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Monday Oct 17, 2016

Prescribing for Opioid Addiction Is My Responsibility

I consider myself to be a caring, comprehensive family physician, but when the FDA approved buprenorphine (Subutex) and buprenorphine with naloxone (Suboxone) for opioid addiction in 2002, I was skeptical.

Federal law requires physicians to pass an eight-hour course and apply for a waiver to prescribe the drugs, and this would put me in the position of attracting more patients who had addictions into my office. Considering the frustrations that we all face at times with these patients, I figured someone else could do that, not me.

It is 2016. Times have changed, and not for the better.

  • The opioid epidemic is getting worse. Two to three people die of overdoses every day in my state, and one dies every 20 to 30 minutes nationally. The U.S. overdose death rate in 2008 was nearly four times what it was in 1999(www.asam.org).
  • Sales of prescription painkillers in 2010 were four times higher than in 1999.
  • Finally, and most disturbing to me as a prescriber, prescription opiates -- not illegal drugs like heroin or "street" morphine, but our legal scripts! -- are the leading cause of morbidity and mortality in those who are prescribed opioids and/or addicted to opiates.

Opioid use -- both prescription and the illegal variety -- has skyrocketed, but the number of physicians available to help those affected has not. According to HHS, less than half of the 2.2 million Americans who need treatment for opioid addiction are getting it. The Pew Charitable Trusts(www.pewtrusts.org) has noted, for example, that almost 500 patients in Vermont are on waiting lists to receive medication for opioid dependence. For the majority, the wait will last nearly a year. The issue of supply and demand for approved prescribers isn't limited to that state, and the long wait for help proves too long for many(khn.org).

My patients need help, so it has to be me. I have to take responsibility.

In the past month, three patients came to me wanting more opioid medications or refills that I did not feel were appropriate. All three essentially said that if I didn't prescribe the medications, they could get drugs -- more easily and cheaply -- on the street. Those drugs, of course, are unregulated and dangerous, and some are illegal. I asked myself why I didn't have anything else to offer them.

The tipping point for me came last month when Aleksandra Zgierska, M.D., Ph.D., a family physician from the University of Wisconsin School of Medicine and Public Health, made a presentation at a Wisconsin AFP Board meeting. It was a practice changer for me.

I was reminded that addiction is a chronic brain disease, not a weakness of character or a social, moral or criminal justice problem. Medication for opioid addiction is not a new addiction, but treatment. Buprenorphine can be prescribed in the office, as opposed to methadone treatment, which may require my patients to drive 50 to 100 miles daily. Most importantly, it works!

Like diabetes and hypertension, treatment of opioid addiction involves counseling, medications, regular lab tests, routine visits and thoughtful management. And, according to Zgierska, treating opioid addiction with buprenorphine can work as well as common treatments for diabetes and hypertension.

She noted that after six to 12 months of treatment with buprenorphine, 50 percent to 80 percent of patients no longer use opioids. By comparison, after the same length of time in treatment, 40 percent to 70 percent of patients have type 1 diabetes under control, and less than half are adhering to their medication regime. Twenty percent to 50 percent of patients with hypertension achieve good control of their condition during the same period, and less than 30 percent adhere to medical therapy.

Medication-assisted treatment (MAT) allows patients to lead normal, productive lives. Every dollar spent on treating opioid addiction saves society as much as $7 in drug-related crime and criminal justice costs and $5 in health care costs.

Now I felt I could offer my patients something other than referral to a long waiting list. So on a recent Saturday, I took the American Society of Addiction Medicine buprenorphine waiver course and applied for a waiver. The cost was $200, which was a bargain considering I can report eight hours of CME.

I learned that prescribing and monitoring MAT is easier than I thought, and I can do so in my office with the type of adjustments that we make to treat hypertension, diabetes and other chronic diseases.

Barriers still remain, including costs, patient motivation, a dearth of treatment programs and, most importantly for AAFP members, lack of access to MAT. You and I can address this lack of access to care. Family physicians account for 20 percent of U.S. office visits, but we comprise less than 20 percent of physicians who are approved to prescribe buprenorphine.

The call to action in the AAFP's policy on chronic pain management and opioid misuse urges family physicians to "consider obtaining a Drug Addiction Treatment Act of 2000 waiver to deliver office-based opioid treatment." I hope you will consider getting the waiver, like I did, and implementing MAT in your practice.

You can find out more about the required training online(pcssmat.org). For other resources related to treating chronic pain see the AAFP's chronic pain management toolkit

Alan Schwartzstein, M.D., is vice speaker of the AAFP Congress of Delegates.

Posted at 03:45PM Oct 17, 2016 by Alan Schwartzstein, M.D.

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