SAMHSA Helps Bring Buprenorphine to the Field
By Rebecca A. Clay
Ask Anthony H. Dekker, D.O., about the ideal candidate for buprenorphine-based
opioid dependence treatment, and he'll tell you the story of a patient
who started injecting heroin again right after finishing a long
prison sentence. Intent on turning his life around, the man came
to the Indian Health Service facility where Dr. Dekker works and
asked for help. Dr. Dekker's new patient had never heard of buprenorphine—a
recently approved medication that alleviates drug cravings and eases
the withdrawal of patients addicted to heroin, prescription narcotics,
or other opioid drugs.
"Since this patient works 12 hours a day, the convenience
of going to a local doctor's office for his medication was a big
plus," said Dr. Dekker, Associate Director of the Phoenix Indian
Medical Center in Phoenix, AZ. "Getting this man on buprenorphine
means he has time to be involved in our support groups, sweat lodge,
and a lot of other things. It's a way to help him get his life back."
Dr. Dekker is just one of many physicians around the country who
are putting this new medication to use. Approved by the Food and
Drug Administration (FDA) in 2002 and available in pharmacies in
2003, buprenorphine allows opioid-dependent patients to bypass specialized
methadone clinics and—for the first time—seek treatment
in the privacy of their own doctor's office.
To increase the number of physicians prescribing buprenorphine
and thus increase patients' access to care, SAMHSA's Center for
Substance Abuse Treatment (CSAT) is helping physicians get the training
they need to prescribe the medication. The Center is studying how
the new drug is actually being used in the field. And, the Center
is developing resources to help physicians overcome some of the
potential barriers to prescribing the medication.
"Buprenorphine allows physicians to treat
opioid addiction just like they treat diabetes, hypertension,
or any other chronic disease."
Charles G. Curie, M.A., A.C.S.W.
"Qualified physicians are now able to prescribe a therapeutic
controlled medication in an office setting," said SAMHSA Administrator
Charles G. Curie, M.A., A.C.S.W. "Now, buprenorphine allows
physicians to treat opioid addiction just like they treat diabetes,
hypertension, or any other chronic disease."
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Treating patients with buprenorphine involves more than just writing
a prescription. To comply with the Drug Addiction Treatment Act
of 2000, physicians who want to prescribe the medication for use
in detoxification or maintenance treatment must first obtain a waiver
from SAMHSA that exempts them from certain Federal requirements
related to the prescribing of controlled substances. To qualify
for the waiver, licensed physicians must have subspecialty board
certification in addiction medicine or undergo at least 8 hours
of approved training in buprenorphine use.
To help physicians meet these requirements, CSAT funded the development
of a curriculum to be used in these 8-hour training sessions. A
consensus panel of addiction medicine experts representing three
medical societies—the American Academy of Addiction Psychiatry
(AAAP), the American Osteopathic Academy of Addiction Medicine (AOAAM),
and the American Society of Addiction Medicine (ASAM)—developed
Use of Buprenorphine in the Pharmacologic Management of Opioid
Dependence: A Curriculum for Physicians gives trainers an easy
way to prepare lectures and other educational activities related
to buprenorphine treatment. The curriculum includes sample slides
and sample questions trainers can use to develop pre- and post-training
tests, for instance.
"The goal of the curriculum is to provide a structured, uniform
set of materials that address a variety of important issues in the
treatment of opioid-dependent patients," said David A. Fiellin,
M.D., an associate professor of medicine at Yale University Medical
School, who helped write the curriculum in his role as chair of
ASAM's Buprenorphine Training Subcommittee. "We wanted to develop
the curriculum in such a way that it would be appropriate for both
specialists in addiction medicine and generalists."
To meet those goals, the curriculum begins with an overview of
the legislation and pharmacology behind buprenorphine as well as
a discussion of nonpharmacological treatment of opioid-dependent
patients. Another section explains how to assess and select patients
for treatment, including discussions of what to do when a patient
has other psychiatric or medical problems beyond opioid addiction.
A large part of the curriculum focuses on the logistical aspects
of buprenorphine treatment, including sections on protecting a patient's
privacy, establishing appropriate office policies and procedures,
and keeping good medical records. The curriculum concludes with
several case studies.
Estimating that trainers use about 80 percent of the curriculum's
slides in their current form, Dr. Fiellin noted that he and other
trainers are already modifying the slides or adding slides of their
own. When Dr. Fiellin gives trainings, for example, he adds information
about incorporating psychosocial treatment into an office-based
setting. Dr. Dekker's trainings feature more detailed information
about prescription drug abuse than the basic curriculum offers.
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Using the Curriculum
In addition to funding the curriculum's development, CSAT is providing
support for the trainings where Dr. Fiellin, Dr. Dekker, and other
experts use the curriculum. Buprenorphine's manufacturer recently
decided to provide additional funding for training. Sponsored by
the three medical societies involved in the curriculum's development
as well as the American Psychiatric Association (APA), these ongoing
training events are taking place nationwide. AAAP and APA also offer
Web-based instruction that allows physicians to get their training
As of February, 3,722 physicians had been trained in the use of
So far, the trainings have attracted addiction specialists who
technically don't need the training but who want to learn more about
buprenorphine. Trainings also attract primary care physicians. "Most
physicians are not addiction specialists. The more we can get primary
care physicians interested in taking a course, the greater the likelihood
they will become interested in treating this population," stated
H. Westley Clark, M.D., J.D., M.P.H., CSAT Director.
Now CSAT is reaching out to other organizations that can help
bring in more physicians. The Health Resources and Services Administration's
HIV/AIDS Bureau, for instance, is working to convince physicians
that treating opioid addiction can enhance prevention as well as
adherence to HIV treatment regimens. CSAT is also working with ASAM
and other organizations to educate physicians involved in pain management
about buprenorphine's role in treating patients addicted to prescription
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