SAMHSA Helps Bring Buprenorphine to the Field continued (Part 2)

Overcoming Barriers

More than 2,500 physicians have received their waivers so far. And, approximately 1,700 are listed on CSAT's Buprenorphine Physician Locator.

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 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 information.

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 Content:

From the Administrator: How Is Buprenorphine
Treatment Working? »

Resources »

Training Available for Counselors »

In Action: One Community's Story »

See Also—Next Article »

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