Buprenorphine: How many patients is too many?
Last week the Department of Health and Human Services published in the Federal Register a notice of rulemaking for medication assisted treatment – MAT – for opioid abuse that would increase the maximum number of patients a practitioner can treat from 100 to 200.
The proposed rule would apply specifically to buprenorphine, also known as “bupe”among drug users. The drug is used to wean addicts off prescription and street opioids, such as oxycodone and heroin. Buprenorphine joins methadone and naltrexone as the only three drugs approved by the Food and Drug Administration to treat opioid addiction.
The irony of the government’s efforts to regulate patient limits for buprenorphine, is that there are no limits on the number of patients a practitioner can treat with the prescription opioids that feed addition. In fact, there is no other prescription medications with patient limits.
With the exception of naltrexone, which blocks the euphoric effect of opioids and prevents an addict from getting high, methadone and buprenorphine are highly regulated. Methadone can only be dispensed at approved locations and requires daily administration.
Currently, practitioners who are licensed to prescribe buprenorphine are limited to 30 patients. After a year, that cap can be increased to 100 patients. The HHS rules proposed last week would up the cap to 200 patients, impose additional rules for record-keeping, require physicians to certify that they will provide patients with behavioral health services.
There is no question that buprenorphine works, especially when combined with behavioral therapys.
There is also no question that bupe can be abused and will get you high (unless it is combined with naloxone.) Although the high is much less than heroin or methadone, there is a chance – sometimes a good chance – that a prescription of buprenorphine will end up being bought, sold and used on the street like heroin.
As someone in recovery, I know first hand that anything that can – or even might – get an addict high will be crushed, swallowed, injected, inhaled, inserted in an attempt to do so. And because addicts undergoing trreatment with buprenorphine will go into withdrawal without it – they will buy burprenorphine on the street if for some reason they run out or cannot fill their own prescription.
Then there are the doctors with buprenorphine licenses. Most will be well-intentioned, but we learned during the pill-mill crisis that there are plenty of unethical physicians who didn’t wince at getting patients hooked on prescription opioid painkillers. Now they have an opportunity to get those same patients hooked on the drugs that will break that addiction and possibly create a whole new pill mill crisis.
Sound far fetched? These are just a few of the concerns I heard quietly discussed at two recent conferences on prescription drug and heroin abuse and treatment, including the National RX Drug & Heroin Summit in Atlanta last week, where President Obama touted his commitment to increasing access to MAT.
MAT is emerging as the weapon of choice in combating the nation’s opioid abuse epidemic. Hundreds of millions of dollars are being committed to MAT programs and it is supported by professional groups, such as the American Society of Addiction Medicine.
The movement is also doing a great service in breaking the stigma against addiction – showing that addiction is a real disease and like other real diseases, such as diabetes, it can be controlled with medication.
But unmentioned in any of the discussions I have heard is how MAT will be accepted in the 12-Step community, which endorses complete abstinence. Even now, many 12-steppers scorn others who use anti-depressants like Lexapro and Wellbutrin, claiming they are mind altering drugs – even though they will not get you high.
Since MAT’s success largely depends on combining it with behavioral therapy – such as 12-step programs – addicts on buprenorphine or the ever-popular benzodiazapine gabapentin – will find themselves ridiculed in some 12-step meetings.
HHS us accepting comments on its proposed rules until May 31. The comments will surely be interesting, controversial and divisive. With a record-number of people dying of opioid overdoses, this rule could open the door to hope or more corruption.
Prescription pad image available from Shutterstock.
Stapleton, C. (2016). Buprenorphine: How many patients is too many?. Psych Central. Retrieved on February 25, 2018, from https://blogs.psychcentral.com/depression/2016/04/buprenorphine-how-many-patients-is-too-many/