The Buprenorphine Saga, Continued: More Highlights From ASAM 2015
Another policy issue that received attention at the ASAM 2015 meeting related to buprenorphine. I and many other addiction professionals regard this medication as having significantly improved our ability to treat opioid addiction effectively. As a result, the number of patients being prescribed buprenorphine has been increasing and has now reached the one million level.
Another sign of its success is that traditional sources of resistance to the use of buprenorphine appear to be softening. Traditional 12-Step based residential rehabilitation programs, such as Hazelden in Minnesota, are integrating it into their treatment. There are also early signs that Narcotics Anonymous is becoming more supportive of its use.
This success and the accompanying popularity of the medication have led, however, to new problems. During his remarks at the ASAM 2015 meeting, Dr. Wesley Clark, the now-retired former head of the federal government’s Center for Substance Abuse Treatment, described some of these, including the upsurge in diversion of the medication as well as the increased incidence of overdose by children. In addition, some physicians have engaged in poorly supervised prescribing practices, as well as engaging in what some regard as predatory pricing. Some of the more egregious examples of these problems have resulted in a negative focus on buprenorphine in the media and the U.S. Congress.
Buprenorphine is unique among medications in that physicians are limited to prescribing for a maximum of 100 patients. Because relatively few physicians have obtained the waiver to prescribe buprenorphine, there are some areas of the country where patients have difficulty getting the medication. Many people have argued that the 100 patient limit should be increased or eliminated entirely. A straw poll at the ASAM 2015 meeting revealed that most of the physicians present were in favor of such a change. Another suggestion for relieving this problem is to allow it to be prescribed by nurse practitioners and physicians assistants, who are now currently prohibited from doing so.
Dr. Clark presented the pros and cons of raising the 100 patient limit. His conclusion, with which I agree, was that such a change would create more problems than it would solve and that the quality of care issues that he identified should be addressed first. The access problems that exist in some areas of the country definitely need to be resolved, but this should be done in a careful and thoughtful way. If it is done in a way that is dominated by emotional, political, or economic factors, a useful medication that is already suffering to some extent from its own success may become further compromised.