Reduction in clinic days
Beginning May, 2019, I am reducing my clinic days. I will no longer have a clinic day on Friday.
Friday was reserved for new patient appointments. This year there have been very few requests for appointments on Fridays, … so I have decided to cancel Friday clinics.
I will instead offer expanded hours on Mondays and Wednesdays; extending the clinic to 5:30pm, … to help people who miss their appointments
Now offering in-home induction.
Induction is the procedure when a patient is administered Buprenorphine/Suboxone for the first time. It is typically done in the office and patients have to be in withdrawal to receive their first dose. It is best done over two days.
First day the patient need not be in withdrawal, medical exam and enrollment is completed, patients are given Clonidine and Benzodiazepine prescription for one to three days, and asked to return to office for induction.
On the second day patient is examined to confirm withdrawal status and is administered a partial dose of Buprenorphine/Suboxone, and observed for allergic reactions, side effects, and resolution of symptoms.
This was done due to the fear that if not monitored the patient may take the medication too early, that is without going into full withdrawal, then suffer a precipitated withdrawal that may require ER visit or hospital admission. Patients who experience precipitated withdrawal are then reluctant to get into treatment and relapse.
Now that we have had several years of accumulated experience, we feel that this fear of precipitated withdrawal is overblown. If patients follow the instructions properly then there is practically very little risk of precipitated withdrawal.
Now I offer in-home induction to selected patients. This is offered to patients:
- Who have no history of allergic reactions.
- Do not have any other significant medical problem.
- Are not on any other prescription medication that may result in a drug-drug interaction.
- Have at least one person to observe them and communicate with the medical provider during in-home induction.
- Patient understands, and is willing to go to Emergency Room if there is any adverse effect during the procedure.
In-home induction procedure
- Patient completes the medical exam and enrollment in the clinic. Patient need not be in full withdrawal during this step, but should not be under the influence either. If found eligible, patient is provided in-home induction instructions and prescription for medication.
- At home, prior to taking the first dose, patient fills out a pre-induction checklist and calls the medical provider at the appointed time. The medical provider confirms that the patient is in withdrawal and allows the patient to take the first dose.
- Patient takes the first dose and calls the medical provider after five minutes and then after 15 to 20 minutes.
- Medical provider is available by phone if patient experiences any adverse effects.
- If there are any adverse effects, then, depending on their severity the patient may be required to go to the emergency room.
No new notice.
I have a part time practice. Currently the clinic is held for one week every month.
Changes in fee schedule, treatment protocol, and program policies with effect from Jan 2016.
- Changes in counseling requirement; counseling is optional after patients taper to 8mg/day
- Counseling is required for all relapses
- 12mg/day dose period increased from 6 months to 12 months
- Missed appointments allowed to continue at lower dose
- Patients at 4mg/day or lower can follow up as needed.
My program is only appropriate for those patients that are well motivated, have a high degree of self discipline, and are aiming for a complete recovery. If you need high doses, for a long time then my program is not appropriate for you.
Changes in counseling requirement:
Most of the patients coming into my practice have been transfers from other programs. Many of these patients have had counseling before. To simplify counseling requirement and make it uniform for all patients, counseling will depend on the dose that the patient is currently on.
Any patient who has had a relapse must bring a record of counseling following the relapse. This applies to even those patients for whom counseling is optional.
Counseling is mandatory for patients that start my program, and as long as they are on 12mg/day.
Counseling is optional for patients who have successfully tapered their dose to 8mg/day or less.
A relapse will require mandatory counseling.
Change in dosing schedule:
I do not prescribe more than 12mg/day for follow-up visits. The maximum period that a patient can receive 12mg/day is changed from six months to twelve months. After twelve months patients will not be prescribed more than 8mg/day.
Most patients in my program taper to 8mg/day within six months.
Patients that have achieved the dose of 4mg/day or less are allowed to follow-up as needed. Patients are encouraged to complete the program in less than a year.
Current enrollment fee for patients starting Suboxone for the first time is $325 + $25
Enrollment without induction for transfer patients, or for patients re-enrolling after a relapse = $275
Who requires induction?
- Patients that have never been prescribed Suboxone.
- Patients that have relapsed and are using long acting opioids such as Methadone, MS Contin, Oxycontin, Opana ER.
- Patients transferring from Methadone program.
- Patients that are unable to withstand withdrawal and need medications to smooth-en the process.
Enrollment and induction is usually a two day process.
