I first heard about Suboxone in 2004. I was a second-year medical student, and the clinical pharmacist teaching my pharmacy lecture that day described Suboxone as, “the single most effective medication ever developed to serve its purpose.” And that was saying something — we were learning about medications like penicillin and insulin. At the time, I didn’t have any real clinical context for that statement, but it stuck with me. So when I was paired with a great addiction medicine-trained mentor during residency, I signed up immediately to get my x-waiver to prescribe Suboxone.
The first time I actually prescribed Suboxone, I was really nervous.
I had to take a deep breath and remind myself that the oxycodone I prescribed the day before to a different patient was much more deadly, and the heroin being injected daily by the patient in front of me most certainly was too. My patient was so sick and desperate. His skin was infected and he had no money left to avoid being sick from withdrawal and unbearable pain. So I pushed forward, wrote the prescription, and diligently added my shiny new x-waiver number under my signature. Magically, the pharmacist filled the prescription, and my patient started treatment. Two days later, when that patient returned to my office, I realized I’d done something incredible for him — he was an entirely different person. He could smile, the color was already back in his face, he was no longer suffering, and his sense of relief was palpable. For the next 3 years of residency, he was my easiest patient — always on time, happy to perform whatever testing I asked of him, and diligent about taking his medication. And I delighted in sharing in his successes, from skin wounds healing to completing his GED.
My dad was a doctor — he spent 35 years taking care of patients in Emergency Rooms around Philadelphia. Medicine changed dramatically over those years, and he struggled with how shift work kept him from his four kids growing up. So it was not difficult to understand why, when I was young and told him I dreamt of becoming a physician, my dad tried to talk me out of it.
Thankfully, he didn’t succeed, and when I completed medical school, I loved medicine so much, and loved every specialty so deeply, that I couldn’t pick just one thing, and decided to go into Family Medicine. I started in full-scope rural medicine where I was the only doctor in the hospital at night. I’d go from admitting people to the ICU to running to catch a baby in Labor and Delivery. After a few years, I moved to practice academic medicine, giving me the opportunity to train Family Medicine Residents. Later, I worked for several years for an amazing healthcare organization where I carried a busy panel of over 2000 patients from newborns to geriatrics, and became the main referral source for patients with terminal diagnoses seeking physician-certification to be able to access a compassionate death through Oregon’s Death with Dignity law.
I have had an incredibly varied career, and looking back, I know I have had the incredible privilege of doing some of the most rewarding work in medicine: treating and following pregnant families and delivering their babies, teaching new doctors the practice of medicine, and sharing in the most deeply vulnerable moments at the end of a person’s life.
And in spite of all these amazing experiences, I can easily say that the most rewarding patients, the ones who filled my buckets time and time again, who kept me passionate about medicine for so many years, were my patients with substance use disorders.
Which is why I want to share what an incredible gift it can be to care for people struggling with substance use disorders. To see the transformation of patients’ lives from chaos and pain to hopefulness and security. To be there for someone when very few other people can. It has defined my career and brought me so much joy. And I believe it could do the same for many others too.
There’s a great need for more providers in treating SUDs — 40% of all US communities do not have a single Suboxone prescriber and another 24% have insufficient providers. And although it only requires an 8 hour class for physicians to get a waiver to prescribe it, most eligible doctors have not done so. Even for those waivered to prescribe Suboxone, only a small percentage ever write a single prescription. Why are so many reluctant to participate in SUD treatment?
The top clinician fears
There are structural barriers in place, yes, but in my experience, most fears and concerns can easily be addressed. Here are my thoughts on some of the common issues clinicians cite:
- Many clinicians are afraid that by getting the x-waiver, they’re also going to be signing themselves up for a complicated audit by the DEA that will be invasive, time consuming, and expose them to risk. As it turns out, the audit is fairly rare, and although I was audited once, my experience was very easy and straightforward. The DEA is looking to ensure you are keeping records and tracking numbers of your patients on Suboxone, but you can gather that information easily in your state’s Prescription Drug Monitoring Program, or pull that information from your health record.
- Others are concerned that patients with addiction might mean a lot of work and will require too much time. Clinicians worry these patients will require you to hire social workers, therapists, etc. But in fact, you can refer the patient out for these other services if your office doesn’t have the support already. And most likely, you are already seeing your patients with SUD for other medical issues, so treating their addiction actually simplifies, not complicates, the time you’ll spend with them.
- Some clinicians fear that they’ll have to see patients on Suboxone so frequently it will impact their practice, or they’ll have to build out an entire program just to support these patients. But many patients on Suboxone only need to be seen a few times a year, and it’s such an effective medication, that follow up visits are often pleasant, rewarding visits to reflect on how well things have been going.
- And lastly, some clinicians are concerned they’ll get a flood of new patients looking for meds if people know they prescribe Suboxone. But that’s not realistic. And, if it is a big concern, you are able to prescribe Suboxone without putting your name on SAMHSA’s registry if you choose, thereby keeping your waiver private for just you and your current patients who need it. It’s really up to you how much you prescribe the medication or don’t.
Other effects created by lack of access
The lack of access to Suboxone has negative effects on our patients and our communities too. The truth is, we are actually causing additional harms by not participating in SUD treatments:
- A lack of prescribers perpetuates the stigma and judgment around SUDs and makes people feel like they aren’t worth care. This is especially true when people can’t get this help from their primary care provider. I believe this treatment should be part of someone’s normal healthcare, as routine as other forms of chronic disease medication management.
- Separating SUD treatment from the rest of medicine sends a damaging message. We are signaling that SUD is not the chronic disease we know it to be, with good treatment options available.
- Without a prescriber in their community to treat them, people avoid getting treated at all. The result is lives lost, and this is preventable.
- Getting SUD treatment from an existing provider is highly effective and has a lot of value. It allows for a holistic approach that helps people and improves other health conditions too. Not becoming a prescriber as a primary care provider denies that holistic option to patients suffering from SUDs.
It is normal to fear the unknown, but the long-standing requirement of the x-waiver and the unfortunate stigma surrounding SUDs have perpetuated this issue.
Providing treatment for Substance Use Disorders is the most gratifying medicine I’ve practiced. It shouldn’t be feared.
Recently, the federal regulations around prescribing have become even easier (as part of the public health emergency declaration made by the Biden Administration). You don’t even need to take the class and get the official waiver — you can simply declare your intent to prescribe with SAMHSA and still treat up to 30 people (a small number that can still have a huge impact).
For many years in primary care, I felt like somehow I was on the wrong team — in ways I couldn’t explain, despite having always built strong relationships with my patients, I somehow felt like much of my job was trying to convince people to do things for their health they didn’t want to do or trying to help people understand why I’d want to avoid prescribing long-term medicines like benzodiazepines or opioids that I knew would cause more harm than good. The list goes on, and ultimately, most of my days ended with me feeling like a failure and unsure I was helping anyone. But that’s not how it is in addiction care.
Providers have many reasons for not wanting to prescribe Suboxone or care for patients with SUDs, but I fear they are missing out on all the reward that comes with doing this work. It’s a chance to play for the right team.
Our patients with SUDs need us, collaborate with us, and appreciate what we do — where else in medicine do you get that? It’s an opportunity to see and be a part of real meaningful change in someone’s life and the lives of the generations to follow.
Learn more about how to become a prescriber or enter SUD treatment practice from SAMHSA.
