The Addiction Doctor Isn't in

The Addiction Doctor Isn't in
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Overdosing on opioid drugs, from Vicodin to heroin, is a leading cause of accidental death in the country. What is President-elect Donald Trump going to do about it?

For Trump, it’s not just about The Wall keeping heroin and fentanyl out.

The blueprint he unveiled during the election is consistent with Comprehensive Addition Recovery Act that was passed this summer, though only partially funded. The wide-ranging bill seeks to expand addiction treatment access, funding for diversionary programs such as drug court, and funding for naloxone (the opioid antidote that instantly reverses the respiratory suppression of overdose), among other things.

In terms of treatment, the emphasis is on medication. Though actual trade names of medications are not specified, the anti-addiction medication most commonly prescribed medication for people addicted to drugs such as Vicodin and heroin is buprenorphine, or “bupe.”

Bupe usually comes as a film strip that dissolves under the tongue. Like methadone, the classic addiction medication, bupe is itself an opioid. That means it can produce euphoria (though less effectively than most other opioids). Bupe also prevents withdrawal symptoms and suppresses drug craving, as does methadone.

But unlike methadone, bupe’s chemical properties make it less risky if taken in excess. It can also prescribed by any qualified physician from his office.

Methadone must be administered in clinics tightly regulated by the Drug Enforcement Administration (DEA) – I work in such a clinic.

These features of bupe – especially the option of getting it from a doctor in the community– account for its popularity. Bupe is in such demand, in fact, that it’s sometimes difficult to find a doctor to prescribe it.

This is not so much a payment issue, though uneven coverage surely contributes. It is more a matter of physician competence: sole practitioners on their own are simply not equipped to provide quality care to opioid addicts.

In fairness, some of my colleagues have had great success with bupe. But they also tell me that too many of their patients continue to use illicit opioids. Federal guidelines recommend that doctors perform routine urine toxicology screens to check for illicit opioids and other drugs. The guidelines also recommend behavioral counseling.

This is asking a lot of a primary care doctor, the average bupe prescriber. A 2015 study of Medicaid patients in Pennsylvania found that most clinicians provided “poor overall quality” of care with inadequate urine testing and counseling.

Such demands also discourage would-be prescribers – me included. Indeed, under half of the nation’s 33,000 “waivered” doctors – those who completed a required government course enabling them to prescribe bupe -- do not use it at all. Those who do, treat fewer than thirty patients per month.  Nonetheless, the Obama Administration largely ascribes the prescriber deficit to a cap on the number of bupe patients a doctor can care for.

Bupe is also the third most diverted prescription opioid after oxycodone and hydrocodone, according to the DEA – and most of that bupe comes from well-meaning clinicians.   

Sometimes patients cut off a piece of the strip for themselves and sell the rest to addicted individuals who use it detox themselves, “to get high,” or to tide them over for times when heroin isn’t available or is too costly.

Bupe film also finds its way into jails on the backs of postage stamps or laid invisibly over a child’s drawing. This caused Maryland to remove bupe from its Medicaid Pharmacy Preferred Drug List replacing it with bupe pills, which are harder to smuggle.

By now, the story should sound familiar: the more addictive medication in circulation the more diversion there will be. Substitute painkillers for bupe and you can readily grasp the genesis of the current opioid epidemic. 

Unfortunately, treatment advocates do not pay enough attention to these dispiriting details. Instead, they focus on the need for more bupe prescribers – a plan that makes sense on its face, but falters as doctors see how challenging it is to treat addicted individuals.

All this makes me relieved to work in a methadone clinic. Our nurses watch patients swallow the cherry-flavored liquid medication daily for at least the first few months.

If a patient resumes heroin, we can provide more frequent counseling, do more regular toxicology screening, and suspend any take-home doses of methadone. Such careful monitoring accounts for very low rates of diversion of methadone from clinics. 

The state of Rhode Island, where opioid overdose deaths are especially high, has heeded the importance of monitoring. Its new system for bupe treatment may well be a blueprint for other states.

Specifically, Rhode Island will establish “centers of excellence” around the state. Medicaid and privately insured patients needing bupe will be seen at these centers.

Staff will disburse prescriptions for a few days of medication at a time and provide counseling; as patients cease illicit drug use as confirmed by urine toxicology screening and show progress, the supervision will loosen. The goal is to get patients transferred to local clinicians within six months.

But knowing that most doctors are not eager to receive --“they fear the patient will relapse and they won’t be able to deal with it,” Dr. Elinore McCance-Katz, the program’s architect told me in a phone call she has added a vital option.  Doctors can refer patients back to the center for stabilization.

The bupe experience has reinforced truths about opioids. First, opioid anti-addiction medications carry a high risk of being misused. Second, the rigors of the methadone treatment were instituted for a good reason.

By recognizing the challenges of treating an opioid epidemic of out doctors’ offices, the new leaders at HHS will have a better shot at reversing it. 

 

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