Buprenorphine Q&A: Robert Lubran
Editor’s Note: Our guest contributor this week, Robert Lubran, deserves much of the credit for successfully overcoming many of the obstacles and defusing some of the controversies that have surrounded the use of buprenorphine use for opioid addiction. He has always been one of the first people to whom I turn when administrative questions arise about this complex medication. His perspective is welcome on an issue which continues to evolve and about which so many conflicting opinions exist.
“In general things did not go the way I thought they would,” said Robert Lubran when asked about the implementation of the Drug Addiction Treatment Act of 2000.
DATA 2000 permits physicians who meet certain qualifications to treat opioid addiction with Schedule III, IV and V narcotic medications that have been specifically approved by the Food and Drug Administration for that indication.
Lubran, who now consults on medication-assisted treatment (MAT) for substance use disorders, had a front-row seat during the implementation process for DATA 2000. His career with the Substance Abuse and Mental Health Services Administration (SAMHSA), first as a public health advisor and then as director of the division of pharmacologic therapies, spanned more than two decades.
In the latter role, Lubran and his team were responsible for certifying treatment providers and physicians under DATA 2000 to qualify as prescribers of buprenorphine. Recently, Lubran talked with Modern Addiction Recovery and offered his unique perspective on the controversy surrounding the prescribing of buprenorphine: “We have a crisis on our hands, and we’re not doing enough to get people into treatment.”
MAR: You have a unique perspective on the controversy surrounding buprenorphine. What has surprised or disappointed you about how it’s been administered or legislated?
Lubran: I am surprised that it’s taken HHS this long to propose a rule change regarding the number of patients to whom providers can prescribe the drug. There’s concern about the quality of treatment some physicians, who are not well trained, provide, but systems are in place to monitor that. Even though no other part of medicine limits how many patients a physician can see, there remains concern about the small number of physicians who may not be up to standard. Even so, we should let the most qualified physicians (i.e. board certified) and others practice without limitations.
It’s disappointing that there are so few physicians who have opted to treat opioid addiction. The U.S. government could have done more to promote MAT through the Veteran’s Administration and the military. The government should have provided leadership sooner and more aggressively.
MAR: To what do you attribute the current situation?
Lubran: When the law was passed in 2000, I don’t think anyone anticipated the huge expansion in the prescribing of opioids and the huge problems it would create. I don’t think anyone associated overdose deaths with the prescribing of opioids. The law did not allow for the necessary expansion to deal with the situation we’re in today. It’s time to recalibrate. We need policy that both allows highly qualified physicians to treat more people and that gets more people involved even if they only prescribe up to the current limit. I am confident HHS will publish a final rule that allows a higher patient limit for many physicians, and that will be positive. The new proposed rule has got a relatively good balance that allows for more treatment but regulates the potential for abuse.
MAR: What do you hope will happen moving forward?
Lubran: There’s a need for more innovation around the medication itself. We know it has limitations around its potential for diversion and misuse. If pharmaceutical companies could develop an injectable product, it would eliminate the problem of pills being widely abused. An implant, and eventually an injectable, will be good for a lot of people and will restore confidence that buprenorphine is less of a public health or safety concern when it’s diverted. I have done some consulting with companies that are working to develop these products, and I am extremely hopeful that in the next five years, we’ll see a shift to using newer formulations of drugs and giving companies incentives to develop these products.
MAR: What is the biggest misconception about medication-assisted treatment?
Lubran: There remains a school of thought that medication is not consistent with recovery. That’s the greatest challenge. Then, buprenorphine is perceived as being even more incompatible with recovery. In part this perception comes from an orientation that believes there’s only one way to recovery. There are multiple pathways to get to recovery. One size does not fit all. We need to get back to individualized treatment.
One of the difficulties is that treatment providers are either set up to provide medication and support or they are not. MAT is proving to be very effective, especially for people at risk for overdose. In fact, a study by A. Thomas McLellan and George Woody showed that a small percentage of people were able to achieve recovery with medication alone. It’s terribly unfortunate that a lot of treatment programs have chosen not to provide MAT as an option, particularly to those prone to overdose.