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Monday Oct 17, 2016

Prescribing for Opioid Addiction Is My Responsibility

I consider myself to be a caring, comprehensive family physician, but when the FDA approved buprenorphine (Subutex) and buprenorphine with naloxone (Suboxone) for opioid addiction in 2002, I was skeptical.

Federal law requires physicians to pass an eight-hour course and apply for a waiver to prescribe the drugs, and this would put me in the position of attracting more patients who had addictions into my office. Considering the frustrations that we all face at times with these patients, I figured someone else could do that, not me.

It is 2016. Times have changed, and not for the better.

  • The opioid epidemic is getting worse. Two to three people die of overdoses every day in my state, and one dies every 20 to 30 minutes nationally. The U.S. overdose death rate in 2008 was nearly four times what it was in 1999.
  • Sales of prescription painkillers in 2010 were four times higher than in 1999.
  • Finally, and most disturbing to me as a prescriber, prescription opiates -- not illegal drugs like heroin or "street" morphine, but our legal scripts! -- are the leading cause of morbidity and mortality in those who are prescribed opioids and/or addicted to opiates.

Opioid use -- both prescription and the illegal variety -- has skyrocketed, but the number of physicians available to help those affected has not. According to HHS, less than half of the 2.2 million Americans who need treatment for opioid addiction are getting it. The Pew Charitable Trusts has noted, for example, that almost 500 patients in Vermont are on waiting lists to receive medication for opioid dependence. For the majority, the wait will last nearly a year. The issue of supply and demand for approved prescribers isn't limited to that state, and the long wait for help proves too long for many.

My patients need help, so it has to be me. I have to take responsibility.

In the past month, three patients came to me wanting more opioid medications or refills that I did not feel were appropriate. All three essentially said that if I didn't prescribe the medications, they could get drugs -- more easily and cheaply -- on the street. Those drugs, of course, are unregulated and dangerous, and some are illegal. I asked myself why I didn't have anything else to offer them.

The tipping point for me came last month when Aleksandra Zgierska, M.D., Ph.D., a family physician from the University of Wisconsin School of Medicine and Public Health, made a presentation at a Wisconsin AFP Board meeting. It was a practice changer for me.

I was reminded that addiction is a chronic brain disease, not a weakness of character or a social, moral or criminal justice problem. Medication for opioid addiction is not a new addiction, but treatment. Buprenorphine can be prescribed in the office, as opposed to methadone treatment, which may require my patients to drive 50 to 100 miles daily. Most importantly, it works!

Like diabetes and hypertension, treatment of opioid addiction involves counseling, medications, regular lab tests, routine visits and thoughtful management. And, according to Zgierska, treating opioid addiction with buprenorphine can work as well as common treatments for diabetes and hypertension.

She noted that after six to 12 months of treatment with buprenorphine, 50 percent to 80 percent of patients no longer use opioids. By comparison, after the same length of time in treatment, 40 percent to 70 percent of patients have type 1 diabetes under control, and less than half are adhering to their medication regime. Twenty percent to 50 percent of patients with hypertension achieve good control of their condition during the same period, and less than 30 percent adhere to medical therapy.

Medication-assisted treatment (MAT) allows patients to lead normal, productive lives. Every dollar spent on treating opioid addiction saves society as much as $7 in drug-related crime and criminal justice costs and $5 in health care costs.

Now I felt I could offer my patients something other than referral to a long waiting list. So on a recent Saturday, I took the American Society of Addiction Medicine buprenorphine waiver course and applied for a waiver. The cost was $200, which was a bargain considering I can report eight hours of CME.

I learned that prescribing and monitoring MAT is easier than I thought, and I can do so in my office with the type of adjustments that we make to treat hypertension, diabetes and other chronic diseases.

Barriers still remain, including costs, patient motivation, a dearth of treatment programs and, most importantly for AAFP members, lack of access to MAT. You and I can address this lack of access to care. Family physicians account for 20 percent of U.S. office visits, but we comprise less than 20 percent of physicians who are approved to prescribe buprenorphine.

The call to action in the AAFP's policy on chronic pain management and opioid misuse urges family physicians to "consider obtaining a Drug Addiction Treatment Act of 2000 waiver to deliver office-based opioid treatment." I hope you will consider getting the waiver, like I did, and implementing MAT in your practice.

You can find out more about the required training online. For other resources related to treating chronic pain see the AAFP's chronic pain management toolkit

Alan Schwartzstein, M.D., is vice speaker of the AAFP Congress of Delegates.

