re-examing diversion

Buprenorphine Post
Posts: 64

Postby adavid » Fri Jul 17, 2015 7:26 am

Folks its gotten very clear how to minimize diversion and keep your DEA agent happy:
1) Make Bunavail your first line drug. It cannot be snorted and darn hard to inject. And, it is cheaper than Suboxone - in fact, after the Company discount card it cost the patient about as much as a generic Subutex.

2) Only prescribe the buprenorphine mono product (Subutex) to pregnant females and only after you test them in the office from a specimen that an office staffer OBSERVED being produced. In my early days I believed them at their word (who would lie to the doctor about being pregnant?!@)only do discover several months later that they were not.
And the claim that "We are trying to get pregnant" does not count.

3) Only prescribe Suboxone film or tablets or Zubsolv to pts whose insurance demands it.

Posts: 1404

Postby drpasser » Fri Jul 17, 2015 7:26 am

So, from day to day, I really don't worry about the DEA. I do what I am supposed to do. I don't cut corners. I may be naive, but I feel fairly confident that the DEA will not come snd blow my house down.

I could be wrong. I would rather keep with what I am doing and continue working to help my pts, than to spend any time worrying about the DEA. I guess, it's kinda like the serenity prayer.

I worry about my pts, not the DEA.


claude augustine curran
Posts: 52

Postby claude augustine curran » Fri Jul 17, 2015 7:26 am

Diversion is the product of governmental rationing,ie,the 100-patient cap. This cap is illegal. It discriminates against those with addiction in violation of the ADA and yes,addiction is a disability--read the ASAM definition of addiction,long version.

Posts: 104

Postby jmosby1469 » Fri Jul 17, 2015 7:26 am

Hate to ask, but what is "caching"?

Posts: 198

Postby NoDrugs4u » Fri Jul 17, 2015 7:26 am

I wonder if there is a market for empty wrappers (Suboxone)? I collect, count and dispose of, for every patient. I even check lot numbers occasionally, to make sure they match.

Do I like it = NO
Do I agree with it = NO
Do I have an inherent fear of the DEA goons taking my license away = YES

I still have a mortgage to pay and I'm too young for Social Security. So I need to do everything in my power to keep the authorities off my back. (sad face)

Posts: 9

Postby tdbailey » Fri Jul 17, 2015 7:26 am

It seems to me if we take some of the above positions to the reductio ad absurdum then we should prescribe 100 Suboxone strips to every patient we see and with a wink ask them to pass 'em out. Would we be ok with that?

Personally I do feel uncomfortable with a patient who comes to see me with the intention of continuing to lie to me on a regular basis. And that is where all the street bup is coming from is it not? It's not being shoplifted from the pharmacy, it is being obtained by pts who lie about their own need in order to have some to sell. Dishonesty is part of active addiction and it's hard for me to see ongoing dishonesty as consistent with true recovery. (Also I might add that being a current drug dealer is not consistent with being in recovery-which is what selling Suboxone regularily is.) Plus, I am skeptical that all (or close to all) diversion is giving poor grandma an extra strip so she is not dope sick. Without question there are people posing as pts with the sole purpose of getting Suboxone to sell. And, at least in my area I am given to understand that IV use of Suboxone (Naloxone or not) is common.

Yes there is an access problem due to the cap. But as I stated before, I believe diversion is an impediment to raising or eliminating the cap. Yes bup is safer than Methadone and other street drugs but, with all due respect, the way to make treatment more available is not turning a blind eye to diversion. (In my opinion at least.)

Posts: 571

Postby kcairns » Fri Jul 17, 2015 7:26 am

Kevin you are correct, you are not only correct, you are stunningly correct, devastatingly correct, chillingly correct ,Eagle-like correct, Genius-like correct, powerfully correct, so just perfectionly simply correct, it is all so so so overwhelmingly simple....(and of course pill counts a waste when the simple truth is always right in front of our eyes, -- if only the world had eyes to see) -- just follow your straightforward dead right on approach and no need for webboard and if world just simply could omg imagine the wonderfulness that would bloom and flood and thanks, I send you, from "The Marriage of heaven and Hell" by William Blake: "When thou seest an Eagle, thou seest a portion of Genius, lift up thy head!"

Posts: 1404

Postby drpasser » Fri Jul 17, 2015 7:26 am

I would confront the pt in the incident above with the boyfriend.

If we could all spend more time txing pts and less time trying to be super sleuths hunting down diverting; more lives would be saved. If you think about it, the more bupe is diverted, fewer will die from overdose.

Am I correct?

Are pill counts basically a waste of time?


Posts: 571

Postby kcairns » Fri Jul 17, 2015 7:26 am

paper on BMJ Open 2015;5e007629 referred to in ASAM weekly archives july 21, relative risk of fatal poisoning by methadone or buprenorphine -- in England and wales in pts in addiction rx,from 2007-2012 showed bup 6x safer, mtd related death rate was 0.137 per 1000 rxes issued and bup related rate 0.022, or total 2007-2012 2366 mtd and 57 bup, not recorded what other substances mixed, no hard data re bn vs bupomono but in discussion bn shows promise of more safety but by injection bn could have comparable risk of death to mono, ...also quotes austrian study reporting increased deaths post cessation of bup rx...I may be wrong but makes me ask in re grand jury above, what med licenses grand jurors have that their words can carry such wt in complicated medical issues...sure seems to me that nonaddiction knowledgeable people whose words decrease bup care availability should at least be offered the info re the possibility such may be very harmful but I could be wrong...

Posts: 64

Postby adavid » Fri Jul 17, 2015 7:26 am

Tdbailey, I am all with you for "it is imperative that we do all that we can to try to mitigate diversion". Furthermore, I am not that surprised about all the Suboxone relate indictments you reported. In some areas Suboxone and Subutex have become the drug of choice. I am not talking about sharing with someone who is dope sic. I am referring to snorting/injecting Subutex or injecting Suboxone with the intent to get high. The most effective thing to do to mitigate diversion and abuse is to put everyone on Bunavail - It cannot be snorted and is very difficult to inject. I know many of us are still prescribing generic Subutex to patients who CLAIM have no health insurance because of lower cost, but that policy, as is now plainly obvious, has been penny wise and pound foolish.

About a year a go, when I was still delusional and still prescribing Subutex to the alleged uninsured, a couple had come to our office. After I had written them their prescriptions and walked out of the exam room a staff member walked past the room and observed the girlfriend look at the prescriptions in her hand and exclaim the her boyfriend "Caching(sp?). What would you do about that?

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