Buprenorphine/naloxone has been available in the U.S. for both opioid treatment programs (OTPs) and office-based opioid treatment (OBOT) since 2003. While OBOT physicians can prescribe the medication, OTPs must dispense it. Costs and reimbursement problems have been the main barriers to its use in OTPs.
Although more than 15,000 physicians are certified to prescribe buprenorphine to patients, too few of them actually do. Yet the Substance Abuse and Mental Health Services Administration is currently considering increasing or eliminating the cap on the number of patients a certified office-based physician can treat (see related article in this issue).
An August 29 online article in the journal Expert Opinion on Pharmacotherapy discussed opportunities, challenges, and strategies related to the use of buprenorphine to treat opioid addiction. While the article focuses primarily on OBOT, sections of interest to OTPs include a discussion of which patients could be successful candidates for buprenorphine over methadone, and an assessment of alternative delivery models, such as a stepped-care model in a traditional methadone clinic.
Barriers to Prescribing OBOT
The article identifies and discusses potential barriers that need to be overcome if OBOT with buprenorphine is to expand. The article divides the barriers into three categories:
- Stigma related to substance use disorders and their treatment
- Limits on length of treatment
- High monthly copayment
- Formulary restrictions
- Legitimate concerns about buprenorphine misuse and diversion
- Uncertainty about the role of medication in treating addictive disorders
- Concerns about practice disruptions due to stigma and the complexity of induction in the office setting
- Lack of access to addiction specialists and consultation resources
- Lack of remuneration; inadequate financial support from Medicaid
- Lack of institutional support
The authors recommend a multifaceted approach to overcoming barriers. The steps that they suggest include new buprenorphine formulations to minimize misuse, identification of appropriate patients, prescription monitoring programs (PMPs), medical education programs, and policy regulations.
A key step in expanding access to buprenorphine treatment is identifying patients who are likely to have successful treatment outcomes. The authors believe that buprenorphine may offer advantages over methadone in patients with the following conditions:
- Patients with HIV/AIDS. Buprenorphine is compatible with drug therapy to treat HIV/AIDS, and management of both conditions by the same physician improves outcomes. Concomitant use of buprenorphine and highly active antiretroviral therapy (HAART) does not appear to produce significant drug–drug interactions, or to require dose adjustments.
- Patients with chronic pain and opioid use disorders. Practitioners can treat these patients with buprenorphine/naloxone, but optimal dosing strategies for pain (e.g., the amount and timing of medication) have yet to be determined. Sublingual buprenorphine is not FDA-approved for pain management.
- Adolescents with severe opioid use disorder. When possible, first-line treatment for adolescents is psychosocial intervention, with a goal of abstinence.
- Pregnant patients. Neonatal abstinence syndrome may be milder with buprenorphine than with methadone.
OBOT with buprenorphine isn’t the best option for some patients. Based on their research and clinical experience, the authors identified several patient characteristics associated with relative indications and contraindications for OBOT:
|Factors Associated With a Good Outcome in OBOT||Relative Contraindications to Buprenorphine|
The authors add that good office practice from the point of intake includes discussions and expectations about diversion, and the use of PMPs, urine drug screens, and pill counts. These steps will help protect patients and make misuse and diversion less likely. Links to counseling services and more-intensive treatment will facilitate additional care, when needed.
In looking for ways to help patients access buprenorphine, the authors assessed three prescription models:
Nursing Care Management Model—a primary care clinic with an experienced, skilled nurse clinical manager coordinating many aspects of patient care. This model provided good quality of care, but may be of limited use in a small office practice.
Centralized Buprenorphine-Induction Model—a centralized induction clinic. After spending about 20 days in the induction clinic during the difficult buprenorphine-induction period, patients were transferred to a community clinic and pharmacy. If necessary, patients returned to the induction clinic for referral to methadone or residential treatment. The program was highly successful in a setting of extreme poverty. This model requires collaboration between the new clinic and pharmacy, and existing community facilities.
Stepped-care Model—a traditional methadone clinic. In this model, patients started on buprenorphine/naloxone, and switched to methadone if needed. Of 48 patients followed, 20 changed to methadone and completed treatment. Outcomes—retention rate and urine samples free of illicit drugs—were virtually identical in the two groups. This model has the advantage of transforming an existing resource, a methadone clinic, to provide buprenorphine. The authors noted that methadone clinics could be nodes in a provider network that links with office-based providers.
Declaration of Interest: One of the authors of the article, T. R. Kosten, has been a consultant for Reckitt Benckiser, the company that markets Suboxone (buprenorphine/naloxone sublingual film).
Li X, Shorter D, Kosten TR. Buprenorphine in treatment of opioid addiction: opportunities, challenges and strategies. Expert Opin Pharmacother. 2014;15:2263-2275. doi: 10.1517/14656566.2014.955469. http://www.ncbi.nlm.nih.gov/pubmed/25171726
For Additional Reading
Hutchinson E, Catlin M, Holly C, Andrilla A, Baldwin L, Rosenblatt RA. Barriers to primary care physicians prescribing buprenorphine. Ann Fam Med. 2014;12(2):128-133. http://www.annfammed.org/content/12/2/128.long