With all the recent attention over the epidemic of opioid dependence, why do some parts of the country report a shortage of physicians who are DATA-2000 certified, i.e. able to prescribe Suboxone and other buprenorphine products? The shortage of buprenorphine-certified doctors parallels shortages of mental health practitioners in general, including psychiatrists and addictionologists. Larger cities and areas near the east and west coasts are less likely to have shortages of doctors than are smaller and more-rural parts of the country, particularly across the Midwest.
The shortage is caused by a number of factors. All doctors train in medical schools, which are primarily located in larger cities. So by the end of training. most doctors have spent several years living in larger cities, establishing friends and business partners and sending their children to area school districts. As with members of any profession, doctors are more likely to choose positions in areas they know than to move to unknown areas, unless the area holds special attractions like morning sunrises over the ocean or mountain views. Even doctors who grew up in rural areas find it hard to move back, after living in more urban areas during the 12 years of college, medical school, and residency.
Beyond the regionalization pressures, doctors are discouraged from becoming certified to treat opioid dependence using buprenorphine. The coursework is limited by medical school standards, and the cost for buprenorphine training and registration is relatively minor. But to become buprenorphine-certified, doctors must sign an agreement that allows random inspections by the DEA without cause. Other doctors enjoy privacy rights similar to other businessmen, where search of the premises and review of records would require probable cause and issuance of a warrant by a judge. But in order to treat with Suboxone or buprenorphine, doctors must waive that right of privacy and allow inspections with no notice, even if such inspections require closing the clinic doors for the day. The requirement to allow random inspections has an effect on individual doctors, especially since the 100-patient limit (30 patients the first year) guarantees that buprenorphine-prescribing will not support a practice without a significant number of non-buprenorphine patients. And now that most doctors are employees of large health systems, the requirement for inspections is a greater hindrance. Most major health systems are not as interested in treating addiction— an area of medicine with low reimbursement rates, and patients who are more likely to be impoverished by their illness– as in attracting orthopedic or heart patients, the ‘cash cows’ of modern medicine. If you were CEO of a multi-physician network, would you permit random DEA inspections of your physicians’ offices in exchange for the ability to treat more patients addicted to drugs including opioids?
I can’t blame those CEOs and physicians for the decisions they make. The result is a shortage of buprenorphine-certified doctors, and the attraction of businessmen-doctors who find a way to turn buprenorphine treatment into a profitable enterprise, by signing doctors to increase their patient-limit, and seeing as many patients in as short a time as possible. Other doctors tend to be physicians who enjoy working in the field of addiction because of their own experiences with addiction and recovery. To those physicians, treating a fatal disease, in a disrespected and stigmatized patients, can be very a very rewarding way to practice medicine.
There are calls to raise the patient cap, or to find other ways to reduce the stigma over opioid dependence that discourages doctors from entering the field of addiction treatment. But now as more and more states are writing regulations of their own, sometimes through well-motivated but misguided efforts to reduce ‘diversion’, I’m not holding my breath that the shortage will end soon. And since much diversion consists of people using Suboxone on their own after failing to find a physician, don’t expect state regulations to move the diversion problem in the right direction!
Doctor preparing injection image available from Shutterstock.