Am Fam Physician. 2006 May 1;73(9):1513-1514.
Many physicians avoid involving themselves in the treatment of addictive disorders because of poor education about addiction, limited opportunities to coordinate a patient's transition to recovery, and limited access to effective treatments.1 In this issue of American Family Physician, Donaher and Welsh2 discuss how physicians can use buprenorphine (Subutex) or buprenorphine/naloxone (Suboxone) as effective office-based treatments for opioid addiction.
Prescription opioid use and dependence are at a record high and affect patients regardless of geographic location or socioeconomic status.3 Prescribing opioid medications, which commonly are used in pain management, can lead to problematic use in patients who are predisposed to addiction. The transition from appropriate to inappropriate use is difficult to predict. Evidence suggests that certain patients have a genetic predisposition to the neurobiologic changes that cause opioid addiction.4 In addition, the wide availability of prescription opioids (e.g., Internet, diverted prescriptions) and heroin has helped cause opioid dependence in an estimated 2 million Americans.5,6 Most alarmingly, nearly 10 percent of high school seniors have experimented with prescription drugs.7
Detoxification through opioid withdrawal is not an effective treatment for most patients with opioid dependence.8 This finding has been demonstrated in a wide spectrum of patients, including highly motivated patients, and reflects the disruption of normal brain function that occurs with long-term use and abuse of opioids and the need for ongoing treatment. Relapse rates approach 90 percent at six months after detoxification through withdrawal. Longer-term treatment with medications such as buprenorphine usually results in increased retention and abstinence rates, decreased human immunodeficiency virus risk, and improved functioning.
Opioid addiction can profoundly impact a person's daily functioning. These lifestyle disturbances include repeated change in physicians; dishonesty; financial loss; depression; and family, job, and legal problems. These disturbances can leave patients feeling trapped with limited treatment options; however, buprenorphine treatment can dramatically reverse these disruptions within weeks or months. Few treatments are as immediately rewarding to physicians and patients. Clinical response, for instance, can occur much quicker than when selective serotonin reuptake inhibitors are used to treat depression.
Buprenorphine is not a cure-all, however. It is important for physicians to understand that medications for addictive disorders generally are most effective when provided with counseling, which helps decrease the risk of relapse and addresses the effects of addiction.9 In addition, buprenorphine is not effective in the treatment of addiction to nonopioid substances (e.g., cocaine, alcohol); counseling and lifestyle changes often are needed to address these addictions.
Because the capacity to refer patients for counseling and ancillary services is a criterion for qualifying to prescribe buprenorphine, physicians are encouraged to cultivate relationships with nurses, social workers, mental health counselors, addiction treatment facilities, and local self-help groups (e.g., Narcotics Anonymous). Finally, buprenorphine allows family physicians to treat these patients for comorbid medical and psychiatric disorders (e.g., hepatitis C, depression) that commonly occur in patients with opioid dependence.
Since the passage of the Drug Addiction Treatment Act of 2000, which enabled qualified physicians to provide office-based opioid maintenance treatment, the use of buprenorphine therapy has steadily increased. Preliminary results from a three-year evaluation10,11 indicate that more than 10,000 physicians have been trained to use buprenorphine, that a significant proportion of those who have begun to prescribe the medication have limited experience treating opioid addiction, and that many patients who seek addiction treatment are dependent on prescription opioids and are new to pharmacologically assisted treatment. In addition, recent data12 indicate limited buprenorphine diversion.
Information about in-person and online training is available at http://www.buprenorphine.samhsa.gov. In addition, the American Academy of Family Physicians has partnered with a nationwide system of experienced physicians to form the Physician Clinical Support System (PCSS; http://www.pcssmentor.org), which provides standardized resources as well as e-mail, telephone, and in-person support to physicians regarding all phases of buprenorphine treatment.
Buprenorphine has provided a much-needed opportunity for family physicians to address addictive disorders with their patients. Successfully treating patients with buprenorphine allows physicians to develop experience and confidence in addiction disorders, enabling them to provide more comprehensive office-based treatment.13
DAVID A. FIELLIN, M.D., is associate professor in the Department of Internal Medicine at Yale University School of Medicine, New Haven, Conn., and is medical director of the Physician Clinical Support System. He is a Robert Wood Johnson Foundation Generalist Physician Faculty Scholar.
Address correspondence to David A. Fiellin, M.D., Yale University School of Medicine, 333 Cedar St., P.O. Box 208025, New Haven, CT 06520–8025 (e-mail: firstname.lastname@example.org). Reprints are not available from the author.
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10. Sullivan LE, Chawarski M, O'Connor PG, Schottenfeld RS, Fiellin DA. The practice of office-based buprenorphine treatment of opioid dependence: is it associated with new patients entering into treatment? Drug Alcohol Depend. 2005;79:113–6.
11. McLeod CC, WB Kissin, Stanton A, Sonnefeld J. 30-day outcomes for buprenorphine patients treated by a national sample of qualified physicians. Findings from the Center for Substance Abuse Treatment's evaluation of the Buprenorphine Waiver Program. Accessed online, March 13, 2006, at: http://www.buprenorphine.samhsa.gov/findings.pdf.
12. Cicero TJ, Inciardi JA. Potential for abuse of buprenorphine in office-based treatment of opioid dependence. N Engl J Med. 2005;353:1863–5.
13. Fiellin DA, O'Connor PG. Clinical practice. Office-based treatment of opioid-dependent patients. N Engl J Med. 2002;347:817–23.
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