The Addiction Drug, Buprenorphine, is Underused by Primary Care Docs in U.S.
THURSDAY, Aug. 3, 2017 -- Many doctors aren't making full use of a medication that can wean people off addiction to heroin and prescription painkillers, according to results of a new survey.
Buprenorphine is the first drug for opioid use disorder that's approved for prescription by primary care physicians, allowing treatment in the privacy of a doctor's office.
But many doctors aren't applying for the federal waiver that would allow them to prescribe buprenorphine, said researcher Andrew Huhn. He's a postdoctoral fellow with the Johns Hopkins University School of Medicine's behavioral pharmacology research unit.
Further, most who have obtained a buprenorphine waiver aren't prescribing the drug to as many patients as allowed, Huhn said.
This reluctance to fully utilize buprenorphine is hampering efforts to combat the epidemic of opioid abuse in the United States, Huhn said.
"This year is probably going to be the worst on record for overdose deaths," Huhn said. "It's possible we're going to have more drug overdose deaths this year than people that died in the Vietnam War."
More than 52,400 people died from overdose in 2015, and more than 59,000 OD deaths likely occurred in 2016, according to a recent article in The New York Times. By comparison, the U.S. military reports 58,220 personnel killed during the Vietnam War.
Buprenorphine acts upon the same brain receptors as opioid drugs, but its effects are weaker and level off even with increasing doses, according to the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA). This "ceiling effect" lowers the risk of misuse and addiction.
"We know when we put people on buprenorphine, the risk of overdose goes way down and the risk of relapse goes way down," Huhn said. "It is a medication that is effective at stabilizing people's lives."
Since 2002, physicians have been able to prescribe it directly after they obtain a waiver from SAMHSA, even if they aren't addiction medicine specialists, the agency noted.
"It takes eight hours to do a class, and then you get a waiver and you can prescribe," Huhn said.
Huhn and colleagues surveyed 558 U.S. physicians in 2016 to see how many had gotten this waiver and were making full use of it.
More than eight out of 10 said they have a buprenorphine waiver, the researchers found.
However, more than half with a waiver said they were not currently prescribing to capacity. SAMHSA rules at the time of the survey allowed physicians to prescribe buprenorphine to only 100 patients; this year, the cap was increased to 275.
Doctors who have a waiver but are not using it to capacity said they regularly turn away one to three patients a month who approach them for buprenorphine treatment, the researchers said.
"There are a lot of physicians who are waivered that just aren't prescribing to very many people," Huhn said.
The most common reasons given for not prescribing to capacity is that the doctor hasn't the time to take on more patients (36 percent) and inadequate reimbursement for addiction treatment services (15 percent), the findings showed.
Since the U.S. health care system is based on capitalist principles, "you do have to make the business model make sense for physicians to adopt it," Huhn said.
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, the study authors said.
The one in 10 unwaivered doctors said they didn't want to be inundated with requests for drug treatment (30 percent) and were concerned that patients would resell the medication (26 percent).
"They kind of represent more negative attitudes toward this line of treatment in the first place," Huhn explained.
A small number of doctors who don't have a waiver or aren't using it to capacity said they wanted more information about local counseling resources, would like to be paired with another physician experienced in buprenorphine therapy, and want access to more continuing medical education courses for addiction treatment, the survey found.
Addiction treatment is very complex, and that likely is dissuading many doctors from becoming more involved in it, said New York psychiatrist Dr. Kevin Cotterell. He's with Northwell Health's South Oaks Hospital in Amityville.
"Primary care physicians have not been willing to treat patients' opioid use disorders, at least not in the numbers some expected, because their care involves so many psychosocial factors, which they don't have the time to address," Cotterell said. "They don't have the time or the training to address the spectrum of problems that are a part of addiction."
Dr. Scott Krakower, assistant unit chief of psychiatry for Zucker Hillside Hospital in Glen Oaks, N.Y., agreed. Many doctors may have "increased anxiety with how to use the agent and lack of familiarity with dosing and prescribing it," he said.
"Induction of this agent can be time-consuming and cumbersome to a practice, if enough resources are not in place," Krakower said.
Huhn presented the study Thursday at the annual meeting of the American Psychological Association in Washington, D.C. Research presented at meetings is usually considered preliminary until published in a peer-reviewed medical journal.
For more on buprenorphine, visit the U.S. Substance Abuse and Mental Health Services Administration.
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Posted: August 2017