Currently, the opioid epidemic is a major crisis in the United States. “In 2014 alone, approximately 28,647 deaths occurred nationally due to prescription opioid overdoses, with 2300 of those deaths, roughly 8 percent, in New York State. In 2013, 1601 people died in New York State from an opioid related overdose … This shocking loss of life to heroin and opioid drugs, an average of two deaths per day, demonstrates a death rate 68.7% higher than in 2008.” [1] “Since the beginning of the year, there have been at least 15 confirmed and 18 suspected overdose deaths in Orange County (New York), with about 70 deaths last year.” [2] Current solutions to this problem include Suboxone and Zubsolv (buprenorphine/naloxone combinations), Vivitrol (an extended-release naltrexone), and methadone. Though these treatments have had much success, there are still many problems, including limited access, lack of treatment programs, and poor insurance coverage of the drugs [2] . An additional hurdle to diminishing the opioid epidemic includes the unwillingness of doctors to prescribe these drugs. “In the US, only 49% of people with an opioid dependence can potentially receive treatment because too few doctors prescribe the medicine (Suboxone), and those that do can serve only a limited number of patients because of federal restrictions.” [3] Effective August 5^th, 2016, the federal government raised the limit of opioid dependent patients that doctors can treat with Suboxone from 200 to 275 [4] . However, with not enough providers and treatment centers, the opioid epidemic is still rampant across Orange County, NY. To compile the data, 32 doctors were surveyed using two 10-question instruments: one survey for Suboxone providers, and another survey for non-Suboxone providers. This approach was taken to find out why doctors in Orange County, NY are unwilling to treat more Suboxone patients or take the certification course to be able to provide the drug. Though there are over 1000 physicians and physician’s assistants in Orange County that are eligible to take the certification course, there are only about 25 Suboxone providers in the area [5] [6] . The main goal of this research project was to understand why majority of doctors in this county do not wish to prescribe Suboxone.

Participants were contacted by means of email and telephone (Table 1 & Table 2).

Demographics of the participants are all of the physicians in Orange County, NY who are registered to prescribe Suboxone, and all of those who are not registered.

The population size (N), for Table 3, was determined by the Substance Abuse and Mental Health Services Administration (SAMHSA) registry [6] . There are 25 Suboxone providers in Orange County, New York. The sample size (n) is 7. The response rate was 88%. The majority of Suboxone providers prescribed

*-Because seven doctors were interviewed, everything has been rounded to the nearest whole percentage.

Suboxone because they believed that it helps patients, the community, and the society. Many of these doctors also prescribed other opioid medications to their patients, and screened for opioid dependence in their practice. All of the doctors were aware of the opioid risk tool, and most of these doctors believed that insurance coverage of Suboxone was a problem. If their patients wanted to seek treatment for their opioid addiction, these doctors would send them to local rehabilitation facilities or hospitals. Almost all doctors agreed that there is a social stigma among doctors to prescribe Suboxone, and that there is a social stigma among patients when taking Suboxone. In the survey 29% of the doctors had a very low number of Suboxone patients, 43% are building up their practice, and only one physician has close to the maximum number of Suboxone patients. Some doctors believed that the impediments of seeing more Suboxone patients included not having enough time, and a non-compliant patient population. Better reimbursement and insurance coverage, and improved patient education would motivate these doctors to see more Suboxone patients. Recommendations for treating the current opioid epidemic in Orange County, NY include more treatment availability and rehabilitation, additional patient education, limiting the prescription of opiates, and increasing insurance coverage for Suboxone.

The population size (N), for Table 4, was determined by the New York State Education Department [5] . There are estimated to be 1167 physicians and physician’s assistants in Orange County, New York. The sample size (n), is 25. The response rate was 100%. Majority of the non-Suboxone providers did not pre-

scribe Suboxone because they did not want to deal with this type of patient population. Almost all of the physicians prescribed other opioid medications, mainly for chronic pain and arthritis. They also monitored these patients with frequent follow up visits, random drug and urine testing, and the New York State Prescription Monitoring program. Majority of these doctors believed that there is substance abuse in their practice, and 72% screened for opioid dependence. Though almost 50% of the doctors believed that insurance coverage of Suboxone was a problem for the patients, a quarter of the doctors did not think that insurance coverage was a problem, and another quarter did not know if it was an issue. If patients wanted to seek treatment for their opioid addiction, physicians would send them to pain management doctors, addiction specialists, or local rehabilitation facilities. More than half of the doctors believed that there was a social stigma among doctors who prescribe Suboxone, whereas the other 40% thought that there wasn’t a stigma or did not know. However, majority of the doctors thought that there was a social stigma among patients when taking Suboxone. For most of the physicians, having more ancillary staff (psychologists, physical therapists, mid level providers) would motivate them to prescribe Suboxone. Recommendations for treating the current opioid epidemic in Orange County, NY include patient and doctor education on opioids, more drug screening and patient monitoring, and finding alternatives to opioids when prescribing pain medications.

Some hurdles in collecting the data included reaching out to Suboxone providers, as there are not many in the area. Furthermore, many of the non-providers did not know how to answer certain questions on the survey, as they were not familiar with those topics (such as insurance coverage and social stigmas). From the data collected, it is clear that providers should be in major treatment facilities instead of in small private practices, as these providers would be less affected by the insurance coverage problems of Suboxone. From the Suboxone providers questioned, those that were part of major corporations had a much more positive attitude towards Suboxone and were willing to take in more Suboxone patients. Therefore, Suboxone needs to be aimed at treatment facilities rather than at individual practitioners, although it was originally aimed at private practitioners. Many of the private practitioners that provided Suboxone did not want to take in more Suboxone patients because they had to deal with a difficult patient population and with patients who “constantly lied, went behind their backs, would not listen to doctors, etc.”. Non-prescribers were unwilling to take the certification course or take in patients for the same reason, or because they did not have enough time in their practice to take in more patients. Next, there needs to be more awareness and education for doctors on this issue. Furthermore, many physicians assistants and nurse practitioners are unaware that they can take the certification course to prescribe Suboxone, and that they can obtain the DEA (Drug Enforcement Agency) number for providing this treatment drug.

A major conclusion drawn from this research project is that it is necessary to destigmatize the use of Suboxone by having national, state, and local county societies to endorse its use and emphasize that it is a necessary medical practice. There should also be more outreach to nurse practitioners and physician’s assistants to provide this treatment drug, as many are unaware that they could take the certification course. National organizations such as AMA (American Medical Association) and ASAM (American Society of Addiction Medicine) should publicize that it is feasible for these people to take the course. Furthermore, making the 8-hour certification course free online, or even decreasing the required course hours may encourage more providers to take the course. Another conclusion is to have more mental health providers in addiction medicine, who can help opioid addicts with their problems and keep them from relapsing or overdosing. Next, there should be more widespread drug education among doctors. We applaud the recent mandatory opioid course for all doctors in New York State, and recommend that it should be expanded throughout the nation. We also strongly applaud the New York Department of Health’s recent Buprenorphine Access Initiative, which discusses about increasing the number of Suboxone providers and improving patient access to this medication in New York. All opioid-prescribing doctors should know how to effectively treat a patient who is found to be abusing the opiate. Finally, more access to inpatient rehabilitation programs needs to be provided to ensure that all patients who need it can be treated.

Makam, S., Gevirtz, C., Branche, J., Sperber, K. and Alexeev, E. (2017) Suboxone Prescribing Availability in Orange County, NY. Open Journal of Anesthesiology, 7, 331-340. https://doi.org/10.4236/ojanes.2017.710033