One of the main barriers to the use of buprenorphine for treating opioid dependence is the small number of physicians able to prescribe the medication. The shortage of doctors is aggravated by the limit placed on certified physicians, who can treat no more than 100 patients at a time with buprenorphine (only 30 during the first year of prescribing buprenorphine).
Patients seeking buprenorphine treatment in Eastern Wisconsin find long waiting lists. In many parts of the country residential treatment programs that could incorporate buprenorphine are unable to find physicians who can accept patients for aftercare. The inability to refer for aftercare forces programs to use less effective treatment approaches.
Buprenorphine treatment of opioid dependence requires physicians to be ‘DATA 2000 - Certified’ in order to prescribe the medication. DATA 2000 is the Drug Addiction Treatment Act of 2000, the law that allows for the use of buprenorphine for treating addiction to pain pills and heroin.
Medical practice advances and evolves in every specialty, but doctors are not required to obtain government permission in order to use each of the many new medications...-Jeffrey T. JunigThe certification requires the doctor to take a short course about the drug, a process at odds with other areas of medicine. Medical practice advances and evolves in every specialty, but doctors are not required to obtain government permission in order to use each of the many new medications that come to market! Even with radical changes in practice, such as the use of lasers, endoscopic surgery, or robotic surgery, the government trusts doctors to decide, without government intervention, what education is necessary.
Doctors who obtain certification to prescribe buprenorphine must agree to provide or refer for counseling the patients who they believe would benefit from that type of care. The biggest disincentive for many physicians is the requirement to allow random inspections and audits by the DEA, without cause. In an era when most doctors are employed by large health systems that spend big bucks on marketing, is it surprising that systems do not want their doctors to make such agreements?
Also Read: Buprenorphine’s Black Eye
Beyond the official DATA 2000 requirements, doctors are aware of ‘ghost regulations’ that are not defined on paper, but that are enforced by licensing boards that go after doctors using the ever-changing ‘standard of care.’ Other barriers are placed by insurance companies that won’t cover buprenorphine if a patient is not in counseling, or that require the dose to be tapered after an arbitrary length of time. Some states have codified the standards by creating laws that regulate what other specialties call ‘practice decisions.’
Most patients would prefer to have their physician play a greater role in their care than their state legislator. But some states now require doctors to refer all buprenorphine patients to counseling, even though there is no evidence that mandatory counseling improves addiction treatment outcomes. Should states be able to limit patient access to life-saving medication only to those who agree to attend mandatory counseling or faith-based recovery programs?
Should states be able to limit patient access to life-saving medication only to those who agree to attend mandatory counseling or faith-based recovery programs?-Jeffrey T. Junig
Some states mandate appointment frequency and/or require monthly urine drug screens. They haven’t gone so far as telling doctors what they must do with the results of such testing, so I wonder what they would prefer? Should doctors be required to discharge a patient who tests positive for oxycodone? In other areas of medicine, patients are allowed to suffer aggravations of their conditions — e.g. worsening of diabetes, or exacerbation of asthma, or cancer reoccurrence – without being tossed from treatment. What do politicians want doctors to do with patients who struggle? And why are doctors not allowed to decide what is appropriate for each individual patient, as they do in other areas of medicine?
The biggest irony in the regulations about buprenorphine can be found in comparisons with other medications. The CDC estimates that 15,000 Americans die from overdose on pain pills each year, and over 10 million Americans abuse pain pills. Almost all practicing physicians - and nurse practitioners - are granted DEA licenses to prescribe schedule II narcotics including oxycodone. There is no mandatory education for the licensing beyond the training that occurs while working toward the professional degree.
There are no limits on the number of doctors who prescribe oxycodone, and no limits on the number of patients that a physician can treat with oxycodone. There are no limits on the dose of oxycodone prescribed to patients. There are no requirements for patients prescribed oxycodone to go to therapy, and no required urine drug tests. Doctors and nurse practitioners can treat unlimited numbers of patients with amphetamines or benzodiazepines.
There are no limits on the dose of oxycodone prescribed to patients. There are no requirements for patients prescribed oxycodone to go to therapy, and no required urine drug tests.-Jeffrey T. Junig
Regulators claim that they do not intend to reduce treatment availability, and that patient limits are necessary to insure adequate care. But even with the most complicated and physically-draining surgeries, there are no limits to the number of patients a surgeon can commit to at one time. There are no limits on the number of pregnant women an obstetrician can treat, and no limits on the number of deliveries a doctor can do in one evening or weekend. There are no limits to the number of patients that a doctor can treat using chemotherapy.
Death from buprenorphine is uncommon, and almost always limited to accidental ingestion, ingestion by people naïve to opioids, and use in combination with other drugs. And the buprenorphine diversion that has caught the attention of so many detectives and state legislators consists largely of patients who are at worst trying to treat their own devastating illness, as misguided as the people obsessed with holistic treatments— and in some cases people who seek treatment, but have no access to certified physicians.
I suspect there are a few others who want the benefit of treatment with buprenorphine, but who are not, at this stage of their illness, willing or able to commit to psychotherapy. What do you suppose would be the compliance rate for anti-hypertensive medications, if all patients receiving medication had to to engage in weekly exercise?
Buprenorphine treatment has the potential to save many lives, but only if it survives us!
Photo Source: istock