What’s Not to Love?? by Pat Conrad MD

Under the category of “shocker!” Medscape reports that doctors aren’t rushing the gates to become buprenorphine treatment providers.  The prevalence of opioid addiction is driving headlines, and doctors are being browbeaten to be the solution.  Okay fine, so stop writing Norco 10 mg #120 for the 39-year-old with shoulder pain.

But as we all know, buprenorphine is not an opioid, but kinda is; that it helps addicts to wean off of opioids even though buprenorphine can be used for a high, and has even killed people due to overdose and respiratory depression.  When it first came out, buprenorphine treatment required a special DEA registration as a Narcotic Treatment Program.  In 2000, Congress passed the Drug Addiction Treatment Act that opened a lot of this up, with further waiving and loosening of restrictions in 2002.  Now you need to do an additional 8 hours of training and you can apply.

This article quotes researchers who surveyed 558 U.S. physicians in 2016, 80% of whom had gotten a waiver.  “However, more than half with a waiver said they were not currently prescribing to capacity. SAMHSA (Substance Abuse and Mental Health Services Administration) rules at the time of the survey allowed physicians to prescribe buprenorphine to only 100 patients; this year, the cap was increased to 275.”

Buprenorphine treatment records should include a log identifying prescriptions/recipients.  “Practitioners can decide if they want to keep these records within standard patient charts or if they want to keep separate buprenorphine treatment records. When the physician keeps separate records then only these records would be subject to review during a DEA audit. The DEA does recommend keeping buprenorphine records separate, but it is not required.”  (Authors note:  I could not verify how old this directive is, and whether it even takes EHR’s into account, so consider with discretion.)

A lot of waived docs are not seeing their full capacity of Bupo-users, citing time constraints and inadequate reimbursement.  But then the study authors state:  “Nearly 55 percent of waivered doctors not prescribing to capacity indicated that nothing would increase their willingness to take as many buprenorphine patients as they can.”  Unwaivered docs stated they didn’t want their lobbies full of Bupo-seekers, and feared reselling/diversion.

There are a lot of chronic opioid users, addicts, seekers, and related deaths, over 50,000 per year in the U.S. by some tallies.  And yes, physicians should be very judicious in prescribing narcotics, lest it becomes handing out the candy.  But stories are starting to be written that not enough docs want to become active narc weaners.  Extra CME, more time with a needy patient subset, the need for extra levels of record keeping, the increased exposure to DEA audits, the legal potential of drug diversion, and lousy reimbursement … what’s not to love?

And no, it probably won’t come to this, but just imagine:  what if increased media handwringing led to increased political pressure for docs to take, shall we say, a more active interest?  In my state, every time we renew our license, we have to take extra CME on HIV and domestic violence.  Both of these categories were instituted as requiring extra attention not for demonstrable medical or public health reasons, but due to political pressure from special interest groups.  So the precedent is there for the next concerned group to hit a state capital near you and suggest mandatory buprenorphine awareness training, for starters.  What’s not to love?

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  3 comments for “What’s Not to Love?? by Pat Conrad MD

  1. Mary Helen Morrow, MD
    October 18, 2017 at 9:00 am

    I agree with the prior comments. I had my first DEA oversight visit less than a year after my certification (which I only got to be able to prescribe for jail inmates who needed it). Unannounced and intimidating!! Then they had one issue and it got written up and when I fixed it and sent in the documentation, they supposedly never got it and called back in a threatening manner. (Who needs that **it?)

    Also, I object to SAMSA’s teaching materials which never even mention the idea of weaning the med. when I called and asked about it, they almost seemed confused. It really appeared that the idea was for the addicts to stay , well, addicted!!

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  2. Perry
    October 13, 2017 at 10:08 am

    IF this is what the gov’t wants to do, then they should just hire docs and put them through the training and fund the office staffing to do it, let them control it because that’s what they want to do anyway. In my state there is an uproar because a lot of these clinics are not going through insurance but doing cash pay only.

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  3. Randy
    October 13, 2017 at 9:07 am

    I have a waiver to prescribe Suboxone and did go to the 8 hour course in the early 2000’s. It was actually pretty informative and did a good job teaching how to prescribe Suboxone effectively. My only criticism would be it painted the picture of physicians prescribing Suboxone to grateful, compliant patients and backed by thankful, adequately compensating government and insurance companies.

    Obviously I should have known better. The patients were often unpleasant and aggressive, they were frequently uninsured, and even if they were insured it was hard getting the Suboxone approved at times. Add to that the strange way the government approaches this medication, actually making it more difficult and risky to prescribe than schedule II narcotics. The DEA audits are unannounced – they just drop in and interview you while your schedule gets further and further behind. The records requirements are a pain. And ideally you don’t just prescribe the Suboxone and that’s it, the patients really need to be in an outpatient drug program, something my community sorely lacks.

    Right now I have one patient on Suboxone, a guy I’ve known for over a decade. We are trying to wean him off and if we’re successful I will have no patients on Suboxone, which will be fine. It’s sad because there are many patients that would benefit, but unless you are going to manage this a lot and make a commitment to a formal office program, it’s basically set up to fail.

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