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News & Press: Practicing Physicians

Why Aren’t More Physicians Prescribing Buprenorphine?

Monday, March 7, 2016   (0 Comments)
Posted by: Charlie Adams
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Experts say ideally buprenorphine is prescribed as part of a total recovery-oriented treatment plan including participation in a 12-step program and/or psychotherapy, but physicians say the drug alone can at least remove the drug-seeking behavior that characterizes addiction.

Physicians who regularly prescribe buprenorphine describe it as an ideal treatment for opioid addiction—blocking the “high” achieved from use of opiates and protecting against the craving that keeps addicts coming back for more.

Yet, according to experts who spoke with Psychiatric News , the medication is underused and underprescribed, even as the nation faces a growing epidemic of prescription painkiller and heroin abuse.

According to recent surveys, an estimated 1.9 million Americans meet the criteria for opioid use disorder based on their use of prescription painkillers in the past year, 212,000 people aged 12 or older used heroin for the first time within the past 12 months, and 435,000 people used heroin in the past month.

APA Offers Buprenorphine Training

APA provides waiver-eligible training in prescription of buprenorphine through an online course and also live courses at both the APA Annual Meeting and IPS: Mental Health Services Conference. This year’s Annual Meeting course will be held on Saturday, May 14. The course has already reached registration capacity, but a wait list is being kept. APA’s training is made available through the SAMHSA-funded Providers’ Clinical Support System for Medication Assisted Treatment (PCSS-MAT).

As a partner in the PCSS-MAT, APA offers a monthly webinar that augments the eight-hour training. Each session is recorded and accessible on the APA website and the APA Learning Center. Sessions are organized by the year of presentation. These free sessions earn participants one hour of CME.

For information about APA’s online course, clickhere. For an archive of APA’s monthly webinar series, click here.

“The fundamental issue with people who have opioid use disorders and addictive disorders generally is that they are uncomfortable,” said Stuart Gitlow, M.D., immediate past president of the American Society of Addiction Medicine and executive director of the Annenberg Physician Training Program in Addictions. “When they use their drug of choice, they use it to get comfortable. The downside with opioids and narcotics is that there are significant side effects—especially rebound withdrawal—that leave them even more uncomfortable than before. So they end up chasing the euphoric effect.”

There are three FDA-approved medications to treat opioid use disorder: methadone, extended-release naltrexone, and buprenorphine.

Originally formulated as an injectable medication for pain relief, buprenorphine was approved for treatment of opioid addiction under the Drug Addiction Treatment Act of 2000 (DATA 2000).

Buprenorphine is a partial agonist, binding to the critical mu-opioid receptors in the brain (where analgesics and narcotics work) but not fully activating the receptors—so that the drug satisfies cravings without the euphoria that drives drug-seeking behavior.

Think of a lock and key, John Renner, M.D., vice chair of the APA Council on Addiction Psychiatry and president of the American Academy of Addiction Psychiatry, told Psychiatric News: “The drug is the key. If you stick heroin in the lock, it turns the lock all the way and can kill a person. But with buprenorphine, the lock gets turned only partially—no matter how high the dose, you will never get to a level that can be fatal.”

Photo: Petros Levounis, M.D.

Petros Levounis, M.D., says an advantage of buprenorphine is that it can be dispensed from a physician’s office.

Petros Levounis, M.D.

Petros Levounis, M.D., chair of the Department of Psychiatry at Rutgers New Jersey Medical School, noted another critical benefit of the drug: it can be dispensed in sublingual form in a physician’s office, unlike methadone, which requires patients to seek out treatment in a qualified methadone treatment center.

“Buprenorphine is the first line of treatment for opioid use disorder, unless there is a specific contraindication, such as an allergic reaction, or patients have done very well on methadone or other treatments,” Levounis said.

Patients most likely to benefit from the treatment include those receiving treatment for pain who have become addicted to opiate painkillers and those who are addicted to heroin, Levounis and Renner explained. (There’s significant overlap between these groups, they noted. As prescriptions of opiate painkillers have been restricted, many patients who are addicted to opiates have sought out heroin on the street.)

DATA 2000 required that in order to prescribe or dispense buprenorphine, physicians must complete eight hours of training and apply for a waiver from Substance Abuse and Mental Health Services Administration (SAMHSA). APA provides waiver-eligible training through an online course and live courses at APA meetings (see sidebar).

APA Recommends Revisions to DATA 2000

APA, the American Academy of Addiction Medicine (AAAM), and the American Osteopathic Academy of Addiction Medicine (AOAAM) advocate replacing the current practice limits of 30/100 patients, established under the Drug Abuse Treatment Act of 2000 (DATA 2000), with a three-tiered system.

 

Tier 1. Small Primary Care or Psychiatry Practices. Physicians in this tier would be allowed to follow up to 30 patients at one time, as with the present system; however, there would be no Drug Enforcement Administration (DEA) inspections unless the DEA or state agency review of state Prescription Drug Monitoring Program (PDMP) data suggest that the 30-patient limit has been exceeded.

