How do you order Suboxone for dispensing?

Buprenorphine Post
fishdoc
Posts: 111

Postby fishdoc » Fri Aug 07, 2015 12:28 pm

It sounds to me as if the clinic is either at the limits or has crossed the limits of the law. Is this a government owned clinic or privately owned? If private, is the owner a waived physician? Are you the supervising physician for the nurse practitioner?

You are seeing patients once a week, but in between a nurse practitioner, who does not have an X number, and is not eligible to get one at the present time, prescribes and dispenses Suboxone for 5 day detox on patients you MAY or MAY NOT have seen. Do I have that right?

If so, expect to have problems the first time the DEA visits.

NoDrugs4u
Posts: 198

Postby NoDrugs4u » Fri Aug 07, 2015 12:28 pm

The pharmacy that the clinic is working with developed a "stock order" form, which appears like it was home made in MS Word, but it meets the criteria of not being a prescription.

Dr. Passer, the clinic employs a nurse practitioner that works full time, she evaluates the patients and calls me on the phone to get orders for induction, titration or maintenance. They do drug testing, counseling, etc., in house. I am physically there one day a week and see each patient a minimum of once a month.

They want the stock Suboxone to do 5-day rapid detox's (patient must come in each day) and for same-day inductions. I write scripts for longer maintenance.

I am not happy about the dispensing or the nurse practitioner doing the evaluations. I think that circumvents the purpose of having the x-number certification qualifications. But, honestly, I need the work. My practice is barely breaking even.

drpasser
Posts: 1404

Postby drpasser » Fri Aug 07, 2015 12:28 pm

I am curious how it is working out with this? Have you been personally involved? Please share your experiences, if and when you can.

:-)

NoDrugs4u
Posts: 198

Postby NoDrugs4u » Fri Aug 07, 2015 12:28 pm

Very interesting Dr. Passer, thank you. I have no plans to dispense from my practice, but the clinic that I now work for is a dispensing clinic and I wanted to clarify how dispensing doctors order their stock meds. I would prefer not to dispense, but the clinic insists on it.

drpasser
Posts: 1404

Postby drpasser » Fri Aug 07, 2015 12:28 pm

Here, I have cut and pasted, responses to a similar thread I authored back in 2007. There's some good info here:

drpasser
1277 Posts

Posted - 02/22/2007 : 10:43:39 Show Profile Email Poster Edit Topic Reply with Quote
Is anyone a dispensing physician, ie- sells Suboxone out of one's office? If so, what are your experiences with this? I am thinking of doing it.
Best,
Kevin
MichaelWShoreMD
370 Posts

Posted - 02/23/2007 : 07:32:55 Show Profile Email Poster Reply with Quote
I wouldn't - three years ago or so I had a patient break into my office to steal a bottle of 30 tabs. Better to send to the pharmacy. Mike
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rac1210
84 Posts

Posted - 02/23/2007 : 09:21:06 Show Profile Email Poster Reply with Quote
I dispensed to one patient under the indigent care program w BR... The DEA paid me a 3 hour visit and wanted to see everything including the safe I kept my two bottles of Suboxone tablets in for this one patient. Frankly, I don't think it is worth the hassel to dispense in your office. You clearly open yourself up for DEA inspections and I'm not sure the profit margin is worth it...IMHO.
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Dave
148 Posts

Posted - 02/23/2007 : 10:00:36 Show Profile Email Poster Reply with Quote
It has been done for many patients at our office for the last couple of years. Many prefer that if the price is right. You do have to keep records and distinguish in the medical record between those patients for whom you dispense (Disp.) and those for whom you prescribe (Rx).
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ldmcrook
23 Posts

Posted - 02/23/2007 : 14:02:14 Show Profile Email Poster Reply with Quote
I take it that there are some states that allow certain docs to become "dispensing physicians." There is no such thing in Utah; our statutes define dispensing (of controlled substances) as the function of pharmacists only. However, the DATA overrides state law and specifically allows physicians to both dispense or prescribe buprenorphine. I have been doing some dispensing in order to save my patients a few dollars.

