duration of treatment with buprenorphine

Buprenorphine Post
MChaplin
Posts: 183

Postby MChaplin » Mon Mar 17, 2014 11:24 am

I am resurrecting the original topic of how long to treat - i find it telling that the topic moved into how to deal with the 100 patient limit- what does it tell us? that we would not be stopping treatment if we weren't under pressure to treat more than 100 patients!!! But I am resurrecting the topic for a second reason and that is because I lost a former patient yesterday to OD_ this patient repeatedly used heroin on top of suboxone despite trial of increasing suboxone to 32mg, requiring twice weekly visits, repeated discussion/exploration of why he was using, getting his mental illness under control- there was depression as well as psychosis and warnings- he had come to us from methadone at the request of the dispensary because his psychotic illness was out of control. but the heroin use continued- in our team meetings we agonized over what to do- and i had actually posted on this forum looking for suggestions but no matter what we implemented, he would come in with heroin positive urines about once a month- we never got beyond weekly scripts- so 6 weeks ago I said no more suboxone- go to detox, go to rehab/residential and we can talk about vivitrol (btw we had tried oral naltrexone on one occasion following a 7 day detox and psych admit but they wouldn't start it inpt and by the time i saw him he had already relapsed- he tried to go the next 7 days without using but couldn't)- in any case this time he did the detox and 5 weeks of rehab and the night he was discharged, he used 2 bags of heroin and became unresponsive and died. The rehab unit initially concurred with our recommendation that he go on to 6 months of residential which he had done once before (and relapsed within days of leaving)- but he refused to go and then they didn't even advise us of the discharge because he was refered elsewhere because he wanted suboxone. I felt justified in withholding the suboxone under the grounds that it "wasn't working" but now, i remember the death warrant comment on this forum vis a vis stopping suboxone and i am actually fairly devastated. Yes, the suboxone wasn't helping him achieve sobriety but it appears it was keeping him alive...it has been a hard week- another pt lost a long time "buddy" to overdose, and then before he could get to the funeral, the mom (who he had known since he was 7) hung herself.....today i feel like this- we have met the enemy and it is opioid addiction....people are dying in droves and we as a nation have not dedicated ourselves to stopping it. feeling so sad...

kcairns
Posts: 571

Postby kcairns » Mon Mar 17, 2014 11:24 am

yes, let us not be so ingenuous as to believe the FDA after all these years has suddenly come to care about safe effective non-addictive rx for otherwise intractible severe chronic pain and/or prevention of opioid addiction and/or control of the epidemic of american opioid deaths

adavid
Posts: 64

Postby adavid » Mon Mar 17, 2014 11:24 am

Pts you treat for pain with bup do not count towards your 100.The problem with putting your X number on your Rx is that the pharmacist will so submitted and make it look like these patients are part of your 100.

jmosby1469
Posts: 104

Postby jmosby1469 » Mon Mar 17, 2014 11:24 am

That's fine, but some of my third party payers, most recently a Medicaid program, declined coverage on the grounds that Suboxone use for chronic pain is not a FDA sanctioned indication.

edibill
Posts: 101

Postby edibill » Mon Mar 17, 2014 11:24 am

Yep, same here. I'll guess we'll see just how grey that area is on our next DEA visits. I wouldn't have thought to do it until a DEA agent mentioned it to me at my 2 year visit.

drpasser
Posts: 1404

Postby drpasser » Mon Mar 17, 2014 11:24 am

My friendly neighborhood DEA told me the same thing. He said, to not put my X number on the Rx, just my regular DEA number and then write For Pain on the Rx. The problem with this is, pharmacists won't fill it without the X number. So, I do both. For pain pts, I put both of my DEA numbers and put For Pain. So far, that's worked OK.

Best
Kevin

fishdoc
Posts: 111

Postby fishdoc » Mon Mar 17, 2014 11:24 am

According to the DEA agents who came to my office last summer, Suboxone can be used off-label for pain provided that the initial complaint or workup led to a diagnosis of pain, NOT addiction. Also each and every Suboxone prescription must be designated, "For Pain." As long as both of these are true, then the patient would not be included in the 100. If, however, the paient had previously been an addiction patient they both stated the patient would forever be an addiction patient to be included in the 100, not a pain pateint.

Patients treated with Butrans who were not addiction patients do not count towards the 100. Converting Suboxone addiction patients to Butrans would essentially be using Butrans to treat, off-label, addiction patients and might raise a red flag in an audit.

mack86
Posts: 70

Postby mack86 » Mon Mar 17, 2014 11:24 am

DrPasser,

You said "I do have some pts which are on bupe but are being txed for pain management, and I do not count them as part of my 100."

I have some pts that I believe fit this category. How do I know - or really - document - that they are here for pain, so I don't have to count them in my 100, and not get in any trouble?

Also, would these pts be candidates for butrans instead?

Thanks,
Barb

drpasser
Posts: 1404

Postby drpasser » Mon Mar 17, 2014 11:24 am

No Drugs,

I'm more than happy to help you with marketing you practice. I think I'm rather good at it. It have branded my clinic. You should be able to do that too.

I am interested in helping you brand your self. As a mentor with the Physician Clinical Suupport System, this is something we are supposed to be doing.

Anyway, I am currently out of town and won't be back until next week. Think about this, if you even want me to help you, and then come up with a budget. After that, we can set up a phone call and discuss some plans to brand yourself the most economical ways which also get the biggest bang for the buck.

Best
Kevin

kcairns
Posts: 571

Postby kcairns » Mon Mar 17, 2014 11:24 am

NoDrugs4u thanks for your reply, the story of your local inpt tells a lot of the story, lots of undereducation in your community as in all, (they might want to be in touch w hazelden med dir Dr Marvin Sepala to explain how Hazelden learned to be able to care for ALL their opioid addicted patients)(or they might have repeated abstinence failures that they have no answer for and would like to give another option) ...anyway u r a good guy that knows what he is doing and word will begin to spread fast from person to person whose minds get healed by u w med****ist of bup and they "re-discover the fundmental goodness within themselves" (Dekanawida)


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