buprenorphine prescriptionsPeople who read this blog are aware of the shortage of physicians who can prescribe buprenorphine to treat people addicted to pain pills, even as an epidemic of addiction to heroin and pain pills devastates the heartland of the country.  In order to prescribe buprenorphine, physicians take a short course and obtain special certification.  To obtain certification, physicians must promise to treat no more than 30 patients at one time, a number that can be increased to 100 patients after one year.

If you only have a few minutes, please take the time to go to the White House web site and add you name to a petition to allow individual doctors to treat more than 100 patients using buprenorphine.  The whole process is fast and easy, and only requires your name and email address through this link: http://wh.gov/QR6K

If you have more time, need convincing, or just like hearing a 52-y-o rage against the machine, continue reading my thoughts about limiting treatment for this one health condition.

The reason for the patient cap, according to cap proponents, is to prevent pill-mill practices where patients could obtain narcotic medications without adequate care for their underlying addiction.  That concern is reasonable, I suppose, but I often discover that proponents of the cap have other motives to keep the limits in place.  For example, one person at a ‘linked in’ group argued that individual physicians don’t provide the all-encompassing care that he provides… to the 800+ patients he ‘counsels’ at the methadone clinic where he works!  According to that counselor, all people addicted to opioids need years of counseling—largely from other people with addictions, who after a couple years of school have all the answers.

He would be surprised to see just how well people can do on buprenorphine, a medication that selectively removes craving for opioids.  After years of treating and knowing patients on buprenorphine I realized that ‘character defects’ are largely maintained by active craving.  Yes– people with antisocial tendencies before and during active addiction have the same antisocial tendencies on buprenorphine.  But people who lost good lives to opioid dependence often do remarkably well when their addictions are placed in remission by buprenorphine, regaining their good lives and more.  In fact patients with opioid dependence, when treated with buprenorphine and a bit of human decency, do as well as ‘normal’ people, if there is any such thing.  They just don’t look all that great when standing in line at 6 AM!

Another concern by counselors at residential treatment programs or methadone treatment centers is that doctors who prescribe buprenorphine are in it for the money— never mind that fewer and fewer doctors are willing to work in the relatively low-reimbursement field of addiction medicine.  To those worried about profiteering, I can only suggest a glance in the mirror.  I write from the standpoint of a Board Certified Psychiatrist with 100 patients on buprenorphine who make up less than a third of his practice, who cringes at the flow of emails from patients begging for help.

I’m not certain whether the limit on patients was originally intended to protect patients with addictions or to safeguard society at large.    But no matter the intent, the cap doesn’t make much sense when viewed critically.  Let’s assume that the cap was intended to protect patients treated for addictions, to make sure that doctors don’t see unmanageable numbers of patients.  Does anyone believe that treatment of addiction is uniquely difficult, requiring limits that are not necessary for the treatment of other complex illnesses such as childhood cancer?

Arguments that the limits protect the general public also fall apart under examination.  Buprenorphine can be abused, similar to medications used for treating anxiety, pain, or attention deficit disorder. But nobody believes that buprenorphine is more likely to be diverted than other scheduled medications, including medications that are prescribed without any thought of patient limits. For example, individual pain physicians treat hundreds or even thousands of patients using opioid agonists that pose much greater risk for addiction or overdose than buprenorphine.

The operational reason for the cap is because patients with addictions to opioids treated with buprenorphine are being prescribed opioids, an action prohibited by the Harrison Act.  People have a hard time getting their head around using opioid medications to treat opioid dependence, no matter how effective that treatment may be.  Is it unfair that people addicted to opioids should get off so easy with a medication that actually works, rather than face repeated, ineffective trips to residential treatment centers?

In reality the cap exists for one reason:  because it can.  Congress does not have the ability to make similar decisions in regard to other illnesses, and would not likely gain such power through legislative action.  Limiting the number of operations performed by cardiac surgeons might be a good idea, for example, but society realizes that surgeons themselves are best-positioned to decide when their practices reach maximum capacity.  But buprenorphine treatment was allowed through specific legislative action, as an exception to the Harrison Act.  In this unique setting, Congress was able to set practice parameters in a way that is impossible in other area of medicine.  The result was typical of settings where the government has control; physicians in the trenches of addiction treatment are told what they can or cannot handle, rather than allowed to practice according to their own best judgment.

To the patients on my buprenorphine wait list it goes something like this:

I’m from the government and I’m here to help.  There are no spots for you.

Please add your name after mine, at this site: http://wh.gov/QR6K

Pills in hand photo available from Shutterstock