Currently I am inducing patients while they are in the hospital for 2-4 days, then seeing them at least weekly for the first month after discharge. I don't stock Suboxone to sell to patients, but instead of writing an Rx at discharge for just a week I write for a full month and have the pharmacy split it into two bottles; one with enough Suboxone to last until the next appointment and the balance in the second bottle that stays with me. I keep it locked up in my office and dispense it back to the patient when they bring their bottle back in at each weekly follow-up appointment. If I were to write a separate Rx each week then the patient would have to pay their insurance copay each week, which is usually $25-45. This way they only have to pay the copay once a month. The hospital pharmacy has been very willing to provide the two labeled pill bottles, and I have a pharmacist friend who gave me a spatula and tray for counting out the tablets during the appointment. And the patients really appreciate that I am trying to help manage their cost. I usually dispense a few doses more than actually needed and remind the patient that they should have some left when they come back. It's just another way of checking their compliance.

After a couple of patients just kept on walking with both bottles (and didn't keep their f/u appointment), we learned to not discharge them with all of their belongings until they had returned from the pharmacy. Just keeping their cell phone is pretty good insurance that they will bring the second bottle right back. After those first four weekly visits I have a better idea just how reliable and motivated the patient is, or how involved their parent or significant other is, to help me decide whether to continue the split Rx or let them take a full months Rx home.

The "Suboxone Practice Management Tool Kit" cd-rom that you can get from your drug rep calls this the "Alternate Medication Allocation Model" or AMAM. The cd includes an explanatory handout and a useful consent form to use. Actually, the consent form is essential according to a local DEA field agent. Otherwise it could look like prescription splitting, which they really frown on. Good records are mandatory if anyone decides to use this procedure.

By the way, my office is in the hospital, and on the 5th floor. Since I am just outside the locked psychiatric unit and there is video surveillance of the hallway, I really have not had any concerns about security. But I suppose that could be an issue in other settings.
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scolamec
53 Posts

Posted - 02/24/2007 : 02:44:03 Show Profile Email Poster Reply with Quote
Almost all of my patients have insurance coverage, or they could not afford treatment. If I was interested, NJ law would limit my mark up to a very small amount (a handling fee) that would have to be disclosed. Since that law passed, I am unaware of any docs dispensing medications. The record keeping, labeling, etc. is time consuming. Check your state laws.

Steve C
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scolamec
53 Posts

Posted - 02/24/2007 : 02:44:10 Show Profile Email Poster Reply with Quote
Almost all of my patients have insurance coverage, or they could not afford treatment. If I was interested, NJ law would limit my mark up to a very small amount (a handling fee) that would have to be disclosed. Since that law passed, I am unaware of any docs dispensing medications. The record keeping, labeling, etc. is time consuming. Check your state laws.

Steve C
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vidalia
154 Posts

Posted - 02/25/2007 : 15:46:48 Show Profile Email Poster Reply with Quote
No, I don't. BUT, I have patients who have all sorts of problems with the cost of Suboxone. I have had potential patients who did not come in for screening even, BECAUSE of the cost of Suboxone.I am very interested in the responses you get to this question, particularly if someone has a way to reduce the cost of the drug. So far, my patients find the monthly cost of Suboxone (about $150/month for 30 of the 8 mg tabs) the most expensive part of the program (just less than double my "check up " charge). If they are on more, then it works out to 2 tabs a day= $300/month, and 3tabs a day to $450 a month. So, I think your question addresses a potential solution to a real snag in my program. Ben
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mgh63
29 Posts

Posted - 02/25/2007 : 18:42:05 Show Profile Email Poster Reply with Quote
Interesting that there have been no replies to this topic. Unless there is/was an unusual circumstance my strong suggestion is to avoid selling anything but your service out of your office. The great thing about buprenorphine is that it is the first narcotic medication that we have been allowed to prescribe for the treatment of opiate addiction/dependence for some 80+ years. Patients should be able to go to their local pharmacy to obtain this medication as they would any other. You may garner the enmity of the pharmacist as well as the patients and their families who will see you as either referring to yourself or by some as holding them captive as do many of the methadone patients. Another thing to think about is the Willie Sutton principle which speaks to people looking for money in banks because that is where it is stored. There are/were a number of pharmacies around the country that put up signs saying "we do not keep/sell oxycontin". So far the demand for buprenorphine is not that great but the converse of the statement that "money = drugs" is still true. Finally, though I don't think it is against the law, the practice is not looked upon favorably by most.

