Where in the World is Doctor Jeff Junig?

[jeffg]

@premierhealth
Your approach sounds the same as my Doctors which is great to see, if the current guidelines are followed to the letter then many people fall through the cracks and remain untreated which is unfair, dangerous and misses the opportunity to vastly improve quality of life. The reasons usually used to counter non compliance is " safety issue " but the result of expulsion from a program is the opposite of safe. Someone using a stimulant whilst on subs maintenance is so much safer than using street opiates and stimulants and as in your clients case safer again with a prescribed stimulant.
What daily dose do you allow, how do you advise the intervals to take it and the big question does your client take the whole script in a couple of doses to achieve a stimulant high? I still see that scenario as safe and a great help keeping the person on a better pathway than the street meth alternative, they would get a small manageable high with very little disruption to routine then back on the path.
I believe that disruption is ultimately where we loose our way and fall.

[jennjenn]

I’m sorry but discharging someone who’s repeatedly for months not passed drug screens or even the majority, repeatedly missing their counseling sessions and only showing up for doctors appointments when it’s time for their medication again, coming in counseling when they do show up and they’re high........ you don’t believe that is justifiable in discharging that patient in order to allow someone else on a waiting list a chance? I’m sorry but I don’t understand how on Earth that’s wrong? At some point when is that patient liable for their own actions? I may be misunderstanding what you’re saying jeff but it sounds like you believe in no discharging a patient ever and that just isn’t helpful to that patient. It isn’t healthy for other patients that are doing well. There should be a grace type period imo and once that’s over, if a patient still isn’t doing any better then I don’t see another choice. That’s for someone using meth, using opiates or whatever, if they don’t show enough progress that eventually leads to recovery then in this treatment, regardless of how this doctor treats the patient, there has to be a point where it just becomes enabling and not doing anyone any good and that is what I am talking about.

I am an addict and I’m always going to advocate for the patient but to an extent because sometimes no matter how much we want someone to get recovery, if that person doesn’t want it then it isn’t going to happen. Insinuating that a doctor discharging someone who isn’t progressing after a good period of time is life or death..... that isn’t fair. That’s all I’m gonna say because I’m feeling like I’m repeating myself too much and don’t wanna sound preachy about it but I just don’t see it any other way. The doctors cannot make someone choose recovery and we all know that there are plenty of people that do abuse this program by selling their medication to get their drug of choice. I believe if it goes on too long with little to no progress then it’s really not good for anyone. Unfortunately, in my area, that majority of patients are methamphetamine users..... not always but mostly.

Ok I’ll stop now, I think everyone gets my stance on this particular subject but I couldn’t let it seem like the doctors are sending ppl out to their death if they do have to discharge a patient. That isn’t fair to say and it takes all responsibility away from the patient.

[jeffg]

JenJen obviously common sense should be applied but yes maybe you have missed my point.
I was commenting and supporting premierhealth's practise of allowing the clients wellbeing to override compliance issues where they are counter productive.
The situation described had good attendance and compliance, other than occasional street stimulant use which was turned into a positive outcome through prescribing a legal stimulant.
I can only see good here and that's because of premierhealth methods and i think similar methods should be applied as often as possible to those that may drift from complance in some way but continue to turn up for appointments and prescribing, ultimately those clients will be in a better healthier place.

[suboxdoc]

Thanks for sharing your approach. I too have had patients who use illicit amphetamines, who say that they use them because they can't function without them. If a patient is employed and appears to be trying to make positive changes, I'll sometimes enter into a contract where they can be prescribed Vyvanse providing their drug tests remain negative for cocaine or methamphetamine.

In Wisconsin, patients on state insurance can choose between Vyvanse and methylphenidate-based meds. About a year ago, the state stopped covering Adderall, and patients on state insurance are not allowed to purchase it out-of-pocket unless they've gone through a 4-month process. They must try a month each of two different doses of Vyvanse, then a month each of two different doses of methylphenidate. If they fail all four, they are allowed to purchase Adderall out-of-pocket.

Premier, out of curiosity, how do you prescribe Vyvanse in patients who are used to Adderall? For example, a person taking Adderall typically receives 20 - 30 mg of amphetamine over 4 hours. Vyvanse 30 mg only contains about 10 mg of amphetamine spread over a much longer time - 12 to 16 hours or longer. So 70 mg of Vyvanse, once per day, spreads 23 mg of amphetamine over the entire day - quite a difference from taking 30 mg of amphetamine over 4 hours!!

Wisconsin pays for two doses of Vyvanse per day, but if I prescribe two doses I receive letters from the state 'reminding' me that the FDA max for Vyvanse is 70 mg per day. I keep writing back with my own 'reminder' that the 70 mg dose of Vyvanse was the top FDA dose for CHILDREN for a couple years, before Shire asked for the adult indication. I wish that Shire had done the studies for FDA approval for a higher-dosed capsule.

Some patients complain that Vyvanse 70 mg doesn't provide effective treatment - which is consistent with the relatively small amount of amphetamine they are getting. But now and then I'll have a patient who has strong stimulant side effects, even on 50 mg of Vyvanse (which is less than 12 mg of amphetamine, spread over the entire day!). I'll see them grinding their teeth and even act a little paranoid (and then I lower their dose, of course). Maybe Vyvanse somehow provides a more-efficient delivery of amphetamine? Of course they also may be supplementing with other amphetamine meds like Adderall... Just curious if you've seen similar issues?

[jennjenn]

“Obviously common sense would be applied” that was rude but ok...... oh and I was also going off an earlier post of yours on this thread that I’m not going to bother to look bk up but I got the feeling you were in favor of no discharging patients whatsoever saying something about life or death so yeah, just stating my opinion on it just like you did..... without talking about common sense and all that but you have a wonderful day!

[jeffg]

“Obviously common sense would be applied” that was rude but ok...... oh and I was also going off an earlier post of yours on this thread that I’m not going to bother to look bk up but I got the feeling you were in favor of no discharging patients whatsoever saying something about life or death so yeah, just stating my opinion on it just like you did..... without talking about common sense and all that but you have a wonderful day!

Jenjen, sorry about the common sense comment, i had presumed your rant was about the post it proceeded. Please use the quote function and save confusion.

[jennjenn]

It’s fine, this is a topic that is pretty important to all of us for all kinds of different reasons and different perspectives..... this is very real and at the end of the day I think we all just want to fix it however we can.

Oh and I don’t usually use the quote function, most of the time I’m on my phone and I’m not the most knowledgeable person on using these functions lol that’s just the truth unfortunately.

[CarloPucino]

You can check the American Medical Association website; they have a directory of doctors by specialty, location, and name.

[MusalimHuebes]

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[suboxdoc]

I always see this thread.... I don't have time right now to read back and find out what it is about... but I'm right here! Or if anyone is looking for a doc, find me here: https://www.fdlsuboxone.com

[Crazy_Cat_Lady]

Hey Doc. I appreciate this forum and all of the information contained in it.
Happy Friday