Hello fellow NP's working in drug addiction,
Im currently working in mental health at a recovery center. This is a part time job I mostly treat patients for anxiety, depression, adhd. The Pt population that I see is of course patients with drug addiction that are forced to seek treatment by the court mostly meth abusers. I have been asked if I am interested in starting Suboxone treatment clinic as this practice would like to offer such services. I am declining to due to this for various reasons. One being I don't have a lot of experience working with heroin addicts. And I work solo. No collaborative physician although they said they would hire one. Also I only work in this clinic less than 10 hrs a week. So doesn't make sense.
They would make $$$ but I would essentially continue getting my hourly, no benefits or anything.
Seems like liability and risk are high not worth
I am interested in hearing from other NPs who work in drug addiction what their thoughts are, experiences and how they feel about working in drug addiction and prescribing things like Suboxone and methadone. And also should you be compensated extra for working in these high risk areas.
Do you have the suboxone waiver certification? If not, you could take the course and get it. I admire your caution. I took the suboxone waiver course a while back and I do see these patients in my practice. Yes, it is a high risk demographic but so is any other area of psych. Managing patients with addiction issues is its own specialty area. I prescribe suboxone, but I do it with a treatment plan that gradually weans the patient off, and it usually works well.
The certification requires a lot of hours and if you're going to invest your time into this then it should be worth it to you financially and otherwise. If all you're going to do is 10 hours a week I seriously wouldn't bother. You will not be compensated extra for doing this if you are working for somebody else. To them an NP is an NP is an NP, and you will be not much more than their workhorse. But, it can be VERY lucrative if you start your own clinic and if you network with a good mental health counselor that you can refer the patient's to (if they don't already have one). SAMHSA and ASAM are excellent resources if you are interested in addition medicine.
Thanks for your feedback. That's what I thought. Seems like they just want me to become a prescriber. To me it wouldn't make sense. All the liability would fall on me and for what is not worth. Do you have to pay for this certificate?
Are you required to dispense the Suboxone on site? Or do you give a prescription? If required to dispense then you need another DEA etc.
Sounds like more BS to deal with. Unless we're to renegotiate contract for this to be worth it.
Yes, you have to pay. But its not expensive. I paid $299 to do it when I took it. I don't know what it costs now. I did it through the AANP, and they were offering it at a discount to members at the time. The course was 24 CE hours. And at the end of it you have pass an exam. Then you have to apply to the DEA for the Suboxone endorsement on your license. You will get a new DEA license with a separate number with an 'X' designation for suboxone prescriptions, but you don't have to pay any additional money for this.
You don't just write a prescription and give it to the patient and tell them to come back next month. If they are new, you have to do an induction. And they have to stay in your office for the specific amount of time for observation after they take the first dose. There are protocols. They have to do regular drug testing, and they have to provide evidence of consistent attendance at addiction counseling meetings. Its not BS, just a different way of managing people with certain needs.
I would not just be an arbitrary prescriber of suboxone if I have no control over the plan of care because I don't believe in keeping people on it very extended periods of time. Just enough to stave off the cravings, then I gradually titrate them down. If you are working in a state where physician supervision is required and the MDs are controlling the plan of care then THEY should write for the suboxone.
Thanks for providing more in-depth information. based on all the information you're sharing with me it definitely does not sound like it's appropriate for someone who works in this part time. I work another full-time job elsewhere. And I'm not readily available during other days. I'm not interested in half-assing anything. The practice where I'm working at is owned by social workers. I do not believe they understand what other treatments entail as well as the high risk and liability in medicine when something goes wrong is always a prescriber's fault. And they do have a great practice and I admire them for everything they have done and accomplished their practice is very successful. but I believe that if you're going to provide a service you must be able to offer it right. In the state that I'm and you do not require direct supervision or even collaboration for that matter. In the future with appropriate training and guidance I can't say that I wouldn't consider this. For now I'll just stick to what I'm doing.
It is a lot of extra BS imo. There is the contract, the close follow up, the labs and liability when someone starts using again as many do. Their perceived need for polypharmacy with psychiatric medications is also relentless in the first year or two. The good thing I have found is they are compliant with their frequently scheduled med checks. I'm particular about who I take on, they have to be in therapy and I don't prescribe it with benzos or stimulants. Like Goldenfox my goal is to eventually get them off when therapy and time has healed their brains and perspectives however the problem with this is there is zero data that indicates this is the best way to handle MAT. Unfortunately the literature and for profit nature of this industry has supported this as a lifelong endeavour which I find especially alarming as it is now being prescribed to adolescents. You would definitely need to get paid more imo.
