tounge for half an hour… I started to imediately feel BETTER! Dr. Z said he would put me on two 8 Mgs per day for 30 days and to see him in the office in 30 days.
24 days later I ran out of Suboxone and called Dr. Z… the office lady said I would have to come in and wait to see him. I waited an hour an 40 minutes (1 hr 40 Minutes)!!!! Dr. Z (who is a primary care physician) scolded me for running out early… he said he would NOT approve another prescription unless I followed his program.
To make a Very LONG story shorter, Dr. Z wanted to RUSH me off of Suboxone… he went from 2 a day to 1 a day to 1/2 a day when I ran out 2 weeks early right at Christmas 2009. I was so sick and had flu like symptoms for two weeks prior to finding Dr. Junig. I had thought about finding a Vicodin or Oxicodone dealer and just return to my old life. However, everytime I looked at my young children I wanted to find the correct way out. Dr. Z treated my like I was a run down drug addict. If fact, I was the father of 5 and held a professional job that I performed at a very high level.
I could NOT afford to wait in his lobby for 2 hours everytime I needed a prescription refilled. The average time it took to obtain a Suboxone pill from Dr. Z was about 4 hours including a stop at the local CVS to pick up my prescription. This simply did NOT work for me.
With Dr. Junig my average time it takes is under 90 minutes. I never have to wait in his lobby for more than 10 Minutes… and I can fill my script at the local WalGreens just down from his office. He treats you like a real human being! Dr. J truely understands his patients and their battle they face each day. MY MESSAGE TO THE MEDICAL LAWMAKERS: ” I am a Father… I am a Husband… I am a Professional… I go to Church on Sundays… I Love my country… however, I am addicted to painkillers and without the help of Dr. Junig and the medication known as Suboxone I would Not be writing this comment!” Moreover, I know if Dr. Junig’s door was Not open in January 2010 I would most likely be Divorced, out of work, ingesting as many painkillers as I can get my hands on, and OR taking up a Six Foot Plot in our local cemetary.
SUBOXONE has removed my desire for painkillers… I am employed today, and I play baseball with my son and daughters. I am one of the LUCKY 100 patients Dr. Junig is allowed to treat.
One final thought/comment: I get sick to my stomach when I hear that Dr. Junig is FORCED by our MEDICAL LAWMAKERS to only treat a selected few (100 Patients)while others are turned away. Too many Dads & Moms are dying because they got hooked on a painkiller after a simple shoulder/knee surgery… Opiate addiction is NOT going away and I see it everywhere. We simply need to raise awareness and educate those decision makers of the grave consequences of NOT helping our fellow neighbor who has a quiet (Shameful) addiction that he or she keeps a secret until it’s TOO LATE!
SuboxDoc · July 24, 2011 at 8:30 pm
Thanks for your nice comments. I’ll only add that when Suboxone is used appropriately– i.e. people stay on it long enough to extinguish the conditioning caused by opioids– a practice of 100 people is easy to manage. I understand the problem with a practice that churns out hundreds of patients, each receiving little time to recover, but I wonder if the cap actually pushes some practitioners to discharge patients against their will– as the comments above suggest.
Thanks again,
JJ