Comments:

It may be wiser to call for an end to the waiver. We have these letters after our names... they indicate that we are educated in the field of medicine. We also have a certification that indicates we are well-trained and dedicated to life-long learning. If additional training is imposed on us,then the certifications and diplomas are worthless. In fact, the information on MAT is simple and easy to absorb, I already know it, and would be happy to do formal CME on the topic, but refuse to participate in a discriminatory waiver.

Posted by Dino W Ramzi on October 17, 2016 at 10:20 PM CDT #

I have worked in a few primary care clinics that have an M.D. willing to see opioid addiction patients, but they were salaried, and given the time to do it right. Even then, these patients are frequently difficult with other multiple problems, and more training in residency and model program experience is a must. Suboxone treatment alone, without thorough records of chronic pain workup and consults leads to many failures, and continued opioid seeking.

Posted by Robert Nicewander on October 19, 2016 at 12:47 PM CDT #

Thanks for the update. I think MAT is a good idea overall. Not sure where one would go for the training without some searching. Unfortunately in Ohio, as part of the "war on drugs" the Medical Board has replaced general with now very specific step-by-step regulations on the practice such that I can't imagine anyone wanting to get into this field unless working for an already established clinic situation. Although its a community health problem, our local hospital doesn't want to get involved. Locally, our counseling center and law enforcement take dim views on suboxone tx due to diversion. I chuckle when I hear the Feds talk of promoting MAT when in Ohio the gov't seems to be against it.

Posted by Jeff Harwood, MD on October 19, 2016 at 03:21 PM CDT #

Well said, Dr. Harwood. As a family doctor and a diabetologist, I feel that the use of MAT is certainly saving the lives of many opioid and heroin dependent patient. I urge my peers to adopt this effective therapy for their own practices.

Posted by Jeff Unger MD on October 23, 2016 at 09:44 AM CDT #

I have been prescribing buprenorphine MAT for 6 yrs. I am very encouraged by the efficacy of the program. Why we need a waiver and patient limits for MAT but not for oxycodone is baffling. Typical government dysfunction. Now we have our local Walmart pharmacy refusing to fill buprenorphine (insisting on combination with naloxone) because "they were advised by the DEA." Also, I hear differing answers about whether PA's/NP's can prescribe MAT. We need more education from AAFP and others about MAT.

Posted by Thomas Lindsay on October 23, 2016 at 11:29 AM CDT #

"She noted that after six to 12 months of treatment with buprenorphine, 50 percent to 80 percent of patients no longer use opioids."

I'm curious where this statistic came from. Does that mean they no longer use buprenorphine, or just other opioids?

I'm very skeptical of this statistic, as every education program I've attended on buprenorphine just suggests that you leave the patient on it indefinitely... (and hence you're substituting one addictive medication for another....)

Posted by Wade Carlson MD on October 23, 2016 at 01:44 PM CDT #

"She noted that after six to 12 months of treatment with buprenorphine, 50 percent to 80 percent of patients no longer use opioids."

I am assuming that this relates to abused opioids, and not buprenorphine. I find it very difficult to get patients off buprenorphine, even at >5 years of good compliance, and a stable psychiatric profile. Who has any long term data on discontinuation?

Posted by Thomas Lindsay on October 24, 2016 at 10:25 PM CDT #

I became interested in (and started working) in addiction medicine several years ago. I am not currently practicing full primary care.
After 36 years of continuous board certification in Family Medicine I allowed my board certification to end last December because it seemed to be fairly irrelevant to my work in addiction medicine. Now in order to receive any credentialing in addiction medicine I need to be currently board certified in ANY medical field. The ABFM says my 36 years of certification is irrelevant to them in this effort.
The experience makes me doubt that the AAFP and the ABFM is really interested in helping to address the opioid addiction crisis.

Posted by John W. Aldis, MD on October 25, 2016 at 08:35 AM CDT #

After 12y+ of doing buprenorphine maintenence, and pain docs ratcheting down their prescriptions, it's clear to me that y'all should try using buprenorphine off label for pain ( unless in TN, which forbade this in the second-highest state in union for pain pill Rx!). Legal, safer, less abusable, less street value, than full agonist. Good for hyperalgesic folks, maybe causes a bit less sleep apnea, good for elderly. Insurance companymay balk, especially with cost of branded films, which have great street value amongst the incarcerated. Mono product buprenorphine is cheap and honestly not a great high when injected, but more so than combo, where the naloxone competes for mu opioid receptor temporarily...

Posted by Dave Battista MD on October 25, 2016 at 06:00 PM CDT #

Thank you for these comments. I am glad to hear from others who have decided to provide this care for their patients, as well as the obstacles that have been faced by some members.

