Editor’s Note: This week’s post is the last for which Apryl Motley will be providing support. Working behind the scenes since the blog was relaunched in March 2014, she has been a central influence and steadying force in the choice of topics, conducting interviews, and editing my writings as well as those of our guests. I am very appreciative of the skills that she has brought to this project and the ways in which she has kept me and this blog on track.
Addiction in the News: Implications for Clinical Practice
Addiction treatment, as much or more than other areas of medicine, is influenced by events occurring outside of clinical settings. Government regulators and politicians, for example, acting in the interest of public health and safety, make decisions about problem substances and medications. I track these developments in the news media rather than professional journals or conferences. This week I will focus on a few of these items and comment on their clinical implications.
News: Increased patient limit to 275 from the previous 100 for physicians who are either certified as addiction specialists or who practice in “qualified health settings” that provide psychosocial and certain administrative services. This was done by means of a regulatory change and is therefore already in effect. In addition, a new law was passed, the “Compassionate Addiction Recovery Act,” that will soon allow nurse practitioners and physician assistants to prescribe buprenorphine, which they have previously not been allowed to do.
Implications: Buprenorphine has been found to significantly increase the effectiveness of addiction treatment for people with opioid addiction, as well as reducing fatal overdoses. Because of restrictions that were imposed when this medication was introduced, however, many opioid addicts have not had access to this useful medication. This has led to a black market of diverted buprenorphine, which in turn has led to negative publicity and further misperceptions about this medication. These two changes are intended to address this restriction so that patients can get it more easily, hopefully leading not only to better treatment results but also to reduced diversions.
Some prescribers view buprenorphine as a primary treatment rather than seeing psychosocial services as being primary with buprenorphine serving a valuable supporting role. The specifications of the qualified health setting are intended to discourage the increased patient limit from being used to fuel the growth of this “stripped down” treatment approach.
News: FDA requirements of 1) black box warnings on co-prescribing of benzodiazepines and opioid analgesics and 2) reviewing more closely the co-prescribing of benzodiazepines with methadone and buprenorphine.
Implications: Some prescribers of buprenorphine may not be aware of the addictive potential of benzodiazepines, especially for those patients already addicted to opioid medications. In addition, while benzodiazepines themselves do not cause fatal overdoses, they can increase the overdose danger of opioids. These new FDA requirements will hopefully reduce the incidence of both opioid/benzodiazepine overdoses and cross-addiction to benzodiazepines.
News: FDA will review its black box warning for varenicline (“Chantix”), a partial nicotine receptor agonist. In Europe, the warning was removed this year.
Implications: Although tobacco causes more medical problems and deaths than any other addictive substance, treatment for tobacco addiction lags behind treatment for other substance use disorders. Varenicline is more effective than any other medication in reducing nicotine withdrawal symptoms, cravings, and relapses, but anecdotal reports after its release about possible psychiatric side effects led to a black box warning by the FDA that has discouraged its use. Although follow-up studies have failed to substantiate these concerns, the FDA has refused to alter its recommendation. I believe that the removal of this alarming warning will lead to broader use and more recovery from tobacco addiction.
This quick overview is just the tip of the iceberg. You can check back here for my analysis and thoughts on the most pressing issues facing the communities we serve.