I've recently started treating some people with opiate dependence in my private practice, using buprenorphine. This is something most docs in the area don't do, partly because you need to get special training and certification, and partly because most docs would just as soon not deal with opiate addicts if they can avoid it.
I decided to give it a try, partly out of curiosity, partly out of civic responsibility (there have been appeals from the state department of substance abuse pleading with us us to get certified and start treating people), and partly because business has been slow and I really need more income.
That last aspect is definitely tricky. Most people doing this treatment in private practice don't take insurance for it, and most of people who call me asking about buprenorphine don't have insurance anyway. Most, if not all, have a terrible story of woe and financial ruin, and would like be seen for reduced fee, or half fee, or free.
I researched what other docs and clinics charge for buprenorphine treatment. It's not cheap-- somewhere on the order of $1,000 for the first month, and $200-500 a month thereafter, for office visits (medication comes from a pharmacy, so is separate-- might be in the $300 a month range depending.) I've set up my rates to be considerably less than what seems to be the national average, but still, I'm not free, because doing this work isn't easy.
So a year's worth of my help in keeping off street drugs might cost someone $2,000, plus another $3,000 for their meds. Seems like a lot, until you compare it with the cost of using street drugs. My last new client told me he spent over $50,000 on oxycontin last year. Heroin isn't free either. So the argument goes, if an opiate user can afford a steady street drug habit, he can surely afford treatment to stop using. Here's a hard-nosed missive on that topic from a doc who is a recovering addict himself
But here's the rub: to pay for their drug habits, these patients have almost universally done bad stuff. Unless they happen to have a huge trust fund, by the the time they seek serious treatment they've almost certainly drained their own bank accounts. Most likely they've borrowed extensively from friends and family, who are not not going to loan them another nickel. Quite possibly they've been stealing, cheating, and/or dealing in order to pay for their habits. In other words, they do have ways of paying for their street drugs-- but it may not be pretty, or legal, or anything that a doctor wants anything to do with.
That poses a real ethical dilemma for me. Let's say, for example, that someone is embezzling $10,000 a year from his employer to pay for oxys. And he comes to me saying, "I'd really like to kick my habit, and stop being a criminal. I'm totally willing to pay you your full fee-- I'll still have to steal $5,000 a year, but that's okay. If you could see me for half fee, though, I'd probably be able to afford it without stealing. I'd feel really good about that. If you can't help me I guess I'll just go on stealing $10,000 a year and using oxys." The only option that doesn't leave me feeling guilty at all is the one where I don't make a living myself. Of the other two, I'm not sure which makes me feel least guilty.
And this isn't an exceptional scenario. This is, in one form or another, the usual story. A new patient last week had discussed payment with me in detail on the phone prior to her first visit. Then, at the end of the visit, she was shocked to "learn" that payment was due; she said she though I was going to bill Medicare for the fee. She had called so many doctors seeking treatment, she said, that she must've gotten confused about who had which policy. She rummaged in her purse, pulling out some cash, and said she could pay me about half. She went to see if she could borrow some money from her friend in the waiting room, but not surprisingly, he was unable or unwilling to loan her any. She had another $20 she could give me, she said, if I really insisted, but it would mean she couldn't buy diapers for her baby this week (I declined the $20, unsure if that made me compassionate, or a total sucker.) She said she would have more money in five days, and would put an envelope of cash in my mailbox as soon as she did. I didn't expect to see it, and didn't, and didn't hear from her.
But then a month later I found an envelope with $60 in my mailbox. "Sorry this is so late", was scribbled on it, with a smiley face. Sometimes people surprise you. I had a warm and humanity-loving feeling. Until it occurred to me that her kid might be without diapers, or some cash register might be short $60, or one week's worth of the prescription I'd written her might've been sold on the street to pay me. Then I started thinking about getting out of the opiate-dependency treatment business. Then I thought of the plea from the department of substance abuse. Then I went to bed and tried to stop thinking.