Primary care physicians in Vermont are walking away from prescribing Suboxone, saying that they are ill-equipped to treat the many problems of the opioid-addicted, the Burlington Free Press reported this fall. One physician, John Matthews, MD, with the Health Center in Plainfield, summed it up by saying the eight-hour course required by the federal government to be listed as a Suboxone provider is only “rudimentary” and doesn’t give physicians the training needed to deal with the behavioral problems of opioid-addicted patients. “I don’t want to be listed as a Suboxone provider anymore,” he told the newspaper. “I’m pretty dubious about it. It’s like methadone. It ought to be in the hands of an addictionologist.” Contacted after the Burlington Free Press story was published, Dr. Matthews declined to speak with AT Forum.
But he and other primary care physicians have the sympathy of Peter Cohen, MD, opioid treatment authority for Maryland, where this very problem has occurred in Baltimore.
“Doctors are hesitant to start people on buprenorphine because of the implications for their practice,” Dr. Cohen told AT Forum.
‘Medication in Search of a System of Care’
“When buprenorphine first came out, I thought it was a medication in search of a system of care. The federal government said, ‘We want it in doctors’ offices but it’s up to you to figure out how to do this,’” he told AT Forum. The federal government had guidelines, but it was up to states and local entities to figure out how to implement buprenorphine. In a publicly funded system, especially in an urban area like Baltimore, the solution has proved to be induction centers with intensive case management, where patients go for their first dose, and aren’t referred to private physicians until they are stable and “smelling like a rose.”
One big problem with buprenorphine is that the first dose can’t be given unless the patient is in withdrawal. “Would a doctor who has a busy practice want someone who is going through withdrawal in their waiting room?” asked Dr. Cohen. “I’m not talking about stigma, I’m talking about logistics.”
If a patient calls asking for an appointment to get buprenorphine, the physician is supposed to say to come in immediately—that day—for an appointment. That in itself is not easy for a busy physician, because the exam is time-consuming. And when the patient is scheduled for an exam, he or she is told to stop taking opioids and to come in when withdrawal symptoms begin. The entire process is cumbersome.
Induction centers are best suited to urban areas, Dr. Cohen said. “Vermont is going to be different, because it’s rural.” In private practice, what physicians need is a “supporting structure” if they are going to be providing buprenorphine, he pointed out. That structure is always present in OTPs. “As a physician, I know by experience that there’s more to the person than the medication.”
There are 325,000 to 375,000 patients taking Suboxone at any given time. About 21,500 physicians nationwide are certified to treat a maximum of 30 patients, while an additional 5,560 physicians are approved to treat a maximum of 100 patients.
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