Physicians Are a Problem

Data published by the Centers for Disease Control that prescription pain medicine is the largest cause of accidental deaths in this country is widely reported. The corollary very strongly states that doctors are the number-one cause of accidental deaths in this country, but I have yet to hear this indictment made. Sure, much of the prescription pain medicine causing all of these deaths is stolen, diverted, bought illicitly or otherwise obtained, but it is still prescription medicine from physicians who overprescribe without oversight or accountability, leading to three of every four opioid overdose deaths.

More than double the number of U.S. deaths in the entire Vietnam conflict died of opiate overdose in the last decade in this country. This epidemic led to the embrace by federal officials of the use of Suboxone (which contains buprenorphine) as a safer, less-stigmatized alternative to methadone for the treatment of opiate addiction. The group contributing greatly to this epidemic—physicians—would now be tasked with treating it using Suboxone. Instead of getting the fox out of the henhouse, rabbits were added to the henhouse, giving the fox another choice! At least this is the reality that has emerged.

Buprenorphine is now experiencing the exact same problem that opiate over-prescribing fuels. Many physicians who have no experience in addiction treatment are indiscriminately prescribing it. The law describing who could prescribe Suboxone requires an eight-hour online course, then “Presto!” an addiction expert is created. In my own experience, a pharm rep came to my office and basically told me how to answer the questions, and it took 45 minutes. This is the norm, according to the Suboxone docs in many areas of the country I have polled. There are addiction specialists prescribing Suboxone, but the same federal law making it available limited the number of patients a single doctor could treat to one hundred at any given time. The reasoning for this is baffling and unclear, but there has been great resistance among lawmakers to change it.

The law requires regular UDS testing, counseling, groups and other provisions. There is basically no enforcement.

Patients often pay cash for the doctor visit and the med. One hundred patients added to a practice at prices ranging from 200 to 600 dollars per month each for the visit in many non-addiction specialist offices attracts many for profit motives in this day of declining reimbursements for everything. If addiction treatment is not addressed, these patients can be seen in less than five minutes. 

Buprenorphine can be abused. It is. It is also illicitly bought and sold. Addicts want buprenorphine around to keep from withdrawing, even if not used to get high, so it is sought on the street. 

Addicts showing up for treatment at the office of a Suboxone doctor often abuse many different substances, and they often have co-occurring disorders. The non-addiction specialist providing the med more often than not has no experience or training to address these issues. Being a Suboxone “expert” tells me nothing about detoxing someone with an anxiety disorder from benzos.

Addicts seeking treatment, and even referring doctors, know nothing of these issues. They are duped. I hear in my office regularly the question “why did the doctor do that?” when talking about either the large number of opiates and alprazolam they were prescribed or the large amount of buprenorphine they were regularly prescribed with no other real addiction treatment. 

At this pint let me say, there are many well intentioned and ethical Suboxone providers that have been placed in a position of caring for a disease that is far more complex than what is taught in the online certification course. However, too many doctors are using it only as a profit center.

These problems and others have led to a general “bad rap” for buprenorphine in general. Evidence-based medicine practices strongly demonstrate the benefits of buprenorphine in the appropriate setting. This setting must include professional addiction counseling, treatment of co-occurring disorders, and strict accountability measures by the prescribing physician. 

Addiction societies and others have been lobbying strongly to rectify these problems. It may be a while. In the meantime, we must do our best to make sure patients with addictions are appropriately treated by addiction specialists. Medicine-assisted treatment of addiction is proven to save lives. We must not judge the use of medicines for this brain disease because they are misapplied.

Primum non nocere.  First, do no harm. 

Terrance R Reeves, MD, FACS, ABAM