kcairns
Posts: 571

Postby kcairns » Fri Aug 07, 2015 12:28 pm

ones coming in not even wanting to take the first dose is perplexing, are they faking being in mild/mod wdrl or did they fake their answers to dsm5...for all I see for induction have same story on dsm5, suffering physical and mentally, lost jobs, lost savings, lost or losing family, prison time, po's, last chance and hope, looking Godawful suicidal etc...they could be hoping to sell some of their rx to defray costs of rx or not, but in view of this place the dark side of addiction has taken them to, it would be strange to me that they didn't this moment put life change now ahead of change in pocket to spend to get get more of what did this to them in the first place.... or who would rather have the $20-50 they would have gotten for their sold dose than to be able to return the very next day after the first dose, feeling better than ever felt, having felt the goodness of gf/bf rapport, already having been able to get to the gym for working out again...Also premise of data 2000 and obot is that yes will be diversion but benefits far outweigh such and DHHS believes strongly in such and putting more monies into this rx...in my OTP work about 3% try divert their directly observed dose,about 5% get caught diverting take homes, and don't know how many divert unknown, but of those we are able to be compliant enough that we can retain them in rx, 100% are still alive and are grateful for their better lives and it is worth anything to no longer be in the hopeless life of opioid addiction (which , tell me if you disagree) can be really known by absolutely no single person who is not an opioid addict, and .....compare w reports form NH where 2016 contenders keep hearing most important issue in the state is heroin/pills and no one there seems have a prayer of awareness of great proved help...and as we procede of course do all we can against diversion but think of costs of daily dosing in obot to docs/staff and peoples jobs, vacations, time on the road, fuel burned , car crashes ...yes in NH and all over problem horrendous but w : 1)simply end to judgementalism, 2) belief in science of medicine and 3) economic access to MAT coming ahead of all that money in us goes to instead ...this disease is very controllable, America just has different goals instead

NoDrugs4u
Posts: 198

Postby NoDrugs4u » Fri Aug 07, 2015 12:28 pm

Wow, adavid, that is very enlightening! I wish we could dose all of the patients in the office, but that would defeat the convenience of buprenorphine over methadone treatment.

I do not plan to dispense from my office practice. I was asking about ordering stock because my new clinic job dispenses and they wanted me to just write a Rx for "stock", but according to DEA regs that is not kosher.

adavid
Posts: 64

Postby adavid » Fri Aug 07, 2015 12:28 pm

I dose all new patients in he office, now exclusively with Bunavail. To get it I just all my friendly local pharmacist who delivers it with a receipt. The requirements that to keep this stuff in your office are:
1) It must be stored under "substantial security". I bought a 200lb
Money Safe(not "document safe") from a local locksmith who
delivered it and bolted it to the floor.
2) Must keep all those pharmacy receipts for the DEA agent to revue
when he comes on his visitation.
3) Must keep a log of to whom, when and how many you dispensed.
Again this is so the DEA can revue.

This is a little nuisance to set up but once done it's pretty simple.

Dosing in the office can be eye opening. You will be shocked by how many people will walk out of your office at the prospect of having to be watched taking a dose. These people have no intention of taking your prescription themselves. All they want to do is supplement their income. Back in the era of the Suboxone tablets I developed the "Ten seconds test". I would place the tablet under their tongue than excuse myself from the room, count to 10 then go back into the exam room and ask to see the tablet. Far too often it was no longer there.

Dosing under supervision is not the total answer in curbing diversion but it helps a lot.

drpasser
Posts: 1404

Postby drpasser » Fri Aug 07, 2015 12:28 pm

Step 1. Ask your malpractice company if you're covered for that.

Step 2. Contact the DEA and ask them to help you set it up.



Step 3. (Probably decide, it's too much of a hassle, abandoning the idea).

More power to you. Keep us informed, after you've gotten past Step 2, above.

Best,
Kevin :-)


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