The opioid overdose epidemic has led to a call by some to raise the 100-patient cap on buprenorphine, which can be dispensed and prescribed by office-based physicians. Even before Sen. Ed Markey of Massachusetts proposed a bill in July allowing physicians to treat an “unlimited” number of patients with buprenorphine, the American Association for the Treatment of Opioid Dependence (AATOD) took proactive steps to educate policymakers about the unintended consequences of such a move.
On July 2, AATOD president Mark Parrino, MPA, distributed a policy paper to regulators at the Substance Abuse and Mental Health Services Administration (SAMHSA), which, along with the Drug Enforcement Administration, oversees the waiver process that allows office-based physicians to treat patients with buprenorphine. He also distributed the policy paper to stakeholders in the field. It is a masterful analysis of using medication in the treatment of opioid dependence, outlining the history of opioid treatment programs (OTPs), methadone maintenance treatment (MMT), and the need patients have for comprehensive care.
Many prospective patients, given the choice between the rigor of treatment in an OTP, and being able to walk into a physician’s office and get buprenorphine immediately, followed by a prescription, would choose the physician’s office. But Mr. Parrino carefully did not use the policy paper to defend OTPs or OTP “turf.”
Asked whether unrestricted access to buprenorphine is a threat to OTPs, Mr. Parrino told AT Forum that “aside from being a threat, it’s a challenge to our principles of how we treat opioid addiction.” Noting that SAMHSA has issued research findings and practice guidelines supporting treatment the way it’s provided in OTPs, Mr. Parrino pointed out that if SAMHSA supports the approach of medication only, in the case of raising the buprenorphine cap, it is “endorsing the concept that medication is sufficient in and of itself.”
Contradicting the Evidence
If the National Institute on Drug Abuse (NIDA) and SAMHSA agree that physicians should be able to prescribe buprenorphine to more than 100 patients, and that those patients will not be getting access to other treatment interventions beyond the prescription, that would “contradict everything they have published in the past 40 or 50 years,” said Mr. Parrino.
The AATOD policy paper, however, makes it clear that not every patient needs access to all interventions throughout the course of their treatment. There are patients who are stabilized, whether it’s by MMT in an OTP or through office- based buprenorphine treatment. “Not all patients need access to a full range of services throughout their treatment,” he said.
Already, OTPs are able to treat a significant number of patients. In many cases OTPs can expand without having to go back to SAMHSA, he noted. That raises the question: why are policymakers focusing on office-based buprenorphine instead of OTPs as they struggle to find ways to handle the heroin epidemic? The reason is that the groups pressing for expansion of buprenorphine are the physicians— the American Medical Association and the American Society of Addiction Medicine (ASAM)—said Mr. Parrino.
There are already questions about how the 7,500 physicians currently certified to treat 100 patients with buprenorphine are doing. SAMHSA, for example, doesn’t know how many of these are at the patient limit, or how many are organized in group medical practices. Many of them are “rendering excellent care, are principled, and are treating patients effectively,” said Mr. Parrino. But as is well known to OTPs, there are some patients who want the medication but don’t want any services. Office-based buprenorphine caters to these patients.
Why Not Expand OTP Funding?
The AATOD policy paper references a very important document released by ASAM last year, which describes the difficulty of getting public and private payers to cover MAT in an OTP. Many states don’t even allow Medicaid to pay for treating patients in OTPs. “ASAM did a great job of describing the funding impediments,” said Mr. Parrino. “People want to expand access to treatment—what about putting increased public money into OTPs?”
There is no counterpart to the AATOD policy paper—nothing else has been written on such a complex topic. From what we have heard, SAMHSA and other administration officials who have seen it are impressed—at least, they are not discounting it. What the policy paper does is to ask them to think about the unintended consequences of abandoning what has been learned over the past 40 years. “This rush to—‘We need to lift the cap, and flood the market with buprenorphine’—is all based on the fact that there is a public health crisis,” said Mr. Parrino. “The reaction is that they have to do something.” Mr. Parrino hopes that they will not abandon comprehensive treatment in favor of only writing prescriptions.
For the policy paper, go to http://www.aatod.org/wp-content/uploads/2014/07/MAT-Policy-Paper-FINAL-070214-2.pdf.
