With great unmet demand for substance abuse treatment, addiction experts are looking for ways to expand treatment options. Many experts agree there is a need to increase the number of patients treated with Suboxone (buprenorphine/naloxone). Elinore McCance-Katz, MD, PhD, Professor of Psychiatry at the University of California San Francisco and former president of the American Academy of Addiction Psychiatry, talked with Join Together about ways to increase Suboxone treatment.
Join Together: Currently physicians who receive a waiver to provide Suboxone treatment are limited to treating 100 patients with the drug at one time. Why is that?
Dr. McCance-Katz: There are both historical and clinical reasons. The Harrison Narcotics Tax Act, passed in 1914, criminalized physicians who prescribed narcotics for people addicted to the drugs. The Act was passed in response to the many people who had become addicted to opiates that were prescribed to them by their physician. That changed when the Drug Addiction Treatment Act of 2000 (DATA 2000) was passed, which allowed qualified physicians to obtain a waiver from the requirements of the Narcotics Addict Treatment Act to treat opioid addiction with Suboxone and other approved opioid medications in their office-based practices. The law allowed these physicians or group practices to treat only 30 patients with opioids at one time. In 2006, the law was updated to allow approved physicians to treat 100 patients at a time with these medications. If all doctors in a group practice receive a waiver, each can have 100 patients. In the first year after receiving their waiver, physicians must stick to the 30-patient limit before going up to the 100-patient limit.
The reason for the cap on the number of patients is that a person with opioid dependence has substantial needs. These are not patients who can come in a couple of times a year. In addition to having a physical dependence, many of them have medical and mental disorders and behavioral issues, all of which require a lot of time and effort to treat. We know from research that just giving these patients medication does not heal their addiction. They need more than that. Because of these multiple needs, a doctor would be hard pressed to meet the needs of more than 100 such patients.
Join Together: What is the best way to increase access to Suboxone treatment?
Dr. McCance-Katz: All physicians need to be trained in how to appropriately assess and treat opioid addiction. We need more doctors who feel comfortable and competent in providing Suboxone treatment. The government has developed a training program to allow doctors to receive a waiver for Suboxone treatment, but we don’t have nearly enough doctors participating. I am the Medical Director of the program, called the Physicians’ Clinical Support System for Buprenorphine (PCSS-B). The program provides training and clinical mentorship to practicing physicians and physicians-in-training who want to include office-based treatment of opioid use disorders in their practice. This program, sponsored by the Center for Substance Abuse Treatment (CSAT) of the Substance Abuse and Mental Health Services Administration (SAMHSA), includes training at no charge to physicians. The peer mentoring program allows doctors to ask questions on setting up a practice, and to discuss treatment issues as they arise.
Join Together: Why aren’t more doctors signing up for this program?
Dr. McCance-Katz: There is not a big emphasis on treating substance abuse disorders in medical school or residency training, therefore many doctors come out without a broad knowledge base about how to treat these patients. There is some stigma around substance abuse patients, which comes from doctors not having a lot of experience with this population. So they aren’t comfortable or experienced in treating addiction disorders. Others simply don’t know about the program.
Join Together: What is the best way to address the problem of Suboxone diversion?
Dr. McCance-Katz: Suboxone is in demand for obvious reasons. People who are addicted to opioids and cannot get their drug of choice want Suboxone to deal with their withdrawal symptoms. The way in which people are able to get their hands on doses of the drug may in part be linked to the way it is prescribed. The package insert for Suboxone indicates an upper dosing limit of 24 milligrams per day. However, in 2004 CSAT published Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction, which recommended an upper dosing limit of 32 mg per day. When I train doctors, I tell them 12 to 16 mg is the average clinical dose. I can count on one hand the patients who have needed more than 16 mg. When patients are given a higher dose, they quickly realize they don’t need such a high dose, and they then have extra doses that can be diverted. Instead of starting with 24 mg, I tell doctors to start with 16 mg and inform patients that if after several weeks they still need more, they can come back and discuss it. I find it’s very rare for patients to need more, but they find it empowering and respectful to have a doctor tell them they have the option to raise the limit if they need to.
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