How many of these patients can you see in an hour? Sounds time consuming. I don't think the practice knows what it's trying to get it self into. Right now they only want me to work 1 day a week. I can only do so much. Are these meds kept in a safe that only the practitioner has access to ? After the induction who dispenses these meds? .
Sounds like there is still a gray area. More research needed.
I can see how many of these patients continue to abuse the opioids despite being on this medication. I have one patient coming in because he was fired from mental health for violating contract. He said someone else told him not to stop his hereoin use as he's part of a clinical trial. He tested positive . But he needs his psych meds. Of course those meds are stimulants for ADHD.
While I already decided not to do this . I appreciate all the feedback because it helps to affirm my decision. I don't need added stress in my life. And I certainly don't want to risk my license.
For the first year, SAMHSA will not allow you to prescribe for more than 30 patients at a time. After your first year you can apply for a waiver to increase the number of patients. I do not have a dispensary in my office so I don't supply any drugs to patients except for samples of non-controlled meds that I offer for them to try. They get the medication from their pharmacy and then return to the office for the induction. I ask them to come back once a week for the first month. I give them prescriptions for dosing that lasts only until the next time I see them. If they are stable, the appointments are monthly. If they break the contract they have to find another provider.
As Jules said, suboxone can easily create more problems if the patient is unstable and rebounds to using again between doses. Many of the patients get suboxone off the street just as they do heroin and benzos and everything else. You have to go with your gut instinct from your observations and what the labs show rather than what they tell you. Most have a lot of psych issues and need to be on other meds. You have to be very careful of those who are taking benzodiazepines and stims. Some will do their utmost to manipulate you.
You have to also be careful of some of these substance abuse clinics. They are now popping up on every corner---kinda like the pain clinics of yore and the urgent care centers that are everywhere now. The common thing with many of these places is to staff with NPs, underpay them, and make them see a ridiculous number of patients every day. Many of these places claim to be responding to the opioid epidemic but I've seen some of their protocols and they are much more about money-making than they are about reducing opioid dependency. Addiction recovery patients require additional responsibility and follow-up. If you are going to go through the additional training and certification and follow-up that is required to manage these types of patients then they should most definitely pay you more. They are going to be making a LOT of money from that suboxone clinic.
Good points. They did not mentioned paying me more. In fact they made it sound like they would help with incurring some of the cost for the cert. Under these circumstances I don't see why on Earth I would add more work and liability to myself. This is a high risk population. And how do these patients find it suboxone on the street.? Obviously people who are prescribed the drug then sell it. I just read an article about a patient who shared it with his buddy and the friend had
an overdose. I'm so thankful for this site because it's incredibly hard to obtain information in this area.
Quote from Goldenfox
Many of these places claim to be responding to the opioid epidemic but I've seen some of their protocols and they are much more about money-making than they are about reducing opioid dependency. Addiction recovery patients require additional responsibility and follow-up. If you are going to go through the additional training and certification and follow-up that is required to manage these types of patients then they should most definitely pay you more. They are going to be making a LOT of money from that suboxone clinic.
I'm skeptical of the for profit methadone and suboxone clinics and do feel they can be like the unscrupulous pain management practices, not all but certainly enough. I believe bup is one of the most common contraband smuggled into correctional institutions. In addictions there now seems to be an attraction, especially for NPs, to work in this specialty by those with family members who have or had addictions issues which in my experience can drastically blur boundaries and alter one's professional judgement.
I don't remember paying for my certificate so if you want to do it check around to see if there are organizations offering the education for free.
I decided not to do it. I don't feel comfortable. For me to feel comfortable and confident aside from doing the certificate I would have to do an internship in a sub clinic for weeks and I doubt this practice would be willing to pay for that. I don't believe a certificate will count for experience. The board of nursing states you are working within your scope when you have received adeaquate training. I just don't feel that taking a cert would be sufficient. Aside from that as I stated before I can find and incentive to do this. As other posters have said. Working with these patients requires intense monitoring. And from another perspective I don't want to feel like I am putting these drugs on the streets. I remember back when people have to go in daily for their methadone dose. In such setting I would feel more comfortable.
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