The Frontline of Suboxone Providers

Typical media coverage of Suboxone providers in Kentucky tends to focus on its diversion, featuring those who have abused the drug by injecting it after obtaining it on the black market, or on doctors who face suspicion for running a cash-only business, like the pill mills of yore. Television news coverage often plays this to the extreme, using stake-out footage of blurry-faced heroin addicts descending upon a nondescript building in what viewers once assumed was a serene neighborhood, only to have their cameras turned away by doctors who for some reason take issue with the threat of their patients’ face and secret being broadcast on the evening news.

In the latter coverage, the context of what Suboxone is and how it works is brief, if not nonexistent.

IL spoke with three Suboxone providers in the Louisville area who argue that while diversion remains an issue, too often neglected is the fact that the medication is literally saving the lives of many patients – despite the obstacles that regulations and stigma surrounding MAT are throwing in their way to discourage doctors from offering such treatment.

“The patients say that it has really turned their life around,” says Kathy Doll, the office manager of Behavioral Healthcare Management in St. Matthews, where psychiatrist Cathy Tao has prescribed Suboxone for seven years. “They’re able to work and reestablish family ties that have been severed because of the addiction. I think there’s been nothing but positive reaction from patients who have been on Suboxone in part of a program.”

Doll emphasizes that Suboxone is not a quick-fix magic cure that is given out indiscriminately, as patients must be in opioid withdrawal and attend in-house therapy once a week. Patients are initially given only week-long prescriptions that max out at 16 mg before being carefully weened off Suboxone to avoid a relapse, but she says this process can take up to a year, if not more.

Dr. Lori Nation of Kentucky Medical Group in Hurstbourne has prescribed Suboxone and provided outpatient counseling from Pikeville to Paducah for over a decade, and now she works with fellow psychiatrist Dr. Sara Johnson in her current office. They limit MAT to those who have been dependent on opioids for at least a year and have impairment in function, and Nation says she’s seen such patients have great success with Suboxone and become productive members of society.

“We have a treatment that works, and it’s hard to understand why some people could be against it when I’ve seen so many success stories over my career,” says Nation.

Dr. Molly Rutherford has provided therapy plus Suboxone to patients for eight years and now runs a family practice in Oldham County, where she often has a waiting list of 20 to 30 patients due to the federal limits and demand for treatment outpacing supply in the more rural area. She says that while methadone might be the best medication-assisted treatment for those needing the daily scheduling and contact with health care providers at a clinic, Suboxone is geared for those with steady jobs and high motivation.

“If patients come in because they were pushed in by a family member or the criminal justice system, I’ve seen those people struggle a little more, because if they’re not ready they can find a way to not follow the program,” says Rutherford. “But I would say anyone who’s truly committed to getting off of heroin will do well on Suboxone.”

heroin od overdoseRutherford is also the president of the Kentucky chapter of the American Society of Addiction Medicine and one of the handful of MAT providers who vocally stands up for such treatment in the face of criticism and regulatory hurdles. She says that while the federal government and many states are beginning to embrace MAT and Suboxone, Kentucky remains hyper-focused on criminal diversion instead of viewing the problem as a public health crisis.

She says one of the reasons for this is an emergency regulation handed down by then-Gov. Steve Beshear in 2014, which only exacerbated an existing weakness among managed care organizations to create a disincentive for those wanting to provide MAT to low-income Kentuckians covered by Medicaid.

Rutherford was one of the many providers who attempted to build a practice serving Medicaid patients with therapy and Suboxone, but the managed care organizations required onerous prior authorizations for the medication and provided such delayed and meager reimbursements for doctors’ services that they could not stay in business unless they charged on a cash-only basis. While Medicaid patients could still be reimbursed for their Suboxone prescriptions, the Beshear administration then enacted a regulation saying that doctors could no longer be Medicaid providers if they charged cash for office visits, further pushing Medicaid patients away.

