Increase Access to Buprenorphine Treatment in the United States

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The U.S. faces an epidemic of heroin and prescription narcotic addiction. When prescribed in conjunction with physician supervision and adjunctive treatment like counseling and support groups, the medication buprenorphine has repeatedly been shown to be effective in treating opioid addiction. (Graph below taken from http://www.drugabuse.gov/publications/topics-in-brief/buprenorphine-treatment-opiate-addiction-right-in-doctors-office)

Buprenorphine and Buprenorphine/Naloxone Help Patients Quit Opiate Abuse graph

Under federal law, buprenorphine can only be prescribed in outpatient settings by physicians who have undergone eight hours of specialized training. Additionally, a physician can only prescribe buprenorphine to up to 100 patients at a time. This limits care for patients with opioid addiction who are interested in buprenorphine therapy, but can’t find a physician who prescribes buprenorphine and isn’t already capped.

To expand access to treatment, the 100 patients/physician cap should be eliminated or increased. Current policy makes it far easier for patients to obtain other opioids such as Dilaudid, Oxycontin, and oxycodone – which have greater potential for diversion than buprenorphine and which cannot be used to treat addiction – than to access medical therapy for substance abuse treatment. Stigmatization of substance abuse should not prevent access to this relatively safe, effective, and inexpensive therapy. Please contact your senators and representative to encourage them to lift the cap.

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4 Responses to “Increase Access to Buprenorphine Treatment in the United States”

  1. sarahmarshall2014 Says:

    I am curious to know the extent of the problem of the shortage of buprenorphine providers. Do you have a sense of what percentage of trained providers have reached the cap of 100 patients? I am wondering specifically if there is a shortage of trained providers period, or if there are trained providers, but they are swamped with patients and reach the 100 patient cap. How does access fare in rural areas and outside urban centers? How does buprenorphine compare to methadone maintenance for heroin addicts? What are the advantages and disadvantages? I imagine buprenorphine is easier for people to use, since they don’t have to go to a methadone clinic to be monitored using the drug. Also, there is less potential for overdose, right? Thanks to anyone who can chime in with their expertise.

  2. jabalsewicz Says:

    Thanks for the interesting post. I believe you illustrate there is a strong demand for these behavioral health services and they need to be addressed. In conjugation with increasing the patient volume for a physician, I was curious on why there is a shortage of physicians that can prescribe buprenorphine. Is it a difficult field to specialize in? Is the physicians salary drastically lower? Does specializing in behavioral health have shorten physician career lives due to burnout? What sort of ways can we incentive physicians to pursue this patient mix so that the shortage is remedied by more providers rather than solely expanding their patient volume. Behavioral health cases are on a dramatic rise over the past few years in Illinois (where I work and know of hospital trends) and I think there may be a larger institutional problem swelling below the lack of services we are currently experiencing.

  3. alexadamsrph Says:

    The White House’s National Drug Control Strategy has two references to buprenorphine’s role, encouraging its use for opioid use disorders. It does not currently have specific recommendations with respect to increasing the accessibility of providers.(http://www.whitehouse.gov/sites/default/files/ondcp/policy-and-research/ndcs_2014.pdf) For your advocacy efforts, you may want to discuss this with the Office of National Drug Control Policy (ONDCP). Getting explicit recognition of the access issues, with appropriate sources, may be a first step in setting up your efforts for success.

  4. ekravinsky Says:

    Hi, this is a really interesting topic, thank you. This is a link to a lengthy New York Times article on buprenorphine, http://www.nytimes.com/2013/11/17/health/in-demand-in-clinics-and-on-the-street-bupe-can-be-savior-or-menace.html?pagewanted=all&_r=0 which I think does a good job of covering the issues you raise. One problem with lifting the cap is that physicians who treat large numbers of patients for buprenorphine tend not to follow them carefully (with thorough histories, urine tests, etc), which increases the potential for diversion and abuse of the drug. To answer the question from Jabalsewicz, dispensing buprenorphine is actually very lucrative, as, especially in higher volume settings, visits are short and many pay cash, so income is up to $500,000.00 dollars a year, which is certainly a lot more than the average income for psychiatrists. Unfortunately, as the article notes, buprenorphine prescribing has tended to attract physicians who may have problems themselves, and who might have difficulty finding employment elsewhere, which does not augur well for the quality of care. The other issue is that many people with addictions have other psychiatric and social issues, and the treatment is complex and challenging. Rather than simply eliminating the cap, I think it would be helpful to increase the number of nurse practitioners and PAs with specialized training in addictions, so that there would be enough well trained providers in the field. It might also make sense to provide buprenorphine care within the context of primary health care in an integrated psychiatry/medicine framework, rather than in isolated buprenorphine offices. This model has been shown in other settings to improve access and care.

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