 

Tier 2. Solo or Multidisciplinary Practice Model.In the solo practice model (including a group or multiple physicians practicing within the same system), physicians would be able to apply (after one year) to increase their patient load receiving buprenorphine from the 30 patients to 150 patients. Prescribers in this group would be required to take three hours of approved addiction-related CME annually, certify that they follow a nationally recognized set of standard evidence-based guidelines for the treatment of patients with substance use disorders, and undergo occasional DEA inspections, as in the current system.

In the multidisciplinary practice model, a physician would be able to apply (after one year) to increase the patient load receiving buprenorphine from the 30 patients to a range of up to 340 patients with the addition of up to three physician extenders to the practice (either physician assistant or nurse practitioner). The physician would be capped at 100 patients; each physician extender would be capped at 80 patients, with the total practice capped at 180 to 340 patients depending on the number of physician extenders in the group.

Tier 3. Specialized Opioid Treatment Programs.These practices would be permitted to treat more than 340 patients. They would need separate registration as a specialized Opioid Treatment Program and would be monitored accordingly with varying staffing requirements related to the number of patients being treated and subject to periodic reviews by the DEA and the Commission on Accreditation of Rehabilitation Facilities or The Joint Commission.

Further APA, AAAM, and AOAAM recommend expanding the numbers of prescribers in the following ways:

  • Permit buprenorphine prescribing by physician assistants and nurse practitioners (in those states or jurisdictions where such practice is permitted) who have taken an eight-hour face-to-face waiver course, who take three hours of approved addiction-related CME annually, and who practice under the supervision of a physician certified in addiction psychiatry or addiction medicine.

  • Explore options utilizing telemedicine that would permit delivery of buprenorphine services in rural or underserved areas.

  • Enhance federal funding for buprenorphine training for physicians and physician extenders, as well as ongoing CME programs to enhance the clinical skills of treatment providers.

  • Set aside government funding for residency programs to provide training in medication-assisted treatment (MAT), physician training in MAT through ABPN-approved addiction psychiatry fellowships, and general practice addiction medicine fellowships.

  • Provide funds to cover the costs of an expanded treatment system for uninsured individuals with opioid use disorders, as well as those covered under Medicaid programs.

With this waiver, physicians are permitted to treat up to 30 patients in settings other than an opioid treatment program such as a methadone clinic; after one year, they can apply to receive a waiver to treat up to no more than 100 patients at a time. In contrast, physicians do not need to obtain a waiver to administer monthly injections of naltrexone, but patients must go to certified treatment centers to receive methadone for the treatment of symptoms of opiate withdrawal. (Physicians who prescribe methadone as a painkiller are able to do so without obtaining a waiver.)

According to SAMHSA statistics obtained at the end of February, there are 31,862 physicians who have a waiver to prescribe buprenorphine. Of that number, 21,581 (67.7 percent) are certified to treat 30 patients, and 10,281 (32.3 percent) are certified to treat 100 patients. However, according to SAMHSA, 40 percent of the physicians who have a waiver do not prescribe buprenorphine at all.

Why are so many certified physicians staying away from prescribing buprenorphine? Gitlow toldPsychiatric News he thinks this may be because physicians are reluctant to have people with addictive disorders frequenting their office practice. (The latter is not a trivial problem; Gitlow said he has had to move his practice twice owing to complaints from the surrounding community or other professional tenants in an office building about the appearance of people with addictive disorders at the practice.) Levounis suggested that other physicians do not use their prescribing certification because they fear being audited by the Drug Enforcement Administration (DEA).

Renner told Psychiatric News that patient limits were incorporated into DATA 2000 out of concern for quality of care, but he acknowledged that the resulting limitation in treatment access is among several factors that have contributed to some diversion of the drug. The Department of Health and Human Services is developing a proposed rule aimed at expanding treatment access. Modifications to the patient limits are expected to be included in the rule, which is likely to be released for public comment in the near future.

APA does not advocate for removing the patient caps entirely, Renner explained, due to concern that such action could lead to large-volume buprenorphine prescribing practices with diminished clinical quality. Rather, along with the American Academy of Addiction Psychiatry and the American Osteopathic Academy of Addiction Medicine, APA has advocated for an incremental increase in the patient caps along with efforts to expand the number of providers (see sidebar).

Ideally, experts say buprenorphine should be prescribed as part of a total addiction treatment plan including participation in 12-step recovery and/or psychotherapy.

“There is little question in my mind that patients who participate in 12-step or psychotherapy do better,” Levounis said. “But if a patient doesn’t want to go to AA or see a therapist, the medication is strong enough that it can give a reasonable chance of success.”

Renner added, “I like to think of buprenorphine as a pharmacological platform that takes away withdrawal. It does not resolve whatever problems led an individual to seek out drugs in the first place, but what does change is that the patient’s life is not dominated by drug-seeking. The pharmacological platform makes recovery possible.” ■

More information about buprenorphine can be accessed here.


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