“The way that this regulation came out, it sort of implied that every single doctor who did buprenorphine was only doing it to make money,” says Rutherford. “So that made a lot of people very uncomfortable, it drove some people out. Maybe it drove out some of those really bad actors or people who maybe weren’t practicing great medicine, but it also drove out some people who were really good and could have helped a lot of people.”

Dr. Nation adds that these rules ultimately meant that “the most oppressed population that we have in this state is further oppressed because they are limited. So I have patients where families or church groups will want to start them in treatment, and according to Kentucky state regulations, I can’t see them.”

The end result is that all Suboxone providers became cash-only clinics, and long-term maintenance on the medication is not cheap. If Suboxone prescriptions are not fully covered by private insurance, this means doctor visits and medication can cost up to $600 a month – cheaper than a bad heroin habit, but still an obstacle to many contemplating a difficult leap to treatment. And the more difficult it is to receive therapy and MAT from a qualified professional, the more likely it is for heroin addicts to seek out Suboxone on the black market, or from less rigorous doctors.

Diversion

The downtown needle exchange van outside of Louisville's health department
The downtown needle exchange van outside of Louisville’s health department | Photo by Joe Sonka

Matt La Rocco, a counselor who works inside the Louisville Metro Department of Public Health and Wellness syringe exchange, has the unique perspective of interacting with hundreds of heroin addicts in the area, hearing their firsthand accounts of struggles with treatment. He says that while he’s seen success in abstinence-based 12-step treatment, he’s seen the same among those receiving therapy and MAT, and that much of the stigma around Suboxone and methadone is unwarranted.

However, from listening to syringe exchange participants, he’s also aware that there are a couple of doctors in Louisville who give MAT a bad name, as heroin addicts know which ones will easily write a prescription without requiring additional counseling.

“I heard one participant go ‘Oh, you should go to this doctor, it’s really easy,’” says La Rocco. “And I asked him, ‘Do you want easy? Because if you want easy, then go there. Or do you want some accountability and to get better?’ He said he wanted to get better, so I said I wouldn’t go to that doctor, then.”

There are participants who are obtaining Suboxone off the street, La Rocco says, and he’s encountered some who have been able to stay off heroin for long periods of time, even without the benefit of professional therapy to go with it.

“I talk to people who say ‘yeah, I got some Suboxone off the street, and I took a few strips and I tapered off and I was able to stay clean for three months,’” says La Rocco. “So somebody with limited coping skills just got some medicine, didn’t take it like it was prescribed, didn’t follow any kind of routine structured thing, and they were able to get clean and hang on to that for three months. Well I wonder what they could do if they had therapy and a doctor who was working them through that process?”

On the debate over abstinence-based treatment and MAT, La Rocco likens the treatment of the disease of addiction to the treatment of cancer. Just like there are many forms of cancer that are treated in many different ways, and each person may respond to treatment in different ways, so too must addiction treatment providers craft a recovery model for each person based on their unique circumstances.

“I think The Healing Place helps a tremendous amount of people, and the people that are successful there are the exact target that The Healing Place needs,” says La Rocco. “The only thing that concerns me is, if I had someone go through my program eight or nine times and they weren’t successful, I might tell you to try something else. But that happens in other forms of treatment like MAT, too… We collectively do a disservice to people who struggle with addiction when we hold onto our own philosophies or theories about what recovery looks like, and we’re not willing to be a little more expansive and accepting that maybe not everybody fits in our model.”

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Joe Sonka
Joe Sonka is a staff writer at Insider Louisville focusing on government, politics, education and public safety. He is a former news editor and staff writer at LEO Weekly and has also freelanced for The Nation and ThinkProgress. He has won first place awards from the Louisville Metro chapter of the Society of Professional Journalists in the categories of Health Reporting, Enterprise Reporting, Government/Politics, Minority/Women’s Affairs Reporting, Continuing Coverage and Best Blog. Email him at [email protected]