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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 6 of 6. This is the beginning of the thread.
Posted by pseudoname on November 3, 2005, at 19:50:58
(Or Ms, of course.)
I want to try the opioid buprenorphine (Subutex®, Suboxone®) for my treatment-resistant depression. It's normally used in treating addiction to the milder opiates. I mentioned it today with my pdoc. She said, "Yes, I thought about that for you, too, when you tried the naltrexone."
But she doesn't have the special waiver you need to prescribe it. I handed her a paper with next week's local Fed-approved training session (1 day, $100). She had a conflict that day but said she would try in the near future. Just for me! What a sweetie.
Until then, I'm trying to find someone willing to prescribe this stuff for a depressed guy WITH NO HISTORY OF ADDICTION. My initial results are not promising.
I got the list of bupe docs in my state from SAMHSA*. Then I started narrowing it down to
(a) psychiatrists
(b) in general practice – i.e., who don't just treat addicts in rehab
(c) within a day's drive of my house.That way, whoever I talk to will have fewer excuses to say No. But it turns out they don't need an excuse.
BUPE-DOC-1: Answers his own phone. (Nice.) Very calming voice. He says, "It is illegal to prescribe Suboxone for anything but opiate addiction."
Sigh. That's complete bullfeathers. (See http://www.dr-bob.org/babble/20051031/msgs/573784.html.) Where the heck do these professionals get their information?! Isn't that covered in the 8-hour training session?! Or med school?! Anyway, I deferentially set him straight on the law.
Then he says, "I specialize in treatment-resistant depression. I have never heard of buprenorphine being used for that."
Again, where the heck do these professionals get their information?! Don't they ever read Babble?!! I mentioned that there were a few published studies.
BUPE-1 says, "Well, I would not prescribe it for a non-addict. Have you considered Vagal Nerve Stimulation?"
Now, I know from my pdoc that the Cyberonics people have been out in force around here the last few weeks pushing their newly-approved VNS. She got visited herself. I'm guessing BUPE-1's recommendation is not based on years of personal experience with VNS but on the fact that he recently got happy-talked by a sales rep!
Sheesh! I wish I could send the Suboxone reps over to him, but drug companies are barred by regulation from promoting off-label uses.
Chairman MAO suggested pretending to have an addiction. I doubt I could pull that off, but I'm not ruling it out. Or, I could just become an oxy user, never mind the bupe. It would be easier to get.
I have a $250 appointment scheduled next week with BUPE-DOC-2, whom I have not spoken with but whose receptionist tried to dissuade me. I'm going in with copies of
(a) the 2 published depression studies
(b) a journal editorial decrying the neglect of bupe for depression
(c) the Fed publications that explicitly allow off-label uses of bupe.Any advice appreciated.
————
*see http://buprenorphine.samhsa.gov/bwns_locator/index.html
Posted by thuso on November 3, 2005, at 23:43:31
In reply to Looking for Mr Bupe Doc, posted by pseudoname on November 3, 2005, at 19:50:58
If I were you, I would get the pdoc who said she had thought about using it for you to write a letter or call Bup-doc 2. The only reason she isn't prescribing it is because she doesn't have the training yet. Maybe she can explain the situation via a letter or over the phone. I doubt bupe-doc 2 is going to decide to rx it to you just based on those copies you are going to bring.
Posted by pseudoname on November 4, 2005, at 11:58:39
In reply to Looking for Mr Bupe Doc, posted by pseudoname on November 3, 2005, at 19:50:58
Ignore my post above. I misunderstood the buprenorphine laws. I'll lay out what I now think I understand. Sorry if TMI, but pdocs don't seem to know this.
SHORT VERSION: My pdoc can give me bupe for depression, right now. So can yours.
