Buprenorphine Controversy: Continued, Further Refinements

My first thought was “Here we go again,” when I saw the provocative opening to a recent New York Times article about people with opioid addiction who were misusing buprenorphine – with the help of misguided prescribing physicians. Media coverage has often been negative regarding a medication that I have found to be not only useful but life-saving to so many patients. As I read further, however, I realized that the reporter was, in fact, considering the complexities surrounding this issue by describing the positive as well as negative features.

The article was consistent with the Arlene C.’s contribution to Modern Addiction Recovery last week. She has now been off of buprenorphine for a full year and is doing well in Narcotics Anonymous after many years of using the medication effectively to achieve a stable recovery.

With all the recent media attention given to buprenorphine, we have been witnessing a familiar three-step “pendulum swing” process that has characterized the response to other medical innovations. An initially overly enthusiastic response, like one newspaper’s front page referencing a “miracle pill,” created unrealistic expectations. When these could not be met, disappointment evolved into angry denunciations, especially when inappropriate uses began to appear. My hope is that the tone of the New York Times article represents the progression to the third stage of a balanced reassessment of the benefits and limitations as well as the dangers of buprenorphine.

At the same time, two new developments introduce possibilities for more opportunities as well as more problems. First, in the hope of reducing some of the problems of diversion and erratic adherence, the FDA has just approved an implantable form of buprenorphine. Having more choices will be of benefit to patients, given the broad range of individual differences.

Second, because in some areas of the country waiting lists for buprenorphine have become a problem, the U.S. Department of Health and Human Services has proposed regulations which would increase the limit on the number of patients for whom a physician may prescribe the medication.

The regulations were done thoughtfully, and I favor the expanded number. However, I am ambivalent. For buprenorphine to be the only medication with such a limit seems unreasonable. On the other hand, I have seen the negative effect of treatment that appears to emphasize volume over quality, and raising the limit could make this problem worse. The formal comment period has just ended, and I plan to follow any further revisions to these regulations as well as the timing of their implementation. Based on what has happened with buprenorphine so far, especially with both addiction and money in the mix, the one thing that is certain will be the appearance of unintended consequences.