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Can my doc prescribe Subutex? SHOULD he?

Posted Aug 24 2010 6:02pm

Hi all!  Sorry for the lapse in posting… I have been gearing up to blog for Psych Central, an opportunity that I am very excited about, and I have a hard time writing one blog and being excited about a second blog at the same time!  Please be sure to visit my blog at psychcentral.com, called ‘An epidemic of addiction.’  The first few posts will be mostly introducing myself with information that people here already know, so come visit in a couple weeks when I am up to speed.

A question/answer post for tonight:

As you know, generic Subutex is cheaper than Suboxone. I want my doctor to switch me to Subutex, but I am so afraid to ask him.  Even though my doc is nice to me, what if he is one of those doctors….gets mad at me, and discharges me as a patient?  I can’t do something that could possibily send me back on that old course of life that seems more and more distant every day.

Can my doctor legally prescribe me Subutex rather than Suboxone?  What good reason could he have for not agreeing to, once I show him how much money it will save me?   Also, do doctors make extra money by writing a prescription that is filled at a certain pharmacy?

My reply:

Thanks for your question.  Isn’t it sad that people are afraid that their doctors will cut them off of life-saving treatment?  The writer is not paranoid;  there are practices where patients are treated as ‘guilty’ just for asking questions that make the doc uncomfortable.  Such a situation does NOT foster the open communication that keeps addiction out in the open, where it can be treated properly and effectively.  And such a situation is a far cry from treating addiction as the disease that it is, rather than a character deficiency.

Any doctor who can prescribe Suboxone can also prescribe Subutex.  There is no difference in the actions of the two medications when they are taken properly;  Suboxone contains naloxone, that supposedly reduces IV use of Suboxone.  But studies show that most ‘diversion’ of buprenorphine is for ‘self-treatment’ of opioid dependence– not for the sake of getting an opiate high.  I suspect– but have no proof– that the RB reps encourage docs to think that if they prescribe generic Subutex, their patients will be shooting up in their lobbies.  This keeps docs prescribing brand-name Suboxone– at least until the Teva generic becomes available.

The main reason a doc won’t prescribe the generic then is fear of diversion, which in my opinion is overblown– not  because there is no diversion, but because both Suboxone and Subutex are diverted at an equal rate and used for the same thing– for illicit self-treatment.  Some docs probably avoid the generic to avoid a common problem– if the pharmacy doesn’t have the generic they will substitute the very-expensive, name brand Subutex– often resulting in calls to the doctor for prior authorizations or replacement scripts.  It is currently easier for the doctor to simply write for Suboxone.  Docs should realize, though, that the cost difference is quite significant;  in my part of Wisconsin, generic Subutex is lesss than $3.00 per tab, and Suboxone is over twice as costly.

I have heard of places in Florida (sorry Florida– maybe it happens elsewhere too, but you folks have a reputation for this) where docs provide scripts for pain pills with the condition that people use specific pharmacies.  I am surprised that such an arrangement would be legal;  it is clearly unethical to have such a conflict of interest.  That arrangement would violate Medicare law, but if they avoid Medicare patients, perhaps they can get away with it…  But to answer the question, I have never seen such a situation in my part of the country.  Docs– post anonymously if you are willing– has anyone heard of profiting by prescribing certain medications?

To the writer, I would like to just say ‘ask your doc if he/she will prescribe the generic.’  I can tell you that I would certainly not be ‘offended’ in any way, or think poorly of you.  Of course there is always some value in being polite;  no doctor likes being told what he/she ‘has to prescribe!’   But you know your doc and I don’t.  If your gut says tread cautiously, then tread cautiously.  You could always ask your pharmacist if doctor so and so ever prescribes the generic– although pharmacists tend to treat addicts even  more poorly than doctors do!

For the docs out there, maybe it would be appropriate to ask yourselves, ‘is this MY patient writing to the blog?  And if it is, why is he afraid to talk to me?’


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