First day is enrollment (paperwork + medical exam + discussion), about one to two hours. Patients do not have to be in withdrawal. Patients are provided instructions and prescription for induction medications.
Second day is induction, patients have to be in withdrawal, patients are given one dose of Buprenorphine and are monitored; takes 30 minutes to an hour. Sometimes the process can be combined into one day.
Patients who do not require induction, need to present in withdrawal, verify that they wish to proceed with self induction, are provided instructions for self induction after relapse, and are given 30 days prescription after enrollment.
Patients are welcome to split this process into two days. First day documentation, second day exam and prescription. This way they do not have to carry the entire process while they are in withdrawal.
Patients that need induction, that is they have never been prescribed Suboxone before, are started at 16mg/day. Following month they are tapered to 12mg/day.
Patients restarting a program after a relapse are started at 12mg/day or less.
Patients transferring from another program are started at their last dose or 12mg/day whichever is lower.
Once the dose is reduced it is not increased in the following months.
Changes in fee schedule for follow-up visits. No change in fee for patients on 12mg/day. The fee is $195 for all follow up visits. These patients receive $50 discount if they bring their workbook and counseling record.
Patients who have tapered their dose to 8mg/day or less will pay $95, and counseling will be deemed optional.
Patients who have tapered their dose to 4mg/day or less can follow as needed. They are not discharged. For example a patient who is taking only 2mg/day will attend the clinic once in two months.
Re-enrollment and transfers from other programs is a one day process, induction is not necessary for such patients.
Re-enrollment is subject to acceptance. Patients who have missed only one month are allowed to continue in the program at lower dose.
Patients who have missed their appointment and dropped out, and wish to re-enroll within two to six months, if accepted, will need to attend counseling first. With the counseling record the fee is $225 for re-enrollment, without the counseling record it is $275.
Patients who have been discharged for cause, … for example not attending counseling, urine drug test issues, running out of medication, lost medications, arguments with provider, etc., are not re-enrolled.
Established patients. (patients who have been in the program for three months or more) or have achieved the dose of 8mg/day or less. Missed appointment can be processed up to one week after the clinic has been closed. Requires reappointment, patient has to be present in the clinic. Clinic encounter is completed by fax and phone. Missed appointment fee of $10 applies.
Patients who have tapered their dose to 4mg/day, are considered close to success, and not discharged. They are instructed to follow-up as needed. They receive a prescription of 15 tablets or films on each follow up visit.
For example a patient who is taking 4mg/day will follow up every month, a patient who is taking 2mg/day will follow up once in two months, a patient who is taking 1mg/day will follow up once in four months.
Currently I have plenty of treatment slots available, this policy may change if the number of treatment slots available decreases. Under DATA 2000, each physician is allowed to treat a maximum of 100 patients.
All new patients are required to attend counseling under their own arrangement. To qualify as a substance abuse counseling program, the program must be run by a counselor licensed in the state, the program must offer a workbook, and provide a minimum of one counseling session per month.
Counseling must be completed before the clinic visit and a signed record must be provided. The counselor must be available and willing to verify the counseling. Patients receive $50 discount on clinic visit for providing the completed counseling record.
Group counseling is also acceptable. To meet the requirement at least two group counseling sessions per month must be attended, and the record provided.
Counseling is made optional once patient achieves a dose of 8mg/day.
Any relapse will require mandatory counseling.
Discharge from practice:
Patients that are discharged from my practice for violation of clinic policy or controlled substances agreement are not re-enrolled.
- Patient lost medications on two occasions. The first time she was given medications till her date of appointment. Second time she was advised to find another doctor.
- Patient was enrolled for the second time in the program. Previous enrollment was three years back. Patient has been to six different Suboxone providers in this interval. Re-enrollment was paid for by his mother. Did not attend counseling till warned that he will be discharged. Relapsed three times, and did not implement remedial measures as advised. Did not inform his mother of his relapse. Patient was advised to find a more intensive program.
- Patient transferred in from out of state at a maintenance dose of 4mg/day, and made good progress to get to 2mg/day. All patients are required to get a blood test done through their PCP within 60 days to check BUN, creatinine, and liver enzymes. He was asked to get CHEM-7 test done through his PCP. On every visit it was “I am waiting for insurance”, or “have an appointment next Monday” … this went on for almost two years. I gave him enough chances considering that he had been successful in tapering his dose and appeared to be doing well, but then two years is a long time for excuses. I do not like to have unpleasant conversations with patient again … and again. Patient was discharged with 30 days prescription.
This page was last modified on: May 12, 2019