I will refrain from commenting on the waiver process, as I am not aware that the AAFP has a position on this.

Yes, the statistic on success of treatment refers to abused opioids. As I learned in my course, the goal of MAT with buprenorphine is to prevent withdrawal, not to replace one opioid addiction for another. As a partial mu agonist, buprenorphine does not provide enough of a high for it to be sought after, especially when prescribed in conjunction with naltrexone (Suboxone).

Duration of buprenorphine therapy: Attendees at the course had experience with patients safely being treated for as many as 8 and more years. Recall, the goal of therapy is to allow the addict to avoid withdrawal. And in terms of failures, we should keep in mind that we all have patients with hypertension, tobacco abuse, and diabetes “fail” therapy, and we do not absolve ourselves from caring for these individuals. The speakers in the course advised being very very cautious at attempting weaning off of MAT, indirectly suggesting that the therapy may be as necessary for some with opioid addiction as insulin is for diabetics,

I agree with Dr. Battista’s advice on using buprenorphine in patients on MAT to control acute pain. Dividing the daily dose provides a level of pain relief without affecting the prevention of withdrawal.

A stumbling block will be if insurance companies attach prior authorizations and co pays to these medications. This will probably take time to convince them of the life saving qualities of these medicines.

I am so glad that Dr. Unger is finding success and recognizes the life saving benefits of this therapy along with his diabetic patient care.

Dr. Harwood (Jeff), I will check with my colleagues in ASAM and get back to you off line on courses in Ohio.

Thank you all again for taking the time to make these great comments on my blog!

Posted by Alan Schwartzstein on October 27, 2016 at 02:26 PM CDT #

@Alan Schwartzstein
"Yes, the statistic on success of treatment refers to abused opioids. As I learned in my course, the goal of MAT with buprenorphine is to prevent withdrawal, not to replace one opioid addiction for another. As a partial mu agonist, buprenorphine does not provide enough of a high for it to be sought after, especially when prescribed in conjunction with naltrexone (Suboxone)."

Thank you for responding to my question. I don't mean to start an online war, and I really do appreciate your response, because I really am trying to justify this in my own mind and begin helping people. Most people get offended at my questions and don't reply.

BUT, I do have a few follow up questions.

1) Most times these "courses" are sponsored by the pharmaceutical companies that have a financial interest in us prescribing these medications. Do you see this as a conflict of interest?

2) How can something that makes you not want the most addictive thing in the world (Heroin) not be more addictive than the thing it is trying to replace? It just doesn't make sense in my mind. A person will lie, steal, and kill for heroin. But now we have something that is going to replace that desire? How can Suboxone not be addictive then if it actually works? In fact, many patients have told me they buy it off the streets as well.

I'm just a little skeptical. When you look at the history of opioids, we should all be skeptical.

-When people were abusing opium, we came up with this great new prescription for opium addiction, it was called Heroin (yes, it was a prescription).
-When Heroin addiction became a problem, Sigmund Freud offered up a new revolutionary treatment; it was called cocaine
-Then the pharmaceutical companies say Oxycontin is the new cure to all our concerns, it's not addictive, etc. We all know how that worked out.

I'm just not sure how Suboxone is any different. I'm sure we were all told "oh no, heroin, cocaine, oxycontin, no it's different" too....

Posted by Wade Carlson on October 31, 2016 at 04:11 PM CDT #

And now we find that buprenorphine doesn't work either...... Surprised?

http://www.cbsnews.com/news/opioid-addiction-treatment-may-be-hindered-by-hidden-problem/?ftag=CNM-00-10aac3a

Posted by Wade Carlson on February 26, 2017 at 09:18 AM CST #

Buprenorphine and methadone definitely work. The science is robust. A person with opioid use disorder in recovery without meds is twice as likely to die as a person who takes meds (bup or methadone) as part of treatment. The challenge to family physicians in providing this life saving treatment is the dysfunctional healthcare system and the involvement of third party payers in primary care. Here's an article I wrote on the topic & how I treat addiction in a direct primary care setting. http://www.asam.org/magazine/read/article/2016/05/27/one-addiction-doctor-s-experience-with-a-new-payment-model--direct-primary-care
My advice to physicians who want to start treating opioid use disorder with buprenorphine would be to join ASAM and attend some of their education conferences. Also, find a mentor on PCSS-MAT to discuss difficult cases and to provide moral support. Addiction physicians face stigma similar to that faced by people with the disease.

Posted by Molly Rutherford on May 03, 2017 at 10:11 AM CDT #

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