SAMHSA Helps Bring Buprenorphine to the Field continued (Part 2)
More than 2,500 physicians have received their waivers so far.
And, approximately 1,700 are listed on CSAT's Buprenorphine
Buprenorphine is proving to be beneficial in rural areas, which
often lack alternative treatment options. "Mostly jail"
is how Art Van Zee, M.D., a general internist at the St. Charles
Clinic described the pre-buprenorphine treatment options when prescription
drug abuse first hit his tiny coal-mining town in southwestern Virginia.
The nearest methadone clinic is more than an hour away. As far as
Dr. Van Zee knows, he is the only physician within 60 miles qualified
to prescribe buprenorphine.
However, buprenorphine is no magic bullet. For one thing, some
physicians just aren't interested in treating patients with opioid
dependence. "This is not a group of patients who are appealing
to some physicians," said George Kolodner, M.D., Director of
Chemical Dependence at Georgetown University Hospital and Medical
School. "They have a history of antisocial behavior and a reputation
of being difficult to manage."
The intensive patient management that buprenorphine requires at
the beginning of the treatment process seems to be an additional
deterrent, especially for physicians in solo private practices.
The Drug Addiction Treatment Act limits individual and group physicians
from having more than 30 patients on buprenorphine at one time.
Because many patients may remain on buprenorphine long term, this
patient limit means that some practices are already at capacity.
It also means that some physicians—especially those in primary
care practice—are deciding that buprenorphine treatment is
not for them.
"Primary care doctors are swamped as it is," said Dr.
Dekker. "Why would they want to jump through these hoops to
take care of such a small number of drug-addicted patients rather
than just refer them to someone else?"
The prospect of Drug Enforcement Administration (DEA) inspections
also generates concern among some physicians, even though the purpose
of most visits is to assess compliance with the 30-patient limit.
According to an official from the DEA, "Physicians should
not view these visits negatively but as an opportunity to identify
any areas of concern." The DEA estimates that only about 3
percent of the waived physicians will be inspected in 2004.
The high cost of the medication and related treatment and, to
date, limited third-party insurance coverage are other potential
barriers to expanding buprenorphine treatment. Furthermore, in practices
lacking Federal funding, physicians cite cost when asked why patients
reject the buprenorphine option, fail to adhere to the treatment
regimen, or drop out of treatment altogether.
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Evaluating the Program
To address any potential concerns, the Drug Addiction Treatment
Act requires the Secretary of Health and Human Services to evaluate
the buprenorphine waiver program.
The evaluation has three primary objectives: to determine whether
buprenorphine treatment provided through the program has been effective,
whether treatment availability has increased, and whether there
have been any adverse public health consequences.
According to Robert Lubran, M.S., M.P.A., Director of CSAT's Division
of Pharmacologic Therapies, "CSAT is carrying out this evaluation
by conducting three specific surveys." One survey will assess
addiction specialists' views of buprenorphine. A second will provide
a longitudinal look at patients' perceptions. A third will focus
on physicians who are actively prescribing the medication. Results
will be used to see if the waiver program's rules—such as
the 30-patient limit—need adjustment.
"At SAMHSA, we're looking at how the medication-and the waiver program-are working for people in the real world."
H. Westley Clark, M.D., J.D., M.P.H.
"At SAMHSA, we are looking at how the medication—and
the waiver program—are working for people in the real world,"
Dr. Clark said.
Although the evaluation's results won't be available until late
2005, SAMHSA is already making use of preliminary feedback. The
Agency has created a special area on SAMHSA's buprenorphine Web
site where physicians can get answers to their questions and share
For example, the password-protected Buprenorphine Clinical Discussion
WebBoard allows physicians with waivers to ask and answer questions, share their experiences, and obtain
advice from expert guest moderators.
Another project under consideration is a clinical support network
that would match physicians concerned about prescribing buprenorphine
for the first time with experienced addiction specialists who can
guide them through the process.
These developments should be good news for trainers like Dr. Dekker
and Dr. Fiellin.
"The doctors involved with us in the training get many, many
calls every day," said Mr. Lubran. "Everybody's always
asking them, 'What do I do with this patient?' "
Now, the doctors have a source for some answers.
See Part 1: SAMHSA Helps Bring Buprenorphine to the Field
See Also Buprenorphine-Related
Administrator: How Is Buprenorphine
Treatment Working? »
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