addiction doctorEach physician who prescribes buprenorphine for opioid dependence can treat only 30 patients at a time during the first year as a certified prescriber. After a year, physicians can apply to have the limit increased to 100 patients.  I have been at the 100-patient limit for some time, in part because of the shortage of providers willing to undergo training and go through the paperwork to get certified.

At the same time, there are no limits at all on the number of patients who can be treated by doctors with high-potency opioids, and no limits or regulations on the types of conditions that can be treated using narcotics.  It is no surprise that I receive several calls per day from people who ask for help, who I am forced to turn away.

The 100-patient cap, combined with the shortage of doctors, results in one of the few areas of true health care rationing, and it is only appropriate that the rationing hit drug addicts– those viewed as society’s least deserving.  I realize that some people see ‘inability to pay’ as a form of rationing, and I understand the point.  But inability to pay has at least a theoretical solution—if not an actual solution if enough hoops are jumped through.  For opioid dependence, the patient cap is an absolute restriction, with no grievance or appeal process for those left out.

I feel for the patients who call asking for help, and for the parents who sometimes call in place of the child-addict.  If I am the first person called,  the callers are surprised and angry at being turned away.  Here they finally got up the nerve to ask for help, and the person on the end of the line won’t DO anything?!  More often, though, my name was found halfway down a long list of telephone numbers from poorly-updated web directories of Suboxone doctors, and disappointment can be heard in the voice of the caller before the entire question is asked: are YOU accepting any new people?

The good part of the cap, I suppose, is that it reduces the opportunity for unscrupulous practices to become ‘Suboxone mills’, turning out addict after addict with easy prescriptions but without adequate education, follow-up, and counseling.  I buy into this argument, but at the same time, I wonder why the concern over unscrupulous practices focuses so intensely over those who treat addiction?  Should there not be equal concern over the number of patients that a neurosurgeon can care for?

Now that we have urgent care centers in supermarkets, is there no limit to the capacity for the doctor in the meat department to provide adequate care and follow-up for the patients who stop by?  Or is it OK if a general practice doctor decides to schedule 20 patients per hour, so that each patient receives a bare minimum of focused care with no time for preventative medicine?

But we think differently about THOSE doctors—those who work in the clean world of treating asthma and ulcers and hemorrhoids—than we do about the docs who work with drug addicts.  With the former, there is an assumption that the doctors are good people who will know their own limits and do the right thing—even as any trip to the doctor points out the folly of that assumption.  And the latter group of doctors—those who stoop to treating addiction—are assumed to be incapable of determining, by themselves, the appropriate number of patients who can be safely seen in their practices.  The expectation of bad practice comes from negative attitudes toward those with addictions, with doctors guilty by association.  In short, the medical specialty of addiction treatment suffers the same negative stigma as do the addicts themselves.

Given these attitudes, I do not expect the shortage of buprenorphine prescribers to end anytime soon.

Photo by Grzesiek, available under a Creative Commons attribution license.