Primary care physicians in Vermont are walking away from prescribing Suboxone, saying that they are ill-equipped to treat the many problems of the opioid-addicted, the Burlington Free Press reported this fall. One physician, John Matthews, MD, with the Health Center in Plainfield, summed it up by saying the eight-hour course required by the federal government to be listed as a Suboxone provider is only “rudimentary” and doesn’t give physicians the training needed to deal with the behavioral problems of opioid-addicted patients. “I don’t want to be listed as a Suboxone provider anymore,” he told the newspaper. “I’m pretty dubious about it. It’s like methadone. It ought to be in the hands of an addictionologist.” Contacted after the Burlington Free Press story was published, Dr. Matthews declined to speak with AT Forum.
But he and other primary care physicians have the sympathy of Peter Cohen, MD, opioid treatment authority for Maryland, where this very problem has occurred in Baltimore.
“Doctors are hesitant to start people on buprenorphine because of the implications for their practice,” Dr. Cohen told AT Forum.
‘Medication in Search of a System of Care’
“When buprenorphine first came out, I thought it was a medication in search of a system of care. The federal government said, ‘We want it in doctors’ offices but it’s up to you to figure out how to do this,’” he told AT Forum. The federal government had guidelines, but it was up to states and local entities to figure out how to implement buprenorphine. In a publicly funded system, especially in an urban area like Baltimore, the solution has proved to be induction centers with intensive case management, where patients go for their first dose, and aren’t referred to private physicians until they are stable and “smelling like a rose.”
One big problem with buprenorphine is that the first dose can’t be given unless the patient is in withdrawal. “Would a doctor who has a busy practice want someone who is going through withdrawal in their waiting room?” asked Dr. Cohen. “I’m not talking about stigma, I’m talking about logistics.”
If a patient calls asking for an appointment to get buprenorphine, the physician is supposed to say to come in immediately—that day—for an appointment. That in itself is not easy for a busy physician, because the exam is time-consuming. And when the patient is scheduled for an exam, he or she is told to stop taking opioids and to come in when withdrawal symptoms begin. The entire process is cumbersome.
Induction centers are best suited to urban areas, Dr. Cohen said. “Vermont is going to be different, because it’s rural.” In private practice, what physicians need is a “supporting structure” if they are going to be providing buprenorphine, he pointed out. That structure is always present in OTPs. “As a physician, I know by experience that there’s more to the person than the medication.”
There are 325,000 to 375,000 patients taking Suboxone at any given time. About 21,500 physicians nationwide are certified to treat a maximum of 30 patients, while an additional 5,560 physicians are approved to treat a maximum of 100 patients.
For additional information:
http://www.ncbi.nlm.nih.gov/pubmed/21664789
A new handbook from the American Society of Addiction Medicine (ASAM), Principles of Addiction Medicine: The Essentials, provides a quick reference on virtually all addiction medicine topics. This 600-page handbook extracts and summarizes key clinical points from each chapter of Principles of Addiction Medicine, 4th Edition, and presents them in an easily readable manner. The book is an excellent reference for a wide variety of practitioners, among them psychiatrists, psychologists, nurses, social workers, internal medicine and primary care physicians, and substance abuse counselors. Further information including the table of contents and ordering information is available at: 
Baltimore, once called by the Drug Enforcement Administration the “heroin capital of the U.S.,” no longer deserves that epithet, says Yngvild Olsen, MD, MPH, medical director and vice president of clinical affairs at Baltimore Substance Abuse Systems, Inc. (BSAS). More heroin users are getting into treatment, including methadone maintenance, thanks to Maryland’s newly expanded Primary Adult Care (PAC) health coverage program. Maryland Medicaid is now paying, for the first time, for comprehensive medication-assisted treatment (MAT) for everyone who qualifies financially, opening up publicly funded methadone treatment to single men without dependent children.
A victory in Warren, Maine for CRC Health Group is a victory for methadone clinics seeking sites across the country. It also means that a community that was staunchly opposed to a methadone clinic will have the chance to see how an opioid treatment program (OTP) can operate as a good neighbor. After a yearlong battle, the town voted to settle a lawsuit filed by the Cupertino, California-based treatment program—and to grant permits and approvals for an OTP there.
The federal agency charged with keeping discrimination out of the workplace has good news for methadone patients in medication-assisted treatment. In a lawsuit filed last summer by the U.S. Equal Employment Opportunity Commission (EEOC) against United Insurance, a Chicago-based company, the federal government is fighting for the rights of people in methadone treatment for opioid dependence. According to the complaint, United Insurance offered a position as an agent to Craig Burns, who has been in methadone treatment since 2004. The job offer was contingent upon his passing a drug test; Mr. Burns’ test indicated that he had methadone in his system.
33rd Annual Training Institute on Behavioral Health and Addictive Disorders
Back in the summer of 1992, we published the premier edition of the Addiction Treatment Forum newsletter. With our next edition, Fall 2011, we’re going exclusively electronic—so this, our 70th newsletter, is the last printed version you’ll receive. And it’s one of our best.
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Despite government incentive programs and a 2014 deadline for establishing a fully electronic health record (EHR) system, most health care transactions continue to be carried out manually, on paper.
As more buprenorphine is prescribed in physicians’ offices to treat opioid addiction, the potential for diversion and misuse increases. But people buying buprenorphine on the street are not generally doing so for its euphoric effects. Most are taking it because they are dependent on heroin or prescription opioids, or both, and want to prevent withdrawal symptoms between “highs,” according to Jane C. Maxwell, PhD. Dr. Maxwell, a research professor at the Addiction Research Institute at the University of Texas at Austin, is an epidemiologist who studies drug abuse trends nationwide. She tells AT Forum that the amount of the drug being prescribed reflects increasing demand for opioid treatment.
Over the years AT Forum readers have asked how methadone maintenance (MM) treatment in opioid treatment programs (OTPs) is funded, and why some patients pay for their treatment while others receive it free.
After more than 50 years of evidence showing that methadone maintenance (MM) treatment works, the courts—both civil and criminal—are making decisions only a doctor should make, telling patients to stop taking their legally prescribed methadone. These decisions are coming down particularly hard on women, who in some cases are being told by Child Protective Services (CPS) that they have to get off methadone if they want custody of their newborn child.
Over a ten year-period, admissions to substance abuse treatment for opioids, attributable mainly to prescription opioids, rose from 8 percent in 1999 to 33 percent in 2009, according to the Substance Abuse and Mental Health Services Administration (SAMHSA). Overall, opioids accounted for 21 percent of all treatment admissions—second after alcohol (42 percent) and followed by marijuana (18 percent) and cocaine (9 percent).