LONG VERSION:
The Narcotic Addict Treatment Act of 1974 made it a crime for a doctor to "treat" opioid addicts by giving them opioids. The goal of NATA was to put doctors who were little more than methadone mills out of business. Exceptions were made for highly controlled methadone clinics and other progams with special Federal approval. Beginning in 2003, special waivers were given to private-practice doctors to prescribe the Suboxone and Subutex versions of the opioid buprenorphine to opioid addicts in addiction treatment. Only they can give Suboxone to addicts in treatment.
http://www.nap.edu/openbook/0309052408/html/96.html
http://www.usdoj.gov/dea/pubs/csa/823.htm#gIt still was (and is) legal, however, for ordinary private-practice doctors to prescribe opioids to anyone for purposes other than addiction treatment, and doctors do this every day. A DEA registration is required (different from the bupe waiver), but most doctors have this: it's used to prescribe any "controlled substance" on Schedules III-V – like Ritalin.
http://www.usdoj.gov/dea/pubs/csa/812.htmMost prescribed opioids are FDA-approved for pain. It is still legal, however, for any doctor using her clincial judgment to prescribe any medication for an "off-label" use. Even opioid drugs can be prescribed off-label – except that opioids cannot be prescribed to treat opioid addiction. (That's the NATA law.)
http://buprenorphine.samhsa.gov/faq.html#21The buprenorphine "waiver" that a doctor gets from the Feds only applies when she prescribes (a) the Suboxone or Subutex versions of bupe (b) TO AN ADDICT (c) FOR HIS ADDICTION. After she takes the 8-hour class, the Feds *waive* the restrictions in the 1974 NATA laws for her, allowing her to treat opioid addiction with these opioid drugs. She can then treat no more than 30 *ADDICTS* at a time with these drugs. But she is free to use Suboxone with her other patients, for other purposes.
see Pain Medicine 5(3) 303-308; 2004
http://www.doctordeluca.com/Library/WOD/DearDEA04.htmAny doctor with a Schedule-III registration can prescribe Suboxone and Subutex without further certification as long as he is not using it to treat an opioid addiction. He is as free to write 102 prescriptions for Suboxone as he is for any controlled substance. It's apparently necessary, however, to put the non-addiction treatment on the Suboxone prescription, i.e., "For pain."
http://www.csam-asam.org/pdf/newsletter/summer2003.pdf, pg 6Also, the special waiver never applies to other forms of buprenorphine, such as the injectable painkiller Buprenex, which is a Schedule V drug. Buprenex CANNOT be given to an addict for addiction treatment even if the doc has a waiver. Buprenex is just as available for off-label uses as Ritalin or Adderall, and virtually any doc can prescribe it. No pharmacy should balk at the script, either, since it never requires a waiver ID#.
http://buprenorphine.samhsa.gov/bwns/about.htmlOn the drugbuyers forum, someone points out another reason docs may be reluctant to write bupe scripts:
"Doctors with regular DEA #s can use Subutex and Suboxone off-label for pain, depression, whatever they deem fit. They take a risk, though, when they prescribe anything off-label. In addition to the controlled substance concerns, they need to worry about malpractice. When a doctor prescribes according to the label, it's hard to sue them over the outcome. Not so for off-label prescriptions."He also says that if a doctor uses her Suboxone waiver ID# on your prescription, even if the prescription is for depression, "it's assumed to be for opiate detox or maintenance." (Assumed by whom?)
http://www.drugbuyers.com/freeboard/showflat.php/Cat/0/Number/192041/Main/174995I don't know if pharmacies are as confused about these rules as pdocs seem to be. That could throw another obstacle up.
—————
I'll try to get in touch with my pdoc this weekend to let her know she doesn't have to take a special class to write the script she wanted to write in the first place.Why don't pdocs already know this stuff? Why isn't it stated clearly on the FDA / DEA / SAMHSA web sites?
Posted by pseudoname on November 4, 2005, at 12:32:36
In reply to Re: Looking for Mr Bupe Doc » pseudoname, posted by thuso on November 3, 2005, at 23:43:31
Posted by Chairman_MAO on November 4, 2005, at 12:40:31
In reply to Looking for Mr Bupe Doc, posted by pseudoname on November 3, 2005, at 19:50:58
If you are within driving distance to New Brunswick, NJ I can tell you how to get a script with no hassle.
Posted by pseudoname on November 4, 2005, at 13:02:03
In reply to Re: Looking for Mr Bupe Doc » pseudoname, posted by Chairman_MAO on November 4, 2005, at 12:40:31
This is the end of the thread.
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